Abstracts from the 2024 Annual Meeting of the Society of General Internal Medicine

• Clinical Update

• Clinical Vignette

• Innovation in Healthcare Delivery (IHD)

• Innovation in Medical Education (IME)

• Scientific Abstract

• Special Symposia

• VA Special Series

• Workshop

Clinical Update - Clinical Skills

2024 CLINICAL UPDATES FROM THE U.S. PREVENTIVE SERVICES TASK FORCE

Howard Tracer¹; Joel Tsevat²; John B. Wong³. ¹CEPI, Agency for Healthcare Research and Quality, Rockville, MD; ²The University of Texas Health Science Center at San Antonio, San Antonio, TX; ³Tufts Medical Center, Boston, MA. (Control ID #3982354)

COLLABORATION: None, N/A

SESSION SUMMARY: During this session, the U.S. Preventive Services Task Force (USPSTF) will describe its recommendation development process, how it disseminates its recommendations, and new key recommendations, which include Statin Use for the Primary Prevention of Cardiovascular Disease (CVD) and Screening for Latent Tuberculosis Infection In Adults. Additional new recommendations will also be presented.

Statin Use for the Primary Prevention of Cardiovascular Disease (CVD) (Final Recommendation):

The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e. dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater. (B grade).

The USPSTF recommends that clinicians selectively offer a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 7.5% to less than 10%. The likelihood of benefit is smaller in this group than in persons with a 10-year risk of 10% or greater. (C grade).

Screening for Latent Tuberculosis Infection In Adults (Final Recommendation):

The USPSTF recommends screening for LTBI in populations at increased risk. (B Grade).

RELEVANCE OF TOPIC TO SGIM MEMBERS: The USPSTF recommendations are relevant to all internal medicine clinicians, researchers, and practitioners. They also address nearly all six of the ACGME core competencies. Understanding the new final recommendations will help SGIM members implement evidence-based recommendations in their practice.

CLINICAL UPDATE IN OBESITY MEDICINE

Carolyn Bramante¹; Jessica L. Schwartz²; Jacinda M. Nicklas³. ¹Medicine, University of Minnesota Twin Cities, Minneapolis, MN; ²General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ³General Internal Medicine, University of Colorado School of Medicine, Aurora, CO. (Control ID #3987246)

COLLABORATION: Collaboration: We will build off of a collaboration that was formed for the 2023 annual meeting with the SGIM Obesity Interest Group. We will present an update to the clinical update from 2023.

SESSION SUMMARY: Recent estimates suggest over 45% of US adults have obesity, with highest rates among marginalized groups, which increases health disparities as adults with obesity are 2-3 times more likely to have multi-morbidity. This leads to increased healthcare utilization among patients with obesity in both inpatient and outpatient settings, where internal medicine providers are frequently involved in care. It is therefore essential for providers and researchers at SGIM to remain up-to-date on one of the most prevalent chronic diseases in the US.

The field of obesity medicine is rapidly expanding. Recent articles from 2023 alone demonstrate groundbreaking findings in obesity pharmacotherapy, endoscopic and surgical bariatric procedures, primary care management after bariatric surgery, lifestyle treatment and counseling, and medical education. The session presenters will provide an update on seminal articles in these four categories. Updates will include the use of oral semaglutide (a GLP-1 agonist, the sub-cutaneous form is better known), retatrutide (triple agonist glucose-dependent insulinotropic polypeptide, GLP-1, glucagon receptor), orforglipron (non-peptide GLP-1 receptor) and tirzepatide (a GIP/GLP-1 receptor agonist) for obesity treatment as well as the effectiveness of various bariatric procedures in populations previously felt to not be eligible for bariatric procedures.

They will also cover the latest recommendations on physical activity and nutrition (e.g., consistency of eating for cardiovascular health). They will also highlight developments in obesity training and use of remote approaches for clinical care including reimbursement.

Throughout the presentation, they will emphasize strategies for translating these findings into clinical practice using cases from their own experiences as obesity medicine providers and educators. This method was used during the obesity medicine update last year and was very well received, allowing the audience to learn how obesity medicine providers put evidence into practice. In preparation for this session, the presenters will monitor ongoing publications for relevant articles to include in the materials at SGIM.

We know that there is another clinical update in obesity that was submitted, and we think that having two would be reasonable if the program allows because the obesity workshops and clinical updates are typically standing-room-only, and there are often scheduling conflicts that prevent some members from being able to attend.

RELEVANCE OF TOPIC TO SGIM MEMBERS: Over 75% of US adults have obesity or overweight, and both conditions lead to increased morbidity and mortality. Internal medicine providers care for these patients in both inpatient and outpatient settings and, therefore, are key to successfully addressing the obesity epidemic. While many providers lack obesity-specific training due to gaps in medical education, they also recognize obesity medicine as an area of great importance in patient care and desire further education on this topic.

UPDATE IN PRIMARY CARE

Jeremy Smith¹; Jason T. Alexander³; Amy Chen⁷; Sachin D. Shah⁴; Simran Singh²; Pamela Vohra-Khullar⁶; David Williams⁵. ¹Medicine, University of Wisconsin-Madison, Madison, WI; ²Internal Medicine, Louis Stokes Cleveland VAMC, Cleveland, OH; ³Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ⁴Medicine & Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL; ⁵Boise VA Medical Center, Boise, ID; ⁶Internal Medicine, Emory University School of Medicine, Atlanta, GA; ⁷Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3981893)

SESSION SUMMARY: After careful structured review of the literature, the authors will present the most important practice changing articles on primary care topics from the previous year. The presentation will be case-based and interactive with a focus on application of the evidence to everyday outpatient practice. To introduce each article, participants will answer a pertinent clinical question by digital audience response. Next authors will present a brief case to illustrate the clinical question addressed by each article presented. The authors will then summarize the key points of each article and present a critical analysis of the evidence. Lastly, authors will give their conclusion regarding the impact of the article on practice and how to apply the evidence to the case presented as well as care in the outpatient setting. Each audience response question will be reviewed incorporating the new information from the article presented. There will be time designated for questions and discussion among participants. At the end of the session, participants will be empowered to apply new evidence to outpatient care.

RELEVANCE OF TOPIC TO SGIM MEMBERS: Many SGIM members are practicing general internists who see patients in the ambulatory setting. This update will help ensure clinicians are familiar with the most recent literature and can apply it to routine patient care.

UPDATE IN THE PREVENTION AND TREATMENT OF SEXUALLY TRANSMITTED INFECTIONS

Brian C. Hilgeman¹; Christopher P. Terndrup²; Amy J. Kennedy³; Rebecca Glassman⁴; Jeremy Snyder⁵. ¹General medicine, Medical College of Wisconsin, Milwaukee, WI; ²General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; ³Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA; ⁴medicine, Westchester Medical Center, Valhalla, NY; ⁵Truman Health Services, University of New Mexico Health Sciences Center, Albuquerque, NM. (Control ID #3984335)

COLLABORATION: HIV Interest Group

LGBTQ+ Health Interest Group

SESSION SUMMARY: The rates of sexually transmitted infections (STIs) have risen dramatically in the United States, accelerated by multiple care interruptions in prevention and care services during the COVID-19 pandemic (1). More than 2.5 million cases of chlamydia, gonorrhea, and syphilis were documented in 2021, including a significant increase of treatment-resistant infections (1, 2). These developments have led to updated guidelines in the treatment of STIs and new recommendations regarding screening for at-risk groups (3, 4).

In addition to screening and treatment updates, there are new evidence and debate around novel methods of STI prevention. New developments in the use of antibiotics for bacterial STI prevention are gaining traction, as are new modalities for the provision of HIV pre-exposure prophylaxis (PrEP). These innovative approaches, while promising, are also not without controversy, and have yet to be widely adopted across the country.

In the setting of rising infections and new developments in treatment and prevention, general internists must know the most updated information on the prevention and treatment of STIs in order to bend this curve. In this interactive update, we plan to present a rigorous and strictly evidence-based overview on the prevention and treatment of STIs using 7-10 papers published in the last 12-18 months that significantly impact care delivery. We will review each paper and discuss practice-changing information that is relevant to the general internist practicing in both inpatient and outpatient clinical care settings.

The topics we plan to cover include: updated 2021 STI screening and treatment guidelines; STI prevention with doxycycline post-exposure prophylaxis (DoxyPEP); developments in the prevention of Neisseria gonorrhea with currently available vaccinations; barriers and successes in injectable HIV pre-exposure prophylaxis (PrEP); and challenges for HIV screening in the setting of new medications for prevention.

We plan to utilize visually interesting, audience-engaging slides to accompany a concise discussion of each article. There will be time for pertinent questions and robust discussion from the audience to further enhance learning.

References:

1. Sexually transmitted disease surveillance, 2021. Centers for Disease Control and Prevention. April 11, 2023. Accessed September 14, 2023. https://www.cdc.gov/std/statistics/2021/default.htm.

2. Drug-resistant gonorrhea - STD information from CDC. Centers for Disease Control and Prevention. March 2, 2023. Accessed September 14, 2023. https://www.cdc.gov/std/gonorrhea/drug-resistant/default.htm.

3. STI treatment guidelines. Centers for Disease Control and Prevention. June 13, 2023. Accessed September 14, 2023. https://www.cdc.gov/std/treatment-guidelines/default.htm.

4. US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Screening for Chlamydia and Gonorrhea: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;326(10):949-956.

RELEVANCE OF TOPIC TO SGIM MEMBERS: There are a plethora of new evidence surrounding the STIs. In addition, multiple structural barriers have led to a dis-proportionate impact of STIs on low-income and black, indigenous and people of color. SGIM is at the forefront of care innovation, a leader in evidence-based practice, and a strong advocate for health equity. Hence, this topic is critically important to the SGIM community.

Clinical Update - Geriatrics and Palliative Care

UPDATE IN GERIATRIC MEDICINE

Shahla Baharlou¹; Stephanie Nothelle²; Judith Vick³; Eva P. Szymanski⁴; Vassiliki Pravodelov⁵. ¹Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD; ³Internal Medicine, Duke University, Durham, NC; ⁴Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁵Department of Medicine, Section of Geriatrics, Boston University School of Medicine, Boston, MA. (Control ID #3985282)

COLLABORATION: Geriatrics Commission

SESSION SUMMARY: As the proportion of older adults increases, providing up to date and quality care to them is of great importance to general internists, who provide the bulk of their primary care. The Update in Geriatric Medicine will review important advances in the clinical care of older adults published in the previous year. Topics will include advances in the diagnosis and management of geriatric syndromes, management of multimorbidity, and systems of care. Chronic disease treatment trials focused on older adults or with a significant proportion of older adults will also be included. The strength of the evidence will be discussed as well as potential impact the work could have on current clinical practice and education. Articles selection criteria will emphasize high quality studies that may be immediately applicable in practice. Article presentation will use interactive methods to reinforce key points.

RELEVANCE OF TOPIC TO SGIM MEMBERS: The clinical update in Geriatrics will provide the latest advances in care for older adults, a growing share of generalist practice with unique care needs. The update will include information that should change or affirm current practice in ambulatory, hospital-based, post-acute and long-term care settings. it will also provide the latest information on health system adaptations’ efficacy, feasibility and cost effectiveness in supporting the delivery of high-value care for older adults.

Clinical Update - Health Care Policy and Health Services Research

UPDATES IN HEALTH POLICY

Anders Chen¹; Tracey Henry²; Elisabeth Askin³; Leslie W. Suen³; Celeste M. Newby⁴. ¹Internal Medicine, University of Washington, Seattle, WA; ²Medicine, Emory, Powder Spgs, GA; ³Internal Medicine, UCSF, San Francisco, CA; ⁴John W Deming School of Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #3986819)

COLLABORATION: Health Policy Committee

SESSION SUMMARY: In the past two years, there have been substantial federal policy changes proposed or enacted by Congress, The Centers for Medicare and Medicaid Services (CMS), and other agencies. These policies will have a dramatic impact on SGIM members and the patients they serve, as they govern Medicaid enrollment, Medicare prescription drug prices, primary care and inpatient hospital payments, telehealth regulations, addiction medicine, and health equity. Additionally, significant education-related policies have changed the landscape in how we recruit and support a diverse and equitable workforce. This session will provide major updates in these Clinical Practice and Education health policy topics:

Clinical Practice:

1. Physician payments: CMS has proposed a substantial increase to primary care payments and a landscape-altering, fundamental change to how cognitive care services would be valued moving forward. CMS declared its intention to end its dependency on the procedural-heavy American Medical Association committee that maintains the Relative Value Unit (RVU) system, by establishing an internal and publicly accountable expert panel – changes for which SGIM has been advocating for over 20 years. We will provide brief history of the decline of primary care payments based on policy enacted in the 1990s, review the final rules which will be released in December 2023, and explain the implications for practicing internists.

2. Drug Pricing Reform: The Inflation Reduction Act of 2022 (with detailed rules releasing in 2023 and 2024) has substantial implications for Medicare beneficiaries and the overall landscape of drug prices and drug development, affecting all patients. We will review financial protections for Medicare beneficiaries including caps on out-of-pocket drug spending, and high-level regulations on drugs and drug companies - including rebates, negotiations, and Part D plan redesign.

3. Health Equity: We will review: Medicaid disenrollments, buprenorphine prescribing via virtual care, payments for screening for social risk factors, community health worker services, and equity payments when caring for patients with higher social risk (e.g., experiencing homelessness)

4. Telehealth: We will review the status of waivers set to expire in 2024

Education Policy

1. International Medical Graduates (IMG), J-1 visas and the Conrad 30 Waiver program: Continuation of this program is critical for specialties that train a high number of IMGs in residency. We will discuss current House and Senate bills related to this program.

2. Rural Emergency Hospitals: We will discuss the proposed changes to Graduate Medical Education (GME) payments for Rural Emergency Hospitals and the need for CMS to implement safeguards to ensure accurate updates to GME funding in the future.

3. Student Loans: We will provide updates on federal legislation and Supreme Court decisions as they relate to student loans.

4. GME Expansion: We will provide updates on residency slot allocation.

RELEVANCE OF TOPIC TO SGIM MEMBERS: The topics we will cover impact the vast majority of SGIM members who practice clinical medicine and work in academic medicine and safety net systems. This will include payment policy for primary care and inpatient hospital services, workforce and educational policies, and health equity topics relevant to social determinants of health, substance use disorder treatment and workforce diversity.

Clinical Update - Hospital Medicine

UPDATE IN HOSPITAL MEDICINE

Bradley A. Sharpe¹; Nila Radhakrishnan². ¹Medicine, UCSF, San Francisco, CA; ²Medicine, University of Florida, Gainesville, FL. (Control ID #3985624)

COLLABORATION: This presentation is supported by the SGIM Academic Hospitalists Commission.

SESSION SUMMARY: The care of hospitalized patients continues to be increasingly complex. Healthcare providers responsible for this care should be equipped with the most recent evidence to provide high-quality, safe, equitable, patient-centered, and cost-conscious care. This session, designed for hospitalists and all generalists, will present an update in hospital medicine, outlining the most significant publications and their potential impact on care since the 2023 Annual Meeting.

Using a case-based and interactive format including multiple choice questions, the presenters will review the most important and influential publications in hospital medicine (10-12 total articles) since the spring of 2023. The articles will be selected using a modified Delphi method involving multiple academic hospitalists representing different institutions and regions. Articles will be chosen not only for their scientific rigor but also for their potential to impact and change practice. This update in hospital medicine will specifically focus on non-COVID related evidence.

There will be 10 minutes for questions and answer at the end of the presentation.

RELEVANCE OF TOPIC TO SGIM MEMBERS: The Update in Hospital Medicine is relevant to all SGIM members including hospitalists, generalists, and trainees. For those directly involved in the care of hospitalized patients, this update will promote evidence-based care strategies. For those engaged solely in ambulatory care, the update will ensure knowledge of best practices to help in maximizing the transition from the inpatient to the outpatient setting.

UPDATE IN PERIOPERATIVE MEDICINE

Ethan Kuperman¹; Kay Johnson⁴; Ryan Munyon⁶; Sunil K. Sahai²; Richard Silbert³; Michele Fang⁵. ¹Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; ²Internal Medicine, The University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX; ³General Internal Medicins, Mayo Foundation for Medical Education and Research, Rochester, MN; ⁴Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, WA; ⁵Internal Medicine, Penn Medicine, Philadelphia, PA; ⁶Penn State College of Medicine, Hershey, PA. (Control ID #3981832)

COLLABORATION: Perioperative Medicine Interest Group

SESSION SUMMARY: This update will focus on key areas within perioperative and consultative medicine including cardiovascular care, pulmonary risk, hematologic management, and other aspects of perioperative care. Each area will be presented by a different speaker and will cover 3-4 of the most relevant publications from the past year. Publications will be identified by performing a comprehensive literature review and authors selecting the most important papers through a voting process. Each paper will be presented within the context of a patient care scenario,and authors will provide practical advice on how to apply the paper's findings to patient care.

Session Summary : Perioperative medicine and medical consultation are important aspects in the routine practice of general internal medicine. However, many medical residents, hospitalists and senior internists feel unprepared and uncomfortable in their role as medical consultants to high-risk patients before surgery, and the evidence supporting best practices is rapidly evolving. Therefore, an annual review of the pertinent new perioperative literature is highly useful. A core group of internists reviewed the literature monthly for relevant articles in perioperative medicine. We evaluated articles as to their design and strength of evidence and rated them for their importance and clinical relevance to the practicing internist. Those articles meeting criteria with the highest ratings are summarized, critiqued, and presented for this update. Although the session will be primarily didactic, time will be allotted for discussion and questions from the audience

RELEVANCE OF TOPIC TO SGIM MEMBERS: Perioperative and consultative medicine is important to both ambulatory and hospital-based general internists. More elderly patients and patients with complex medical conditions are receiving surgery and requiring internal medicine care. This update provides essential skills and knowledge for internists to fill this important clinical role.

Clinical Update - Medical Education and Training

CLINICAL UPDATE IN MEDICAL EDUCATION

Katherine Killian¹; Eva P. Szymanski²; Erik X. Tan³; Yihan Yang⁴; Raman Singhal⁵. ¹Internal Medicine, Lenox Hill Hospital, Bronx, NY; ²Department of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ³Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁴Washington State University, Pullman, WA; ⁵Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #3986439)

COLLABORATION: SGIM Medical Education Committee

SESSION SUMMARY: Innovation and scholarship in medical education have paralleled broader social trends which general internists are uniquely positioned to address, including racial injustice and an increasing reliance on technology for education and patient care. In line with the meeting theme “Strengthening Relationships and Valuing Our Diversity,” the 2024 Update in Medical Education will highlight publications that explore these trends, in particular those which examine diversity, equity and inclusion (DEI) efforts and clinician educator relationships with their learners, colleagues, patients, and more. We will emulate the well-attended and highly-rated medical education update workshops from prior SGIM meetings, offering another engaging review of the most influential medical education literature from the past year. Our update will be led by SGIM Education Committee members who are leaders in general internal medicine and will focus on innovations, insights, and transformative works that SGIM members can apply to their educational practice.

The first step in article identification will involve a thorough review of medical education publications over the past year from journals with a history of publishing medical education work applicable to a general internal medicine audience. Selected publications will undergo a rigorous review process with the goal of identifying those most relevant to the education of general internists and medical trainees. Using a modified Delphi technique, the collated articles will be scored by a group of committee members with the following categories in mind: relevance to meeting theme, importance of the study question, quality of study methodology, and impact/generalizability of conclusions or outcomes. Examples of medical education topics that will help general internists strengthen relationships and value diversity may include: DEI - innovations to mitigate bias and racism in both training and healthcare delivery; Learning Environment - enhancing relationships between educators and learners to enable trainee growth and professional identity formation; and Technology - leveraging emerging technologies to support collaboration and innovation in medical education across disciplines and health professions.

Each article will be rated by at least two reviewers. The highest rated articles will undergo a secondary screening by the full committee of reviewers, using the same scoring system as above. Finally, the group will select a small number of articles that best represent the most important medical education publications with respect to the meeting theme. We will present a summary of these studies and their key findings from the perspective of the general internist, keeping in mind the educational context in which the findings can be applied. Our interactive format will invite audience participation and input regarding their own experiences navigating emerging challenges and opportunities for general internists in medical education.

RELEVANCE OF TOPIC TO SGIM MEMBERS: Given the large amount of literature that is published annually, it is challenging for our members to remain informed of the latest innovations in medical education. For many of our members, a major goal of attending the SGIM national conference each year is to keep abreast of current trends in internal medicine education. Our diverse group of educators will develop a concise summary of relevant, high-impact medical education literature that will support our SGIM educators and their learners.

Clinical Update - Mental/Behavioral Health and Substance Use Disorders

UPDATE IN ADDICTION MEDICINE FOR THE GENERAL INTERNIST

Katherine P. Mullins^1,2; Kenneth L. Morford³; Carolyn A. Chan⁴; Stefan Kertesz⁵. ¹Family Health Centers, New York University, Brooklyn, NY; ²Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, NY; ³Internal Medicine, Yale University School of Medicine, New Haven, CT; ⁴General Internal Medicine, Yale School of Medicine, New Haven, CT; ⁵Medicine, Birmingham VA Medical Center & U. Alabama Birmingham, Homewood, AL. (Control ID #3979719)

COLLABORATION: Alcohol, Tobacco, and Other Drug (ATOD) Use Interest Group

SESSION SUMMARY: In this update, we will critically review and present peer-reviewed literature and practice-changing updates from the past year that can guide general internists in caring for patients with substance use and substance use disorders. Content areas will include: overdose prevention and treatment, best practices in diagnosis and treatment of substance use disorders in both primary care and hospital settings, and recent challenges and innovations in access to addiction care. As in past years, we will review the current state of health inequities. In particular, we will underscore the necessity of developing a diverse workforce to meet the needs of people with substance use disorders who have been marginalized, particularly people of color. To maximize audience engagement, we will explore how novel research can impact practice through a case-based approach with multiple-choice questions that highlight key findings.

RELEVANCE OF TOPIC TO SGIM MEMBERS: Generalists play a critical role in managing substance use both as first “points of contact” and through ongoing relationships. Overdose deaths across the US reached 105,000 in the 12 months preceding March 2023. Cannabis, hallucinogen, and alcohol use reached historic highs among adults aged 35 to 50 in 2022. Residency programs continue to work toward fulfilling ACGME addiction training requirements. We aim to share pertinent updates to help internists address these ongoing needs.

Clinical Update - Research Skills

UPDATE IN RESEARCH METHODS FOR THE GENERAL INTERNIST

Melissa Y. Wei^1,2; Seth A. Berkowitz³; Himali Weerahandi⁴. ¹Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²VA Greater Los Angeles Healthcare System, Los Angeles, CA; ³Division of General Medicine & Clinical Epidemiology, UNC School of Medicine, Chapel Hill, NC; ⁴University of California San Francisco School of Medicine, San Francisco, CA. (Control ID #3984764)

COLLABORATION: SGIM Research Committee

SESSION SUMMARY: Generalists must stay abreast of novel research methods to understand, generate, and utilize the most important research findings and to provide the highest quality of care to patients. Being well-informed of cutting-edge research methods allows generalist researchers to conduct innovative and influential research and to critically appraise research methods to select the most appropriate methods to answer a research question. Innovation and methodologic rigor are also major criteria for successful NIH and foundation research grant applications. Thus, it is imperative for generalist researchers to stay current on innovative research methods to remain competitive in a challenging funding milieu.

In this Update in Research Methods for the Generalist, the Research Committee will critically review and present six of the most important peer-reviewed papers published in the past two years that have applied novel methods in studies of interest to generalists. In the setting of a rapidly changing landscape of healthcare access, utilization, delivery, and workforce diversity, we will highlight at least one publication that features novel methods to rigorously study general internist relationships and diversity. In our poll of generalist researchers, we also identified the following research methods of high interest: machine learning, natural language processing, adaptive trial design, estimating uncertainty, social network analysis, and latent class analysis. We anticipate presenting at least a few papers that utilize these methods. When possible, we will present papers that address core generalist values and translatable items through research and policy to make our session particularly relevant to this year’s meeting theme in “strengthening relationships and valuing our diversity.”

We will use a modified Delphi process and devote at least two Research Committee meetings to discuss and select the six top papers for presentation. We will ask Research Committee members to submit the titles and abstracts of at least two articles that applied novel methods on a topic of high interest to generalists. Committee members will then review the title and abstract of each paper. We will select the six top papers to present based on consensus. For the presentation we will use 60 minutes to present the papers (10 minutes per paper). We will summarize findings, methods, strengths and limitations of each method, and tips on how to apply the method. The Research Committee member with the greatest expertise with the method will present the paper. This update in research methods is designed to keep generalists, especially generalist researchers, at the forefront of medical innovation where they can maximize impact.

RELEVANCE OF TOPIC TO SGIM MEMBERS: Generalist researchers must stay well-informed of cutting-edge research methods to conduct innovative research and to compare methods in order to select the most appropriate methods to answer a research question. Innovation is a major component of successful, extramurally funded research grants. Thus, it is imperative for generalist researchers to stay current on innovative methods. This update in research methods is designed to keep generalist researchers at the forefront of medical innovation.

Clinical Update - Women’s Health, Sex, and Gender-Informed Medicine

UPDATE IN WOMEN'S HEALTH

Judith M. Walsh¹; Christine Prifti²; Rachel S. Casas³; Emmanuelle Yecies⁴. ¹Division of General Internal Medicine, UCSF, San Francisco, CA; ²Medicine, Boston Medical Center, Boston, MA; ³General Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA; ⁴Women's Health, VA Palo Alto Health Care System, Palo Alto, CA. (Control ID #3977804)

COLLABORATION: None

SESSION SUMMARY: This session will review the strength and scope of the most significant published advances in Women’s Health in the medical literature from March 2023 through March, 2024. The presenters will identify potential articles through a systematic search of the medical literature. Articles will be selected according to their methodological quality, clinical relevance, and potential to change practice. We will not approach the literature with pre-defined categories, but potential topics include sexually transmitted infections, contraception, screening and treatment for cancer among women, osteoporosis and bone health, domestic violence, women’s cardiovascular disease menopause and incontinence. Selected articles will be critically reviewed, and faculty will use case-based vignettes to highlight how each article impacts clinical practice. Although the articles will be presented in didactic fashion, faculty will encourage audience participation through multiple-choice questions and discussion of selected women’s health controversies at the end of the session.

RELEVANCE OF TOPIC TO SGIM MEMBERS: A primary focus of SGIM is the provision of excellent patient care. Members who attend will learn updated information so that they can provide outstanding evidence based care for women as well as teach learners in their settings.

Clinical Vignette - Adolescent Medicine

BIOPROSTHETIC AORTIC VALVE ENDOCARDITIS FROM STREPTOCOCCUS PARASANGUINIS INFECTION 45 YEARS AFTER INITIAL ENDOCARDITIS EPISODE

Krishnateja Kommera, Joseph P. Hornak. School of Medicine, The University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX. (Control ID #4064418)

CASE: Our patient is a 65-year-old male with a past medical history of hypertension, hyperlipidemia, and multiple aortic valve replacements. He had an episode of infective endocarditis in 1978 after his first surgical valve replacement and had subsequent bioprosthetic valve replacement of the same valve in 2013.

The patient presented to the emergency department with a chief complaint of falls. Imaging was unremarkable for any fractures but the patient showed symptoms of shock: tachycardia, hypotension, and fever. He was seen at a family medicine clinic 1 week earlier for intermittent fevers but no blood cultures were obtained at that time. He also denied any intravenous drug use. The patient was admitted to the hospital for septic shock and further workup.

Blood cultures at the hospital revealed Streptococcus parasanguinis bacteremia. Suspicion of infective endocarditis led to the obtaining of a transthoracic echocardiogram that demonstrated severe bioprosthetic valve stenosis with no endocardial vegetations. After one week of intravenous Zosyn and Vancomycin (broad spectrum coverage for sepsis) in the hospital, repeat blood cultures were negative and the patient’s sepsis resolved. Our patient was discharged with a course of Amoxicillin and scheduled for an outpatient cardiology evaluation in 3 weeks.

Upon cardiology follow-up, our patient remained lethargic and hypotensive. Suspicion of prosthetic valve endocarditis was high and the patient was readmitted to the hospital. An expedited transesophageal echocardiogram revealed a mobile vegetation consistent with aortic prosthetic valve endocarditis (PVE). The patient subsequently underwent an urgent valvectomy and prosthetic valve replacement.

IMPACT/DISCUSSION: Streptococcus parasanguinis is a gram-positive colonizer of the human oral cavity and belongs to the viridans group of streptococci. It is classified as a moderately common cause of bloodstream infection but is less prevalent than its fellow viridans group members, S. sanguinis and S. mitis. S. parasanguinis also has a lower risk of progressing to infective endocarditis than both bacteria mentioned earlier, making our patient’s case uncommon. The patient was also not noted to have poor dentition, recent dentist procedures, or intravenous drug use, leaving the root cause of his infection unknown. Our patient had his first aortic valve replacement and PVE episode at the age of 20. Consequent heart failure and valve replacements have been associated with increased heart remodeling and long-term mortality after each surgery and could explain our patient's complex cardiovascular health.

CONCLUSION: Diagnosis of PVE requires a high index of suspicion to arrive at a diagnosis. Patients should be meticulously evaluated for PVE when both a history of valve replacement (minor Duke criterion) and systemic infection are present. Treatment guidelines recommend a combination of antibiotic therapy and timely valve replacement to reduce mortality risk.

RARE CASE OF ADULT VARICELLA COMPLICATED BY SEVERE RHABDOMYOLYSIS LEADING TO DIALYSIS

Soki Hirota¹; Kazuo Komamura¹; Keisuke Yoneda¹; Mitsunori Iwase². ¹Internal Medicine, Toyota Kinen Byoin, Toyota, Aichi, Japan; ²Cardiology, Toyota Memorial Hospital, Toyota, Aichi, Japan. (Control ID #4064201)

CASE: A 27-year-old unvaccinated male was diagnosed with varicella one week prior to his visit. He was recuperating at home, but was brought to the emergency department with a chief complaint of difficulty moving. When he arrived at the hospital, he had a skin rash over his entire body, prominent swelling of his thighs, and loss of muscle contraction in his lower extremities. Blood samples showed marked elevation of CK (87888 U/L) and renal dysfunction (BUN 44 mg/dL, Cre 5.34 mg/dL), and complications of rhabdomyolysis were suspected. The patient was admitted to the ICU for management of persistent hypotension despite massive infusion of fluids. After admission, a close examination revealed complications of pneumonia and myelitis. On the second day of admission, his renal dysfunction more worsened, and he was started on hemodialysis. However, his renal function improved rapidly just after administration of Acyclovir (antiviral) and additional fluids. Then, he was weaned from hemodialysis on the 11th day of hospitalization. His general condition improved, and rehabilitation was initiated. On the 35th day of hospitalization, the patient was transferred to another hospital for further rehabilitation.

IMPACT/DISCUSSION: The incidence of varicella in children has greatly decreased due to the widespread use of vaccination. On the other hand, the number of cases of varicella in adults is increasing due to the inability to acquire natural immunity. Adult varicella is known to be more severe than childhood varicella and is more likely to be complicated by pneumonia, myelitis, and secondary bacterial skin infections. Causes of rhabdomyolysis include prolonged pressure, excessive alcohol consumption, excessive exercise, heat stroke, drugs, and viral infections. In general, EB virus, echovirus, adenovirus, and measles virus are the most common causative viruses. Although there have been only a few cases of varicella complicated by rhabdomyolysis in the literature to date, severe renal failure can occur, as in the present case, and complications such as rhabdomyolysis should be considered when a patient with varicella complains of severe fatigue. Most cases of pediatric varicella resolve spontaneously, but antiviral medications are essential for the initial treatment of adult varicella. Importantly, early administration of antivirals is known to reduce the severity of the disease. In the present case, the appropriate administration of antivirals may have prevented severe rhabdomyolysis.

CONCLUSION: Initial treatment with antiviral drugs is important to prevent severe complications in patients with adult varicella.

RETROPHARYNGEAL AND EPIDURAL ABSCESSES MASQUERADING AS CERVICAL RADICULOPATHY: AN UNFORTUNATE AND RARE ETIOLOGY OF QUADRIPLEGIA

Gagan Aulakh¹; William Ott¹; Arshdeep Singh²; Sachita Subedi¹; Nooredeen Isbeih¹; Jacob Enyia¹; David Flores¹. ¹Internal Medicine, Jersey City Medical Center, Jersey City, NJ; ²Internal Medicine, Government Medical College Amritsar, Amritsar, Punjab, India. (Control ID #4050016)

CASE: A 56-year-old woman, who has been undergoing home hemodialysis using the buttonhole needling technique for the past seven years, presented to the hospital with a sudden onset of immobility and sensory loss below the neck. Six days prior to her current presentation, she experienced throat and neck pain, leading to the identification of foraminal stenosis on a CT scan, for which she was prescribed a Medrol dose pack. Upon examination, there were absent sensations, motor activity, and reflexes below the neck. Admission blood work revealed significant findings, including neutrophilic leukocytosis of 28,000/mm3 (normal range: 4,000-11,000/mm3) and elevated inflammatory markers (Erythrocyte Sedimentation Rate- 95, C-reactive Protein- 25). A subsequent CT scan revealed a 4.8 cm*2.7 cm*7.5 cm retropharyngeal abscess extending from C1-C6 levels, causing multilevel cord compression.

Urgent interventions, including drainage, decompression, and laminectomy, were performed after intubation. Blood and abscess cultures on the following day confirmed the presence of MRSA, for which the patient was treated with Vancomycin. Her treatment course was complicated by the re-accumulation of the retropharyngeal abscess extending to surrounding muscles, necessitating drainage, discitis, osteomyelitis, and ventilator-associated pneumonia. Despite ongoing medical management, there was no neurological improvement, and the patient was eventually discharged to a long-term care facility after undergoing a tracheotomy and PEG tube placement.

IMPACT/DISCUSSION: To the best of our knowledge upon literature review, the concurrent occurrence of retropharyngeal abscess (RPA), and cervical osteomyelitis with cord compression in the context of the buttonhole needling technique is the first reported case to date. Studies have indicated a higher likelihood of Methicillin-resistant Staphylococcus aureus (MRSA) infection with the buttonhole needling technique compared to the standard method. Given that hemodialysis (HD) patients are already susceptible to infections, in our case, the administration of steroids induced an immunosuppressive state, contributing to the extensive progression of the disease in our patient. Cervical spondylodiscitis is uncommon, and the treatment approach involves a combination of both medical and surgical options.

CONCLUSION:

The occurrence of cervical osteomyelitis and cord compression, along with a retropharyngeal abscess (RPA), in the context of infected buttonholes as hemodialysis access is exceptionally rare, requiring a multidisciplinary approach. Retropharyngeal abscesses are uncommon in adults, and their etiology can be either traumatic or non-traumatic. In our case, the presentation indicates a non-traumatic cause, specifically hematogenous spread.

THE GASTROINTESTINAL SIDE EFFECTS OF USING TEJOCOTE ROOT AS A WEIGHT LOSS SUPPLEMENT

Kanza shamim, Navleen Singh, Cris Elsayad. internal medicine, Nassau University Medical Center, East Meadow, NY. (Control ID #4058692)

CASE: 48 year old female with a past medical history of situs inversus and Bell's palsy presented to the primary care clinic for a follow up of her liver enzyme studies. She had a recent emergency department visit 2 months ago with complaints of chills, nausea, epigastric abdominal pain, diarrhea, and decreased appetite for 3 weeks status-post taking Tejocote root daily for 1 month. Patient discontinued the supplement a few days prior. She denied fever, vomiting, dysuria, rectal bleeding, chest pain, and shortness of breath. Patient denied alcohol, recreational drugs, and medication usage. Physical exam was positive for tenderness in the epigastric region only. Abdomen was soft, nondistended, and bowel sounds were present in all 4 quadrants. Cardiac examination was within normal limits. Labs were pertinent for new onset elevated AST (85), ALT (107), alkaline phosphatase (207), and glucose (212). An EKG done showed normal sinus rhythm. During her recent primary care visit 2 months later, the patient had no complaints. Chills, nausea, epigastric pain, and diarrhea all resolved. However, her labs still showed elevations in AST (68), ALT (135), and alkaline phosphatase (147). Glucose was within normal limits (83).

IMPACT/DISCUSSION: Tejocote root is one of the most popular weight loss supplements used worldwide. Its popularity is skyrocketing due to easy accessibility and increased advertisements on the internet. Tejocote root comes from fruit-bearing Hawthorn trees located mostly in Mexico and Latin America. Although there is not much information known about the compound, it is presumed that high pectin content in Tejocote can lead to early satiety. There have been reports that Tejocote toxicity can lead to arrhythmias, AV block, false elevation of Digoxin (due to similar biochemical structure), and thrombocytopenia. However, Gastrointestinal side effects have not been studied and reported. This case highlights those gastrointestinal side effects - nausea, diarrhea, epigastric pain, and new onset transaminitis in an otherwise healthy female. Although the patient’s symptoms resolved 2 months after discontinuation of supplement, the transaminitis continues to trend upwards, raising concern for the long lasting effects of non-FDA approved supplements. It is important for physicians to recognize these clinical features to educate and warn their patients on purchasing supplements online that are non-FDA approved, especially in the day and age where online medical influence is prominent.

CONCLUSION: Due to internet influence, patients tend to gravitate towards non-FDA approved supplements that have many unknown side effects. It is crucial to note that herbal remedies may have varying effects. The safety of using specific roots or herbs depend on factors such as dosage, individual health conditions, and potential interactions with other medications.As healthcare professionals, it is important for us to recognize these side effects and educate patients to the best of our capabilities.

Clinical Vignette - Ambulatory Medicine

32 YEAR OLD MALE WITH PANNICULITIS-WHEN TO WORRY?

Niveditha Badrinarayanan, Kelly White. Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4064683)

CASE: A 32-year-old male with a history of alpha-1 antitrypsin deficiency (A1AT) heterozygostiy, hepatic steatosis, hemochromatosis carrier state, and a family history of rheumatoid arthritis presented with a 3-week history of fatigue, chills, myalgias, polyarticular arthralgias and multiple painful erythematous nodules on bilateral lower extremities and trunk. He reports having similar episodes for years. Physical exam was notable for tenderness to palpation of thoracic spine (around T2-T4), warmth of right knee with mild tenderness to palpation of the knees, ankles, and feet. Erythematous tender nodules were noted on bilateral lower extremities, thighs and abdomen. Labs were notable for a normal ASO titer, CK, RF, ANCA, CCP and ANA, and slightly elevated CRP to 12.4 and ESR to 16. X-rays of spine, knees and chest were all unremarkable. Treatment with NSAIDs was initiated and symptoms did not improve. Steroid treatment was started and biopsy was obtained. Pathology confirmed septal and lobar panniculitis with a mononuclear constituent and without evidence of vasculitis. Additional testing for underlying etiology has included colonoscopy, CXR, CT chest, abdomen, pelvis, additional pathologic DNA testing for T cell lymphoma, and multiple lab tests, all of which have been negative. In the absence of a clear underlying etiology, this patient's panniculitis is thought to be due to A1AT heterozygosity combined with possible viral illness triggers.

IMPACT/DISCUSSION: Panniculitis is inflammation of the subcutaneous fat which causes painful inflammatory nodules and plaques throughout the body. These are most often triggered by trauma, infection, environmental exposures, malignancy, and inflammatory disorders, such as A1AT. Histologic classification includes septal vs. lobular, with or without the presence of vasculitis. Proper biopsy technique is important and must include an adequate amount of subcutaneous fat tissue. A punch biopsy should be 6-8 mm deep, or an elliptical biopsy may be performed. Special studies may be added, especially if panniculitis-like T cell lymphoma is considered. Treatment is targeted at inflammation reduction with NSAIDs, and can be advanced to steroids, dapsone or hydroxychloroquine if NSAIDs are ineffective. Additional testing should be considered if symptoms persist or recur. This case is an important reminder that panniculitis can be the first manifestation of pancreatic, inflammatory or malignant disease when encountering subcutaneous nodules on the skin, and to be cautious that it can be a challenging diagnosis particularly since it is a relatively rare condition.

CONCLUSION: It is important to consider a wide differential in skin lesions, particularly in patients with systemic symptoms, a family history of autoimmune disorders and known genetic conditions. Panniculitis can be confirmed with an adequate punch biopsy and tests for underlying etiologies can be performed. Treatment involves anti-inflammatory agents and immunosuppression as needed.

A CASE OF ABDOMINAL WALL UNDIFFERENTIATED PLEOMORPHIC SARCOMA

Steven Gadd, Sarah Abdel-Mageed, Michelle Solik. Internal Medicine, Ascension St Vincent, Indianapolis, IN. (Control ID #4063905)

CASE: A 75-year-old gentleman presented to the outpatient clinic with a large (3x3x4cm), violaceous, firm, pedunculated nodule with overlying erosion on his right upper abdomen which had been rapidly growing for six months. He was referred urgently to dermatology due to concern of the size and vascularity of the lesion; he was subsequently scheduled for surgical excision and biopsy the following month for suspected nodular keloid. However, pathology of the biopsy showed diffuse sheetlike proliferation of atypical spindle cells arranged in fascicles, with markedly atypical nuclei, open chromalin, prominent nucleoli, and moderate amounts of eosinophilic cytoplasm with dermal mitotic figures. Further pathology work-up demonstrated diffuse highlighting with Factor XIIIA but CD34-, SMA-, SMA-, SOX10-, and p63- all of which together is consistent with Undifferentiated Pleomorphic Sarcoma. He was referred to a cutaneous surgical oncologist for complete excision. Given the aggressive nature of his diagnosis and substantial size of the lesion, he was referred to radiation oncology where he completed 28 sessions of localized radiation. Computed Tomography of the abdomen and pelvis showed no recurrent or metastatic disease following treatment and he continues to follow with dermatology for regular skin examinations.

IMPACT/DISCUSSION: Undifferentiated Pleomorphic Sarcoma (UPS), previously known as Malignant Fibrous Histiocytoma (MFH), is a rare, high-grade, aggressive soft tissue malignancy which can be disguised as other dermatologic conditions. Each year there are less than 5,000 cases of UPS diagnosed in the United States, with individuals aged 50-70 being most commonly affected. UPS is a diagnosis of exclusion that can only be made after extensive histological evaluation and the confirmed absence of keratins, S100 protein or SOX10, smooth muscle actin (SMA), and desmin which are all directly responsible for other specific soft tissue sarcomas. Treatment for UPS consists of excision and localized radiation therapy. However, chemotherapy is required for metastatic disease which occurs in approximately 35% of patients. Local recurrence has been reported in approximately 7-15% of patients. Follow up is recommended at six months and annually after one year to monitor for disease recurrence.

CONCLUSION: Rapidly growing soft tissue lesions should be biopsied to rule out potential malignancy. Patients with Undifferentiated Pleomorphic Sarcoma require wide-margin surgical excision and radiation therapy.

A CASE OF ACUTE PAINFUL HORNER SYNDROME AND CAROTID ARTERY DISSECTION IN THE PRIMARY CARE SETTING

Andrew Silapaswan¹; Marc Fisher²; Vasileios C. Kyttaris³; Elizabeth Targan¹. ¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Neurology, Beth Israel Deaconess Medical Center, Boston, MA; ³Rheumatology, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4060983)

CASE: A 33-year-old female presented to primary care with left maxillary jaw pain. She was advised to see a dentist due to concern for odontogenic source of pain. There was no underlying dental pathology identified. She represented with left anterior neck pain and left eyelid drooping. She denied a history of recent trauma or cervical manipulation. Her exam was notable for anisocoria with 2mm left pupil, 4mm right pupil, and left eyelid ptosis. Given acute Horner syndrome and neck pain, she was referred to the emergency department to rule out carotid artery dissection. She underwent CTA head and neck that showed a 6mm dissecting aneurysm of the left internal carotid artery (ICA) just distal to the common carotid bifurcation with near occlusion at the C1/C2 level. MRI and MRA head and neck confirmed similar findings. There was no evidence of stroke. She was started on apixaban 5mg twice daily and nortriptyline 12.5mg daily for pain control. She underwent outpatient MRA chest, abdomen, and pelvis which did not show signs of fibromuscular dysplasia (FMD). Interval MRI/MRA head and neck showed ICA reconstitution. After 3 months of anticoagulation, she was transitioned to aspirin 81mg daily.

IMPACT/DISCUSSION: Cervical ICA dissection can present with local symptoms including head and neck pain and Horner syndrome. Most dissections occur due to a mechanical trigger including various degrees of trauma. An underlying predisposition including connective tissue disorders may exist. FMD is the most commonly associated connective tissue disorder, however, the majority of patients do not have an underlying connective tissue or vascular disorder. Urgent MRI/MRA or CT/CTA head and neck are indicated to diagnose carotid artery dissection. Diagnosis of FMD is made by angiography, therefore clinicians can obtain an MRA or CTA torso. Additional testing for an underlying connective tissue disorder is not recommended unless clinical symptoms, signs, or family history are suggestive. After diagnosis, the risk of ischemic stroke is highest in the first two weeks after dissection, therefore antithrombotic therapy is indicated to prevent new or recurrent symptoms. For non-ischemic local symptoms associated with carotid artery dissection, antiplatelet therapy is recommended. For dissection-related TIA or stroke, anti-coagulant or anti-platelet therapy can be used. There is currently no consensus and guidelines suggest either. The risk of recurrent dissection-related stroke is low and extracranial carotid dissecting aneurysms have a favorable prognosis. Repeat imaging should be performed 3-6 months after diagnosis for vessel monitoring.

CONCLUSION: Acute Horner syndrome associated with head and neck pain should be presumed to be due to carotid artery dissection until proven otherwise. Given the potential morbidity associated with carotid artery dissection, it is important for clinicians to recognize acute painful Horner syndrome in patients with carotid artery dissection who present in the primary care setting.

A CASE OF COMPLICATED COMPETING NEEDS IN A NEWLY RESETTLED REFUGEE PATIENT

Menaka Dhingra¹; Rachael Truchil². ¹Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; ²General Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4064817)

CASE: A newly arrived refugee patient with no significant past medical history was diagnosed with chronic hepatitis C with mild transaminase elevation and a viral load of 7.1 million and latent tuberculosis infection with postivie quantiferon gold and negative chest X ray. Unfortunately given this LFT elevation and elevated viral load and the hepatotoxicity of rifampin, the risks of treating LTBI without first treating his Hepatitis C were deemed too high, despite the higher rate of reactivation in the first two years of resettlement for refugee patients. Of note he also had a partner with HIV and was started on Truvada for PrEP, although this medication has no significant interaction with Mavyret or rifampin. His viral load was undetectable after completing two months of Mavyret and his LFTs normalized. He was able to be started on rifampin and successfully completed four months of therapy.

IMPACT/DISCUSSION: This patient had two significant medical conditions necessitating urgent treatment, but the treatment options have signficant interactions with each other. Notably rates of LTBI in refugee patients have been estimated to be as high as 37%, and rates of chronic hepatitis C range from 1-2% of patients with higher rates in patients arriving from endemic regions. As such co-infection is not uncommon and the framework noted above is a useful paradigm for navigating conflicting treatments in such patients. Pharmacologic literature does suggest alternatives for simultaneous co-treatment of HCV and LTBI, which is due to the theoretical risks of reactivation of LTBI with antiviral therapy and presumed immunosuppression. However, this case shows that there is some utility in sequential treatment, particularly when treatment of HCV results in improvement in LFTs and decrease in associated hepatotoxicity risks with first-line LTBI treatment medications.

CONCLUSION: - Sequential treatment of HCV and LTBI is safe and effective in patients with co-infection and LFT abnormalities

- Risk of LTBI treatment with elevated LFTs secondary to HCV likely outweighs the benefits of co-treatment

A CASE OF TREATMENT RESISTANT H. PYLORI AND HOUSEHOLD INFECTION IN A REFUGEE PATIENT

Menaka Dhingra¹; Deepa R. Nandiwada². ¹Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; ²General Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4064866)

CASE: A newly arrived refugee patient from Afghanistan reported persistent bloating and abdominal discomfort for more than one year. H. pylori testing was positive and she was initially treated with triple (clarithromycin, amoxicillin, omeprazole) and then quadruple (tetracycline, metronidazole, omeprazole, bismuth) therapy with persistently positive stool antigen testing. Adherence was confirmed multiple times with the patient using a Pashto interpreter. She was referred for EGD which showed orgnanisms consistent with H. pylori but no susceptibilities were able to be isolated. She was then treated with levofloxacin based therapy (levofloxacin, amoxicillin, pantoprazole) with continued positive stool culture, and finally with rifabutin based therapy (rifabutin, amoxicillin, lansoprazole) with subsequent persistently negative stool testing. Of note, her children and husband were noted to have persistent GI symptoms and tested positive for H. pylori - they were presumed to have the same strain of treatment-resistant H. pylori and were therefore treated with rifabutin based salvage regimen.

IMPACT/DISCUSSION: Management of treatment-resistant H. pylori is complex and requires a sequential and systematic treatment approach. Adherence should always be addressed given the complexity of the treatment regimen, particularly for patients whose primary language is not English as this can be a significant barrier to completing appropriate therapy. Once treatment adherence has been confirmed, ideally susceptibility testing would be available for further directed therapy. However, if such testing is unavailable then use of established third and fourth line therapies with interval tests of cure is a safe and effective way of managing treatment-resistant H. pylori. Furthermore, the possibility of household infection should be considered in patients whose family members report GI symptoms, particularly for those patients with young children.

CONCLUSION: Treatment resistant H. pylori requires diligent assessment of treatment adherence and possible resistance patterns. If susceptibility testing is not available, sequential use of levofloxacin and rifabutin based treatment regimens is recommended. Once test of cure has been established it can be useful to consider household screening if members are also reporting similar symptoms.

A CASE OF URINARY FREQUENCY AND ACUTE UNILATERAL ALLODYNIA

Anna Briker¹; Toshiko Uchida². ¹Medicine, McGaw Medical Center of Northwestern University, Chicago, IL; ²Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4025518)

CASE: A 60 year old woman presents to clinic for 5 days of burning, tingling, and numbness on the left side of her abdomen. The sensation is persistent and worsened by cold objects. It has now spread to her left back and the entirety of her left leg and foot. It does not cross midline. No rash, fevers/chills, gait instability, weakness, dysarthria, headache, vision changes, diarrhea, or constipation.

She has had several years of intermittent pelvic pain and urinary frequency, which have recurred over the past 2 months. She has had 2 culture-proven UTIs and multiple negative urine cultures. She does not smoke, drink, or use drugs and has no relevant family history. She takes chlorthalidone, nortriptyline, and vitamin D. Of note, approximately 7 years prior, she had an MRI brain for headaches which showed non-specific T2 hyperintense lesions in the supratentorial white matter.

She has a normal skin, cranial nerve, strength, and reflex exam. She has normal cerebellar tests, Romberg, and gait. She is intact to light touch, vibration, and proprioception although reports greater sensation to cold on the left side from ~T6 and below.

Labs (CBC, CMP, A1c, vitamin B12, TSH, vitamin D, HIV, syphilis, ANA, urinalysis) are normal. MRI spine shows an abnormal T2 signal with contrast enhancement at the right side of the cord at C7 and hyperintense T2 signal at the anterior central aspect of the cord at T10 without enhancement. MRI brain shows an enhancing lesion along the right lateral medulla posteriorly. Lumbar puncture (LP) shows elevated IgG synthesis rate and 5 oligoclonal bands.

IMPACT/DISCUSSION: The diagnosis is relapsing-remitting MS. By McDonald’s criteria, one must have typical CNS lesions disseminated in space (in at least 2 of 4 classic locations) and time. This patient has lesions in both the spinal cord and the brain; presence of both enhancing and non-enhancing lesions indicates dissemination in time as does the presence of oligoclonal bands. Although the location of her allodynia does not classically correlate with the location of her lesions, the contrast enhancement of the C7 indicates activity. In hindsight, the patient’s LUTS are likely due to undiagnosed MS. Studies show that about 80% of patients with MS have LUTS in the first 10 years of diagnosis; 10% have them at diagnosis. Patients can present with urinary retention and/or urgency, both of which have a major effect on quality of life.

CONCLUSION: By the McDonald 2017 criteria, a patient with a clinical episode concerning for MS can be diagnosed with: 2 or more lesions on CNS imaging (dissemination in space) and oligoclonal bands on LP or MRI evidence of a new lesion on follow up (dissemination in time).

LUTS are common in MS; presentation varies depending on lesion location. Urinary retention and UTI should be evaluated with post-void residual and a urinalysis with culture.

A CASE OF WAXING AND WANING LEFT LEG SWELLING IN A 71 YEAR OLD WOMAN

Herath M. Wijerathna. Adult Medicine, Reliant Medical Group Inc, Worcester, MA. (Control ID #4055738)

CASE: A 71 year old woman with HTN, hypothyroidism and multiple squamous cell cancers was evaluated for intermittent left leg swelling for 2 months. She had a total hysterectomy with bilateral oophorectomy at age 47 and complicated abdominal surgery for ruptured appendix at age 23.

First episode of left leg swelling occurred 2 months ago with severe leg pain. No other associated symptoms. Swelling and pain spontaneously resolved in 5 days. A month later, after a long car ride to Florida, she noticed a recurrence of left leg swelling along with left hip pain. Leg swelling occurred overnight extending from hip to ankle. No other symptoms. She was seen by her orthopedic surgeon. She had a duplex scan of left lower extremity that showed no DVT. A left hip x-ray showed Paget's disease like changes in left mid pelvis. She had progressive leg swelling with occasional mild abdominal discomfort since then. No leg pain, redness, fever, chills, sweats, weight loss, bowel or urinary symptoms or malaise. Three weeks later, her PCP noted extensive swelling of the left lower extremity from hip to ankle with no redness, warmth or tenderness. No skin discoloration or sensory loss. Capillary refill was normal. Abdominal exam was normal. Pelvic exam showed obliteration of left adnexa. CBC, CMP normal . LDH mildly elevated at 291 (110 - 210 U/L). CT scan abdomen / pelvis showed 7 cm pelvic mass with mixed sclerotic and lytic bone lesions in the pelvis and prominent iliac and inguinal lymphadenopathy. MRI Pelvis showed the lesion to be marrow replacing with extraosseous soft tissue extension surrounding the adjacent vessels. Core biopsy of mass demonstrated Grade 1 Follicular lymphoma. She completed 6 cycles of rituximab plus bendamustine with complete resolution of symptoms.

IMPACT/DISCUSSION: Differential diagnosis for chronic unilateral lower extremity edema are chronic venous disease, primary or secondary lymphedema, a pelvic neoplasm compromising pelvic outflow tract and complex regional pain syndrome. Many of these diagnoses can be suspected based on clinical features. Pelvic imaging should be done when cancer is suspected. Transvaginal ultrasound is the initial imaging test of choice If ovarian or endometrial cancer is suspected. Otherwise, a CT scan of the pelvis with contrast is preferred.

CONCLUSION: Pelvic neoplasm compromising pelvic outflow tract is an uncommon cause of unilateral lower extremity swelling. The most common cancers are ovarian cancer, endometrial cancer, bladder cancer, lymphoma, and prostate cancer. Rarely, benign lesions such as uterine fibroids or ovarian cysts can cause unilateral leg swelling.

ADRENAL ADENOMAS RUINING THE RENALS: A CASE OF HYPERALDOSTERONISM-INDUCED HYPERTENSION PRECIPITATING ESRD AND RENAL TRANSPLANTATION

Matthew L. Widlus, Sonali Rodrigues, Rebecca Andrews. Internal Medicine, UConn Health, Farmington, CT. (Control ID #4063446)

CASE: The patient is a 54-year-old male with past medical history of end-stage renal disease likely from hypertensive nephrosclerosis and hypertension who presented for endocrine evaluation. The patient was born in Taiwan, moved to the Dominican Republic in 1993, then migrated to the USA in 2015. He had not seen a physician in the USA until a hospitalization for fluid overload in 2018 when he was found to have impaired renal function requiring dialysis. He reported “kidney damage” since 2005. He was stabilized, dialyzed, and discharged with PCP follow-up. He underwent kidney transplantation in early 2020. He reported a standing history of hypertension for “as long as he can remember” requiring three agents (carvedilol 6.25mg twice daily, lisinopril 20mg twice daily, and amlodipine 5mg daily). Moreover, he had multiple episodes of hypokalemia requiring oral potassium replacement (40mEq thrice daily). On follow up he continued to be hypertensive and hypokalemic to 3.1 though asymptomatic. Family history was positive for hypertension in his maternal grandmother but in no first-degree relatives. He was noted to have a known adrenal adenoma, first identified in 2018, that was stable in size (2.0 cm) on repeat imaging in 2020. Testing revealed an aldosterone of 55ng/dL, low plasma renin activity at 0.87 ng/mL/h, elevated aldosterone:renin ratio of 63.2. Adrenal vein sampling showed lateralization to the left with a lateralization index of 111 pre-ACTH and 87 post-ACTH with suppression of the right adrenal gland. Given these findings, the patient underwent left adrenalectomy and adenoma removal. Pathology confirmed aldosterone-secreting adenoma.

IMPACT/DISCUSSION: Aldosterone-secreting adenomas are a rare but treatable cause of secondary hypertension, making up 15-25% of resistant hypertensive cases. The patient had hypertension for as long as he can remember, requiring three agents, without obesity or first-degree familial family history. Though the patient did not have many subjective findings, his persistent hypokalemia could have supported additional workup in conjunction with his resistant hypertension. With pathological evidence of hypertensive nephrosclerosis, prompt diagnosis of his secondary hypertension could likely have prevented this patient’s dialysis requirement and subsequent transplantation. Though the incidence of primary hyperaldosteronism ranges from 5-15%, retrospective analysis shows that hyperaldosteronism screening tools were only used in 2-3% of cases. Additionally, patients emigrating from other countries and those on long-standing treatment are often continued on the same regimen even if it is not the most appropriate, and without additional workup.

CONCLUSION: -Hyperaldosteronism is a treatable form of resistant hypertension often underdiagnosed.

-Patients on three anti-hypertensives with hypokalemia should garner high levels of suspicion for hyperaldosteronism.

-Missing hyperaldosteronism can cause significant end-organ damage including ESRD.

A FIRST REPORT OF FOODBORNE BOTULISM CAUSED BY TYPE C TOXIN WITHIN A FAMILY IN JAPAN

Michito Sadohara¹; Kosuke Honda¹; Taito Kitamura¹; Hiromichi Tanaka²; Hiroki Irie²; Kunihiko Matsui¹. ¹General Medicine and Primary Care, Kumamoto Daigaku Byoin, Kumamoto, Kumamoto, Japan; ²Emergency Medicine and Critical Care, Kumamoto Daigaku Byoin, Kumamoto, Kumamoto, Japan. (Control ID #4064325)

CASE: A family purchased easy-to-cook food with a vacuum-sealed package from a mass retailer and stored it at room temperature. The family cooked it with a microwave oven, and four family members consumed it for dinner despite it being past its expiration date. The next morning, the wife in her early 40s developed double vision, dysarthria, and limb weakness and was referred to our hospital. Her husband in his late 40s noticed blurred vision and mild difficulty speaking in the afternoon. These symptoms became obvious when he accompanied his wife for referral. Their respiratory status worsened in the ER, leading to admission to the ICU, intubation, and placement on ventilators. In addition to neurological findings, based on information about the food and the family cluster, foodborne botulism was considered. Both were administered botulinum antitoxin. Dilated pupils, autonomic nervous paresis such as sweating impairment, and decreased peristalsis became obvious after several days of admission. The wife developed non-occlusive mesenteric ischemia, underwent small bowel resection, and had a stoma placed during the course. Within weeks, their limb weakness and ileus-like condition showed improvement. About one month later, they were withdrawn from the ventilator and transferred to other hospitals for rehabilitation. Two asymptomatic sons (mid-teens and less than teens) were admitted for observation, and prophylactic doses of antitoxins were administered. The next day, they developed mild limb weakness and respiratory distress, requiring additional therapeutic doses. All children recovered gradually and were discharged without intensive care. Botulinum type C toxins were detected in the affected family’s feces and/or sera.

IMPACT/DISCUSSION: Foodborne Botulism presents life-threatening neurotoxic symptoms. While A, B, and E types are common pathogens in humans, botulism caused by type C toxin is rarely reported. Misidentification of vacuum-packed with retort-packed food and improper storage led to the massive production of toxin despite its low pathogenicity. The history of familial cluster and experience of a similar incident in Japan aided early suspicion. Although the diagnosis was challenging in the early stage, treatment involving antitoxin should be administered within 48 hours. Regardless of the amount of food intake, adults exhibited earlier, and more severe symptoms compared to children in these cases. Susceptibility to type C toxin may differ between adults and children.

CONCLUSION: We experienced the first cases of botulism caused by type C toxin. Acute polyneuropathy in a cluster outbreak with suspicion of food poisoning should prompt consideration of botulism.

A LIDDLE HYPOKALEMIA IN THE OUTPATIENT SETTING WARRANTS FURTHER WORKUP

Marissa Contento. Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #4063919)

CASE: A 44 year old man with hypertension presented to clinic to establish care. He was taking a calcium channel blocker (CCB) and an ACE inhibitor (ACEi) for ten years. Family history included hypertension in his mother and 6 siblings. In the office, he was hypertensive to 158/85 and asymptomatic. Exam was unremarkable. Labs showed hypokalemia to 3.4 meq/L. His ACEi dose was increased, and in the setting of hypokalemia and hypertension, we added on renin and aldosterone labs. Results showed aldosterone 3.7 mg/dL, renin 0.204 ng/mL/hr, with elevated aldosterone/renin ratio to 18.5. We planned to optimize blood pressure, correct hypokalemia, and then repeat labs.

Two months later, labs showed potassium 3.0 meq/L (despite higher dose of the ACEi), aldosterone 13.8 ng/dL, renin 0.266 ng/mL/hr, and aldosterone/renin ratio elevated to 51.9. He was prescribed oral potassium and referred to endocrinology/nephrology.

Further workup was done. CT abdomen and pelvis showed a 9mm left adrenal nodule, which did not meet imaging criteria for an adenoma. He performed a 3 day salt loading test (while off ACEi), showing 24 hour urinary aldosterone excretion at 10.28 mcg/24 hours, not consistent with primary hyperaldosteronism. Discontinued ACEi and CCB and started amiloride due to concern for Liddle Syndrome. Patient is now currently pending further workup for Cushing's Syndrome and genetic testing for familial glucocorticoid remediable aldosteronism and Liddle Syndrome.

IMPACT/DISCUSSION:

This case highlights the importance of evaluation of hypokalemia and hypertension. The differential includes primary hyperaldosteronism, hyperaldosteronism secondary to renovascular disease, Liddle Syndrome, Cushing Syndrome, and non-aldosterone mineralocorticoid excess (some types of congenital adrenal hyperplasia, adrenal tumors, chronic licorice ingestion, and rare genetic syndromes of apparent mineralocorticoid excess).

Physicians should also test for primary hyperaldosteronism in resistant hypertension, onset of hypertension at a young age, severe hypertension, and those with an adrenal incidentaloma and hypertension.

For the initial workup of primary hyperaldosteronism, test plasma aldosterone concentration (PAC) and plasma renin activity (or plasma renin concentration) (PRA) as a morning blood sample in a seated patient. If the PAC >/= 20, PRA <1 mg/mL/hr, and has spontaneous hypokalemia, it is likely primary aldosteronism. Of note, physicians can still test renin/aldosterone for primary aldosteronism in patients on ACEi/ARB, as it is unlikely to produce false-negative results in primary aldosteronism because of the autonomous aldosterone production.

CONCLUSION: Hypokalemia and hypertension in the outpatient setting warrants further workup.

For initial screening of primary hyperaldosteronism, collect aldosterone and renin, even if the patient is taking an ACEi/ARB.

A MYSTERIOUS CASE OF CHRONIC ABDOMINAL PAIN IN THE OUTPATIENT SETTING

Benita K. Glamour, Athanasia Vasiliadis. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4015065)

CASE: A 52-year old female with a past medical history of systemic lupus erythematosus (SLE) presented to an outpatient clinic with five years of abdominal pain, bloating, and diarrhea. The abdominal pain localizes to the right upper quadrant and epigastric region. It worsens with food but improves with gluten elimination. Associated symptoms include nausea, vomiting, postprandial fatigue and diaphoresis. She has a family history of ovarian and uterine cancer. She is a non-smoker with no substance use history. On physical exam, the patient is vitally stable. The abdomen is soft, non-tender, non-distended, and is negative for Murphy’s sign. Over the course of many visits, the patient completed a number of diagnostic studies and medication trials. Her labs were notable for leukopenia and thrombocytopenia secondary to her SLE. She had a mild elevation in liver enzymes attributed to supplements. Her EGD, colonoscopy, and gastric emptying studies were unremarkable. An abdominal ultrasound and MRI enterography were notable for small cysts at the dome of the liver. She was trialed on esomeprazole and amitriptyline without improvement. Her SLE was treated with plaquenil but she self discontinued it during this time and had no worsening of abdominal symptoms. She eventually underwent a CTA abdomen and pelvis which was remarkable for increased angulation of the superior aspect of the celiac axis at the origin, concerning for median arcuate ligament syndrome (MALS). A mesenteric duplex showed 70-99% stenosis of the celiac artery. She subsequently had a MALS release with improvement in her symptoms.

IMPACT/DISCUSSION: This case highlights the importance of maintaining a wide differential for chronic abdominal pain and working up uncommon causes. Chronic abdominal pain can be evaluated with a thorough history, blood work, EGD, colonoscopy, motility studies, and imaging. The differential includes peptic ulcer disease, malignancy, celiac disease, inflammatory bowel syndrome / disease, gastroparesis, SLE, hepatitis, and gallbladder disease. If the work-up is unrevealing, MALS should be considered. The median arcuate ligament bridges the diaphragmatic crura which can cause stenosis of the celiac artery or nerve plexus if the celiac artery originates above the diaphragm. Clinical manifestations include postprandial abdominal pain, weight loss, nausea and vomiting. The diagnosis can be made by cross-sectional imaging and should be confirmed with duplex ultrasound. Treatment involves surgical release of the celiac artery and removal of nerves that are compressed which is effective in 60-80% of cases. Recurrence of symptoms can be resolved with nerve block, bypass or angioplasty.

CONCLUSION: MALS is an uncommon cause of chronic abdominal pain that should be considered after an extensive work-up for abdominal pain has been completed. MALS is diagnosed with cross-sectional imaging and duplex ultrasound and is treated with celiac artery decompression.

ANGIOTENSIN RECEPTOR BLOCKER ASSOCIATED ENTEROPATHY

Taylor Doolan¹; Narinder Maheshwari². ¹School of Medicine, University of Connecticut School of Medicine, Farmington, CT; ²Internal Medicine, UConn Health, Farmington, CT. (Control ID #4063732)

CASE: This is a 66-year-old female with a past medical history of anemia, arthritis, cataracts, HLD, HTN, obesity, osteoarthritis, vertigo, prediabetes, uterine leiomyoma, and alopecia who presented with 15 months of diarrhea, bloating, cramping, and weakness. She did not have any unintentional weight loss, nausea, emesis, fever, hematochezia, melena, or reduced appetite. She had no personal or family history of gastrointestinal problems or malignancies. The patient is a current smoker and alcohol consumer. Her medication list included Olmesartan, Zolpidem, Amlodipine, Flonase, Hydrochlorothiazide, Simvastatin, Cetirizine, fish oil, multivitamin, and Acetaminophen.

The patient’s work up, including CBC and chemistries, did not reveal any significant abnormalities. The patient did have elevated LDL cholesterol. The patient had unremarkable celiac serologies, stool cultures, stool ova and parasite concentration and smear, calprotectin, electrolytes, albumin, and pancreatic elastase. The patient was referred for endoscopy and colonoscopy with biopsies of small intestine, colon, duodenum, and stomach, all of which were unremarkable with no epithelial abnormalities. During this time the patient was started on a proton pump inhibitor and a dairy free diet. Both interventions provided minimal symptomatic relief. The patient stopped taking Olmesartan, and her symptoms improved within a few weeks.

IMPACT/DISCUSSION: ARB-associated enteropathy is an adverse effect that has only recently been established. There is a growing body of evidence to support this relationship, but this association still needs to be better understood. There is variation in the clinical presentation, but these patients often present with symptoms that closely resemble celiac disease. However, these patients usually have negative celiac serologies and do not respond to dietary modifications, such as a gluten free diet. Our patient began to experience symptoms approximately two years after she started taking Olmesartan. Her symptoms were consistent with ARB-associated enteropathy, including abdominal pain and bloating, diarrhea, and fatigue. Her labs did not show hypoalbuminemia or electrolyte abnormalities, and GI biopsies were normal. Typical histological or laboratory findings of ARB-associated enteropathy include villous atrophy, collagenous thickening of the epithelium, hypoalbuminemia, etc. She also had unremarkable celiac serologies, infectious serologies, and did not respond to dietary changes. While her work up did not reflect the typical pattern seen in ARB-associated enteropathy, the patient presents with similar symptoms, an unremarkable work up, and symptom resolution with discontinuation of Olmesartan.

CONCLUSION: There is a growing body of research highlighting ARB-associated enteropathy, but it is still not widely recognized or understood. Providers should be cognizant of this potential, though rare, adverse effect and include it on their differential for patient’s presenting with appropriate symptoms.

AN ITSY BITSY FINDING OF ESTROGEN EXCESS IN A TRANSGENDER FEMALE

Jennifer A. Woodard²; Brian C. Hilgeman¹. ¹General medicine, Medical College of Wisconsin, Milwaukee, WI; ²Geriatrics and Palliative Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4062194)

CASE: A 44 year old transgender female with treated Hepatitis C, alcohol use disorder in remission, and compensated, Child-pugh class A cirrhosis presented to the outpatient clinic for worsening of red spots on her chest. She had been engaged in Gender Affirming Hormone Therapy (GAHT) for the previous 2 years utilizing transdermal estrogen at 0.1mg per 24 hr and oral spironolactone 50 mg BID. She noticed a gradual increase in secondary female characteristics and improvement in gender dysphoria while on therapy without worsening of her underlying synthetic liver function.

On presentation, she noted an increase in the spots when she doubled her dose of transdermal estrogen for increased breast tissue development. She denied any ongoing alcohol, substance use or other medication changes. Exam identified numerous blanchable erythematous lesions with central demarcation and small outward extensions 1 to 2 cm in size on her upper chest. She had no other stigmata or laboratory findings of decompensated liver disease. She had an elevated estradiol (122) and estrone level (46).

She discontinued all hormone therapy due to concerns over her liver function. Three months following discontinuation, her red spots were improved but not completely resolved.

These lesions were diagnosed as spider angiomas.

IMPACT/DISCUSSION: While there are some existing guidelines that guide GAHT, they are based more on experience, professional opinion, and previous research completed on cisgender, post-menopausal women. Transdermal, intramuscular, or sublingual administration of synthetic estradiol compared to oral therapy is thought to carry lower risk of venous thromboembolism and hepatic injury by bypassing hepatic first-pass metabolism, but this evidence is mainly anecdotal.

Multiple spider angiomas are highly specific for chronic liver disease related to alterations in sex hormone metabolism in patients with cirrhosis due to elevation of estrone related to increased peripheral conversion. In patients receiving exogenous hormone therapy, estradiol is directly administered and does not undergo peripheral conversion but also contributes to spider angiomata development at higher doses. While cirrhosis has not been studied in GAHT, her underlying liver disease in combination with her up-titration of estrogen likely contributed to the clinical sign of hyperestrogenism as spider angiomas.

CONCLUSION: Caring for transgender women with cirrhosis presents a unique therapeutic challenge to prescribe gender affirming hormone therapy while not putting the patient at undue risk of complications. More research is needed to understand this unique situation and how to safely care for this group of individuals.

ANKYLOSING SPONDYLITIS AS A CAUSE OF PERIPHERAL ARTHRITIS IN A YOUNG TRANSGENDER FEMALE

Nathaniel Adams, Chelsea Pearson. Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #4056351)

CASE: JA is a 25 y/o transgender F on gender-affirming therapy with anxiety presents to primary care clinic for joint pain. She complains of 1.5 years of joint pains, starting in her L great toe, progressing to include: R great toe, bilateral ankles, hand PIP joints, and shoulders. The pain is dull/sore with stiffness and swelling. It occurs in morning and improves with exercise. Pain is exacerbated by stress. She notes chronic fatigue, dry eyes/mouth. ROS is otherwise negative.

She had bilateral orchiectomy 4 years prior. Her grandmother has RA. No tobacco use, no alcohol use. She is sexually active with 1 male partner.

Meds: escitalopram, vitamin D, progesterone, estradiol valerate IV

Exam: Left 1^st MTP with swelling, erythema, and tenderness. Mild synovitis appreciated. Right hand DIPs/PIPs with pain to palpation without swelling, erythema or synovitis. Right ankle with mild swelling and tenderness to palpation. No other joint findings. Otherwise normal.

Diagnostic Studies:

Labs: Normal CMP, CBC. ESR 8, CRP 3.8. RF and CCP negative. ANA positive 1:160. DsDNA and ENA panel negative. Normal complement, UPCR, uric acid. GCCT, HIV, Hep panel, RPR negative.

Imaging: Foot xrays: Erosions in 1^st metatarsal head.

Hand and ankle xrays: normal.

After her office visit and initial workup above, she was started on daily NSAID and referred to Rheumatology for further evaluation. Before that visit, she developed back pain and stiffness. SI/lumbar spine xray ordered showed: Moderate bilateral sacroiliitis; enthesitis/spondylitis throughout lumbar spine. She was diagnosed with ankylosing spondylitis (AS) with peripheral and axial involvement and started on MTX and Humira with improvement in her symptoms.

IMPACT/DISCUSSION: Here we have a young woman complaining of years of progressively worsening polyarticular joint pains. Initial differential diagnoses considered included seronegative RA, axial vs peripheral spondyloarthritis (e.g., psoriatic, reactive, IBD-arthritis), SLE, crystalline arthritis. Despite a family history of RA, she exhibits both DIP and PIP involvement bilaterally with lower extremity arthralgias which is atypical in RA. Exam, labs and imaging point towards an inflammatory process, but did not point to a final diagnosis. Ultimately, the development of low back pain and subsequent imaging help to clinch the final diagnosis of AS with axial/peripheral involvement.

This case demonstrates the diagnostic challenge of new undifferentiated inflammatory arthritis. Her diagnosis was made ~2 years after symptom onset, owing to atypical presentation. Her age, biological sex at birth and lower extremity-predominant arthralgias subtly point towards a diagnosis of AS. Given her characteristics, lumbar and SI joint imaging should have been considered as a part of her initial workup.

CONCLUSION: - Inflammatory arthritis poses a diagnostic challenge that requires a broad differential to properly diagnose.

- SI joint imaging should be considered in intial workup of inflammatory arthritis in select patients.

ANOMALOUS SYSTEMIC ARTERIAL SUPPLY TO THE BASAL SEGMENTS OF THE LEFT LOWER LOBE: A COMPREHENSIVE CASE REPORT

Karlen Ulubabyan¹; Gregory Petersen¹; Michael Tadonio³; Ruth Abeles^2,1. ¹Internal Medicine, University of California San Diego, Clairemont, CA; ²Medicine, University of California San Diego, La Jolla, CA; ³Interventional Radiology, University of California, San Diego, San Diego, CA. (Control ID #4064435)

CASE: After undergoing a CT for evaluation of abdominal pain, a 35 year old male with a history of lifelong exercise limitation was incidentally found to have 1.4 cm anomalous artery originating from the distal descending thoracic aorta supplying the majority of the left lower lobe of the lung. The patient was referred to Cardiology, Cardiothoracic Surgery and Interventional Radiology and additional testing was performed. V/Q scan demonstrated intact ventilation of the affected lung, ruling out pulmonary sequestration. Echocardiogram which demonstrated intact left and right ventricular function, notably without evidence of pulmonary hypertension.

After consideration of risks and benefits of the more invasive option of surgical arterial ligation and ipsilateral lobectomy, the decision was made to proceed with endovascular embolization of the anomalous artery. The patient underwent two staged endovascular embolizations of the distal anomalous arteries, with a plan for a final staged embolization to achieve complete cessation of anomalous blood flow.

IMPACT/DISCUSSION: Anomalous systemic arterial supply to the basal segments of the left lower lobe (ABLL) represents a rare vascular anomaly with implications for cardiovascular health. This condition involves an abnormal blood vessel arrangement, where a systemic artery, often arising from the descending thoracic aorta, provides blood directly to a specific portion of the lung. The aberrant supply of blood from systemic to pulmonary circulation effectively results in a chronic left-to-right shunt and may result in pulmonary hypertension, heart failure, and/or rupture of the aberrant artery. Symptoms are varied, and may include hemoptysis, exercise intolerance, decreased functional capacity.

The diagnostic approach often involves advanced imaging techniques such as computed tomography or magnetic resonance angiography. Ventilation/ perfusion scintigraphy is often performed to rule out pulmonary sequestration, a related anatomic abnormality in which the airways of the affected lung do not communicate with the rest of the tracheobronchial tree. Echocardiogram, and in rare cases, cardiac catheterization, is also performed to assess cardiac function.

The management of ABLL is individualized and typically requires a multidisciplinary approach that considers a balance between the potential benefits and risks. The options for treatment include observation, medical therapy to manage cardiac sequelae, and surgical resection of the anomalous artery with concurrent ipsilateral lobectomy. An alternative approach of endovascular embolization of the anomalous arterial supply may be performed in certain cases.

CONCLUSION: ABLL is rare anatomic variant that elevates risk of cardiovascular complications without early intervention.

Endovascular embolization offers a minimally invasive alternative to the conventional approach of surgical resection of the anomalous artery and affected lung.

AN UNEXPECTED TURN: INCIDENTALLY FOUND ANOMALOUS AORTIC ORIGIN OF A CORONARY ARTERY

Carl Hashem²; Amanda Fernandes¹. ¹Cardiology, Boston Medical Center, Boston, MA; ²Internal Medicine, Boston Medical Center, Boston, MA. (Control ID #4043432)

CASE: 49-year-old male with HTN, HLD, DM, tobacco use presented to the emergency room with subacute atypical chest pain. Serial ECGs were non-ischemic and serial high sensitivity troponin assays were within normal limits. Physical exam was notable for reproducible chest pain on palpation. Given patient’s cardiac risk factors, coronary CT angiography (CCTA) was performed for risk stratification. CCTA demonstrated a coronary artery calcium score of 0, and an anomalous origin of the right coronary artery (RCA), which subtended the left coronary artery (LCA) and subsequently ran an interarterial (malignant) course between the pulmonary artery and aorta. The findings were determined to be incidental and unrelated to his presentation. He underwent an outpatient exercise echocardiogram stress test which did not produce symptoms or inferior ischemia. He is closely followed by his Cardiologist.

IMPACT/DISCUSSION: CCTA has emerged as an increasingly common tool that can be used in the evaluation of chest pain in certain intermediate risk patients, and provides anatomic information previously not obtained from functional stress testing. Anomalous aortic origin of a coronary artery (AAOCA) is a form of congenital heart disease, and is the second leading cause of sudden cardiac death (SCD) in youth, but its significance and management in adults is less understood. Current guidelines recommend surgery for all patients with anomalous origin of the LCA regardless of symptoms due to risk of SCD. Similarly, surgical repair is recommended for anomalous origin of the RCA with symptoms (anginal pain, aborted SCD, syncope due to ventricular arrhythmia). Management of asymptomatic RCA anomalies are less defined. Exercise stress testing combined with nuclear perfusion or echocardiographic imaging can be pursued to assess for potential ischemic burden of the anatomic variant. Those without symptoms, ischemia during stress testing, or ventricular arrhythmia can be continually monitored or referred for surgical intervention. Certain morphologies such as an intramural or interarterial course, or acute angle changes are considered higher risk and may warrant earlier surgical referral, although data is limited.

CONCLUSION: Coronary CT angiography is an important diagnostic tool in the evaluation of chest pain in select patient populations. Its increasing use will likely lead to an increase in incidental findings, including AAOCA. It is important for clinicians to identify its significance and stratify those who would most likely benefit from surgical referral.

AAOCA involving the left coronary artery should be referred for surgical intervention regardless of symptoms due to high risk of sudden cardiac death. While symptomatic AAOCA involving the right coronary artery warrants surgical intervention, asymptomatic anomalies of the right coronary artery can be risk stratified with stress testing and cardiac monitoring to aid in the decision for surgical referral.

AN UNRELENTING ITCH: PRURIGO NODULARIS IN A PATIENT WITH TYPE 2 DIABETES

Alice Zhao, Helene Strauss, Peggy B. Leung. Internal Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY. (Control ID #4060761)

CASE: Ms. G, a 50-year-old Black woman with a notable past medical history of T2DM, presented to the clinic with diffuse pruritis.

At her initial clinic visit, she endorsed 2 weeks of pruritis on her back. The pruritis affected her daily functioning. She denied any constitutional symptoms, use of new products, or home infestations. Hyperpigmented papules with areas of central keratosis were observed on her upper back. She was prescribed triamcinolone 0.1% cream and referred to dermatology.

3 months later, she presented with continued intense pruritis. The topical triamcinolone was insufficient in relieving her symptoms. She found the lesions, which had increased in number, very disfiguring. Due to the long waitlist to see dermatology, an e-consult to dermatology was ordered. Based on images uploaded to the patient’s EMR, a diagnosis of prurigo nodularis was made the next day by dermatology. The patient was advised to escalate to clobetasol 0.025% cream and to follow-up with dermatology.

IMPACT/DISCUSSION: Prurigo nodularis (PN) is a chronic dermatologic condition that affects approximately 90,000 patients in the U.S. each year. The intense pruritis associated with the condition can cause patients significant distress. The pathogenesis of PN is still unknown, although research suggests involvement of both immune and neural dysregulation. PN is more common in patients with T2DM, CKD, chronic liver disease, and HIV infection. Of note, PN is also more common in Black patients, especially Black women.

PN is generally a clinical diagnosis. Importantly, PN in Black patients can present with larger and more hyperpigmented lesions compared to white patients. Hyperpigmentation lasting months to years is also more common in Black patients.

Treatment is targeted at relieving pruritis to allow the skin to heal. Initial treatment for PN can be addressed in the primary care setting. Topical steroid creams as well as oral antiepileptics and antidepressants such as gabapentin and amitriptyline have been shown to relieve pruritis.

Of note, the patient’s care was greatly expedited by the use of the e-consult system. E-consults can prove useful in outpatient settings where specialist input is needed on an urgent basis, especially when a thorough history and basic laboratory data/imaging have already been completed by the primary care physician.

CONCLUSION: Prurigo nodularis (PN) is a clinical diagnosis that can be managed with topical steroids, gabapentin, and amitriptyline.

PN in Black patients can present with more severe lesions that can cause patients increased distress.

E-consults to specialists can improve delivery of care to patients by expediting diagnosis and treatment.

AN UNUSUAL CASE OF PRESEPTAL CELLULITIS TRIGGERED BY RESIDUAL DENTAL ABSCESS

Wajiha Kazmi, Anne Chen, Jennifer Verbsky. Internal Medicine, Northwell Health, New Hyde Park, NY. (Control ID #4065035)

CASE: A 70-year-old woman had a gum abscess drained and was prescribed amoxicillin. At the same time, she also saw a dermatologist for a forehead papule that was biopsied and prescribed topical fluorouracil. Within a few days, she developed a low-grade fever and progressive facial swelling near her ears. She presented to an urgent care for evaluation, had a positive rapid strep test and was prescribed amoxicillin and then cefdinir after developing worsening lymphadenopathy and an erythematous rash on her forehead. She then presented to our clinic with chills and progressive bilateral eyelid edema, continued forehead erythema and preauricular and cervical lymphadenopathy. There was no sore throat and no limitation in extraocular movements. Skin was notable for right upper forehead erythema with mild desquamation. Labs were significant for EBV serologies suggestive of reactivation. Differential diagnosis included incomplete antibiotic coverage of a dental abscess that progressed to preseptal cellulitis versus EBV reactivation with associated rash from antibiotic use. Less likely were antibiotic induced rash given lack of morbilliform or maculopapular nature often associated with this kind of rash. As a result, she was treated as preseptal cellulitis, and antibiotics were changed to clindamycin with improvement in her facial erythema, eyelid edema and lymphadenopathy.

IMPACT/DISCUSSION: Seeing different providers made it challenging to determine whether the presentation was due to initiating antibiotics in a patient with EBV, an allergic reaction to fluorouracil, or a delayed diagnosis of preseptal cellulitis from an oral source. The appearance of the rash and the timing of fever prior to the initiation of antibiotics made an allergic reaction to the fluorouracil cream or antibiotic rash less likely. Cases of preseptal and orbital cellulitis have been reported in association with dental abscesses, although this remains a rarer cause. If she had proptosis or ophthalmoplegia, there would be concern for orbital cellulitis, necessitating intravenous antibiotics and surgical evaluation. As a result, it was important to recognize the possible diagnosis of preseptal cellulitis and empirically treat. In our case, with the initiation of the appropriate antibiotics to cover staphylococcus aureus (including methicillin resistant strains) and streptococci, she began to recover.

CONCLUSION: For patients presenting with fever, chills, facial erythema and edema, preseptal cellulitis is high on the differential. These patients should be monitored closely and treated. Although not as commonly seen as sinusitis, oral abscesses are a possible source. Antibiotics treated EBV versus cellulitis can be distinguished by rash type (morbilliform and maculopapular for EBV associated antibiotics) and timing of other symptoms. When treating preseptal cellulitis from an oral source, penicillin derivatives are first-line antibiotics, but if symptoms do not improve, it is important to broaden coverage.

APL-IT'S AN EMERGENCY!

Ian Lorang. Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4062120)

CASE: A 51 year old patient, with limited medical history of depression and obesity presented for three weeks of dyspnea on exertion and fatigue. Prior to this, they were in their normal state of health. Patient had been taking Ozempic for 7 months and lost 40lbs. They switched to Mounjaro around symptom onset and Prozac was the only other prescription medication. Initial laboratory work up revealed severe pancytopenia: hemoglobin 3.8, platelets 11 and white blood cell count (WBC) of 0.3. Also notable was a severely low reticulocyte count, elevated total bilirubin with a normal direct bilirubin, and a negative Direct Antiglobin test. Patient was transfused red blood cells and platelets, then admitted for additional work up.

Within 24 hours of admission, bone marrow biopsy was obtained showing many blasts and promyeloctes packed with aur rods. These results raised suspicion for Acute Promyelocytic Leukemia (APL). Patient was started on All-trans Retinoic Acid (ATRA) emergently. With in 48 hours Promyelocytic leukemia-Retinoic Acid Receptor Alph-Fluorescence in situ hybridization (PML-RARA FISH) resulted positive and arsenic trioxide (ATO) was initiated. Their hospital course was complicated by a subarachnoid hemorrhage (SAH) that did not require surgery. They were monitored for DIC and prophylactically treated for neutropenia and tumor lysis syndrome. At the time of writing, Patient is still hospitalized on the hematology service and is showing improvement.

IMPACT/DISCUSSION: APL is estimated at 600-800 case incidences per year in the United States, qualifying it as rare, but the key teaching point is that this is a true medical emergency and rapid initiation of treatment can be the difference in life or death. Fatigue is a common complaint general interests encounter, but APL should be one of the "can't miss diagnoses" on the differential. Clues could be increased body mass index and age greater than 60. A CBC and peripheral smear are common tests interests order frequently and aid in rapid diagnoses.

Rapid diagnoses led to prompt initiation of ATRA and addition of ATO. This is key because the Spanish PETHEMA trial revealed that patients with APL and WBC counts less than ten thousand have improved survival outcomes when receiving combo therapy early in the disease course. This case helps support this literature as the patients WBC was under ten thousand and received the directed therapy within 48 hours of admission.

Distractors are constant in every case. This patient had a 40lb weight loss over 7 months which normally raises suspicion for malignancy, but use of Mounjaro made it less clear. Also, it's vital to respect the suddenness that APL can present with as seen in this case with the patient's symptom onset only weeks prior.

CONCLUSION: -APL is a true medical emergency and can present acutely

-Rapid diagnoses and initation of ATRA and ATO can be the difference in death within months of diagnoses vs prolonged life

-Simple, routine tests can reveal important clues to expedite work up

A RARE CASE OF MALARIA PERCARDITIS IN A PATIENT WITH RECENT TRAVEL TO AN ENDEMIC REGION.

Muhammad Abdullah²; Christine Park¹; Min Pu¹. ¹Cardiology, Montefiore Health System, Bronx, NY; ²Albert Einstein College of Medicine, Bronx, NY. (Control ID #4062238)

CASE: A 34 year old woman with a history of Hepatitis B and epilepsy presented to the emergency department with 1 week of generalized body aches, headaches, and chills. She began to have one day of substernal chest pain that worsened while supine and improved when sitting up. Further history revealed she returned from the Ivory Coast two weeks prior to presentation but did not take malaria prophylaxis.

Initial vitals revealed a fever to 100.5*F, tachycardia to the 110s, and blood pressure ranging from 90/60 to 125/81. Physical exam was unremarkable except for tachycardia and tender abdomen. Her electrocardiogram (ECG) revealed sinus tachycardia with ST-elevations in AVR, V1-2, and diffuse ST depressions in the remaining leads. Laboratory tests were notable for two negative Troponins I (<0.01 ng/mL), thrombocytopenia to 60,000 k/uL, a white blood count to 8.3 k/uL. Her CRP was elevated to 15.8 mg/dL and ESR was 20 mm/h. A transthoracic echocardiogram (TTE) which was unremarkable. Infectious diseases was consulted and additional microbial testing revealed a positive malaria antigen test. She was started on IV fluids, colchicine and ibuprofen, and artemether/lumefantrine upon recommendation from cardiology and infectious diseases respectively. She reported rapid resolution of symptoms, and was discharged with outpatient specialty follow-ups.

IMPACT/DISCUSSION: Acute pericarditis is an inflammatory process involving the pericardial sac leading to sharp, pleuritic, parasternal chest pain, a pericardial friction rub, and an EKG characteristic of diffuse ST segment elevations and PR segment depressions. The etiology of pericarditis includes both infectious and non-infectious causes. The European Society of Cardiology (ESC) states that the diagnosis of acute pericarditis must have at least 2 of the 4 following criteria: 1) pericarditic chest pain, 2) new widespread ST elevations or PR depressions on ECG, 3) pericardial friction rub on exam, or 4) pericardial effusion. Further supportive findings include elevations of inflammatory markers on imaging. Most patients are treated empirically with nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine, however immunosuppressive agents pericardiectomy are options.

CONCLUSION: Our patient is a 34-year-old woman who had recently traveled to the Ivory Coast, who did not take malaria prophylaxis. Returning to the United States, she had headache, fever, and pleuritic chest pain. ECG was remarkable for ST-elevations in AVR, V1-2, and marked ST-depressions in the remaining leads, as opposed to the diffuse ST-elevations classically seen in pericarditis. She had elevated CRP, however, a pericardial friction rub was not auscultated, and the initial TTE was unremarkable.

The patient fulfilled only one out of the four criteria put forth by the ESC. The patient was empirically started on colchicine and Ibuprofen, which led to rapid resolution of her symptoms making acute pericarditis the most likely etiology of her presentation.

A RARE CASE OF YELLOW NAIL SYNDROME

Tebianne Abubaker, Gavin Truong. General Internal Medicine, George Washington University Medical Faculty Associates, Washington, DC. (Control ID #4062205)

CASE: A 41-year-old man with history of asthma presented with 6 months of bilateral lower extremity swelling. Vitals were unremarkable. Physical exam showed 3+ pitting edema of bilateral lower extremities and xanthonychia of bilateral first digits. Bloodwork showed a transaminitis, thrombocytopenia, and anemia that all resolved with repeat labs a month later; spot protein/creatinine ratio was unremarkable. Duplex lower extremity dopplers, right upper quadrant ultrasound, and echocardiogram were all normal. Toenail biopsy was performed that ruled out onychomycosis, and he was ultimately diagnosed with yellow nail syndrome.

IMPACT/DISCUSSION: Yellow Nail Syndrome (YNS) is a rare syndrome that typically presents with slow-growing yellow dystrophic nails, lymphedema (80% of cases), and pulmonary abnormalities (36% of cases). It is commonly observed in adults over the age of 50. In addition to yellow nails, either lymphedema or pulmonary involvement is required to make the diagnosis. YNS is a diagnosis of exclusion, therefore a work-up to exclude liver, kidney, vascular, and cardiac involvement resulting in the lower extremity edema must be completed first. Chest X-ray should be obtained when respiratory symptoms are present to order to visualize effusions or infiltrates. Toenail biopsy can also be considered to rule out fungal pathogens. Once common etiologies are ruled out, a diagnosis YNS should be considered.

The etiology of YNS is unknown but is thought to be associated with immunodeficiency syndromes, rheumatoid arthritis, and certain malignancies. No proven explanation for the fluid accumulation in YNS has been documented, but it is theorized that microangiopathy and increased microvascular filtration of the pleura, liver, and limbs secondary to alterations in interstitial matrix could explain the lymphatic abnormalities observed.

Given its rare etiology, definite treatment for YNS have not been well studied. Review of case reports and review articles focus on symptomatic treatment of symptoms, such as thoracentesis for pleural effusion, antibiotics for bronchiectasia exacerbations, compression wraps or complete decongestive therapy for the lymphedema, and vitamin E and fluconazole for the dystrophic yellow nails. It is unclear how YNS affects long-term prognosis; therefore more robust research is needed to be understand the syndrome.

CONCLUSION: YNS is a rare disorder that presents with the triad of yellow dystrophic nails, pulmonary manifestations, and lymphedema. It is important to recognize the work up required for YNS to exclude other etiologies of the presenting symptoms. Currently, the cornerstone of treatment for YNS is symptomatic care of the involved organ systems. Given its potential relationship to immunodeficiencies, rheumatoid arthritis, and malignancy, more robust studies are needed to better understand the prognosis of YNS and benefits of early recognition and treatment.

A RARE CASE REPORT OF RENAL INSUFFICIENCY SECONDARY TO FIBRILLARY GLOMERULONEPHRITIS

Chinnawat Arayangkool¹; Christie Izutsu². ¹Internal Medicine, University of Hawai'i System, Honolulu, HI; ²Nephrology, University of Hawai'i System, Honolulu, HI. (Control ID #4063875)

CASE: A 71-year-old female with a remote history of follicular thyroid carcinoma status post thyroid lobectomy who presented to the nephrology clinic because of hematuria. The patient had a 10-year history of hematuria previously evaluated by urology. Past investigations included cystoscopy, revealing unremarkable results. She denied family history of renal cancer, autoimmune disease. Vitals were within normal limits. Physical examination was unremarkable. Laboratory findings indicated BUN of 16 mg/dL, creatinine of 0.7 mg/dL, eGFR 93 ml/min/ 1.73 m2, while cystatin C 1.30 mg/L, eGFR by cystatin C 49 ml/min/ 1.73 m2. Urinalysis demonstrated protein 3+ and RBC 6-20. UPCR 2793.5 mg/g. The patient tested positive for ANA but negative for anti-dsDNA, ANCA, complements, HCV, HBV, SPEP, and UPEP. Renal ultrasound showed no remarkable findings. Persistent proteinuria and hematuria led to an ultrasound-guided renal biopsy. IF staining revealed positive IgG (3+), C3 (3+), kappa (2+), and lambda light chains (3+), while EM indicated altered glomerular basement membranes due to fine fibrillary changes. Immunohistochemistry for SAA was negative, and Congo red staining confirmed the absence of amyloid. Liquid chromatography-tandem mass spectrometry performed on microdissected glomeruli from paraffin-embedded blocks showed abundant spectra corresponding to DNAJB9, confirming the diagnosis of fibrillary glomerulonephritis.

IMPACT/DISCUSSION: FGN is a rare condition, accounting for only 0.12 to 0.6% of native kidney biopsies, yet its complex underlying causes remain elusive. It predominantly affects females in their fifth to sixth decades. Most cases of FGN are linked with hepatitis C infection, autoimmune diseases, and various malignancies. The condition typically manifests as nephritic or nephrotic syndrome and more than half experience hypertension. Unfortunately, the prognosis is bleak, with over 90% facing poor renal outcomes, often progressing to ESRD within 24 to 44 months, although a small fraction might undergo spontaneous remission. Diagnosis involves identifying distinct noncongophilic fibrils, irregularly arranged and sized between 12 and 24 nm in glomeruli through EM. The discovery of DNAJB9 revolutionized FGN diagnosis, providing impressive sensitivity and specificity as the new diagnostic standard. However, treatment lacks standardized protocols; it mainly involves managing proteinuria with ACEI or ARBs, regulating blood pressure, a low-sodium diet, and weight management. While evidence supporting the effectiveness of immunosuppression in improving renal outcomes remains inconclusive, rituximab has been the most studied and may potentially delay disease progression. Notably, post-transplantation, FGN recurrence rates stand at 21%, necessitating diligent monitoring and specialized management.

CONCLUSION: - For patients with unclear causes of renal insufficiency, a renal biopsy is warranted.

- Despite its rarity, FGN should be considered as a potential cause of renal insufficiency.

A RARE ENCOUNTER- TESTICULAR CANCER DISGUISED IN A NECK MASS

Aleena Shah¹; Alisha Maity²; Eseoghene Kevu¹. ¹Internal Medicine, Lankenau Medical Center, Wynnewood, PA; ²Hematology/Medical Oncology, Lankenau Medical Center, Wynnewood, PA. (Control ID #4065059)

CASE: This is the case of a 45 year old male with a past medical history of coronary artery disease and hypercholesterolemia. During a visit with his PCP, an X ray of the lumbar spine was ordered for subacute back pain which was found to be normal. A subsequent MRI showed multilevel degenerative changes, disc protrusion at L3-L4, and unexpectedly, masslike retroperitoneal and left iliac chain lymphadenopathy, concerning for lymphoma.

The patient was then referred to oncology; at this time he endorsed ongoing back pain associated with mild weight loss and night sweats in the preceding few months. Physical exam was notable for a 5 cm non-tender mass on the right testicle as well as a supraclavicular neck mass. Pertinent lab findings included an hCG of 126, LDH of 357, and a normal AFP. CT of the chest, abdomen and pelvis demonstrated extensive lymphadenopathy involving the left neck, posterior mediastinum and retroperitoneum, as well as prominent bilateral inguinal lymph nodes. Additionally, a right testicular mass was seen. A biopsy of the neck mass resulted positive for malignant cells: metastatic germ cell tumor, consistent with seminoma.

The patient then underwent a right orchiectomy. Pathology was consistent with seminoma with focal extension into the epididymal soft tissue and lymphovascular invasion. He was initiated on adjuvant chemotherapy with bleomycin, etoposide, and cisplatin. After three cycles administered over a 9-week period, a surveillance PET scan showed no significant activity.

IMPACT/DISCUSSION: This case serves to illustrate an example of an atypical presentation of testicular cancer. It is important to recognize manifestations of extra-gonadal spread, particularly of seminomas to uncommon sites including the neck, as exemplified in this scenario. Other locations include, but are not limited to, the mediastinum which may present as dyspnea and/or cough, retroduodenal metastasis which can precipitate nausea, vomiting and GI hemorrhage, and skeletal metastasis leading to bone pain. Nevertheless, prognosis remains fairly good even with distant spread as is the case with stage III disease, portending a 73% 5-year survival rate, according to the American Cancer Society.

CONCLUSION: Germ cell tumors in the context of testicular cancer can largely be grouped into two categories: seminomas and non-seminomas. Seminomas comprise the vast majority histopathological diagnoses and carry an excellent prognosis, particularly with early recognition. Though the presenting symptom is typically a testicular mass, rarely patients can present with symptoms due to metastatic spread, most commonly to intra-abdominal and retroperitoneal lymph nodes, although various other sites are also possible as discussed in this case report.

A TREATMENT DILLEMMA: CASE OF RECURRENT HELICOBACTER PYLORI INFECTION IN ANTIBIOTIC RESISTANT HMONG POPULATION

Mariam Alamgir, Gursimran S. Grewal. Internal Medicine, Washington State University, Pullman, WA. (Control ID #4065126)

CASE: A 37-year-old Hmong female with history of acid reflux presented to ED with acute episodes of hematochezia with significant drop in hemoglobin requiring transfusion. Next day, endoscopy revealed mild erosions in the gastric antrum with pathology suggestive of chronic active gastritis in the setting of H. pylori with mild B cell infiltrate without dysplasia or metaplasia. Colonoscopy showed a rectal ulcer. History revealed she recently immigrated from China and belonged to the Hmong tribe and was previously treated for H.pylori infection with unknown medications. She was discharged home on quadruple therapy consisting of PPI, doxycycline, bismuth subsalicylate, and metronidazole (PBMT). Three months after completion of therapy, stool H.pylori antigen test was positive. She was then treated with PPI, amoxicillin, Levofloxacin (PAL). Two months after completion of therapy, repeat stool H.pylori antigen test was positive again. After failing two rounds of antibiotics, she was treated with PBMT with high dosage PPI and metronidazole with confirmed eradication of H.pylori on stool testing and antral biopsies. Given findings of B cell infiltrates, colonoscopy was repeated in one year and was negative for malignancy or mucosa-associated lymphoid tissue lymphoma (MALToma).

IMPACT/DISCUSSION: Globally, H pylori infection affects almost half of the world population leading to chronic gastritis, peptic ulcer disease (PUD), and gastric malignancies or MALToma. The Hmong mountain people in East Asia have high degrees of resistance to antibiotics. Most notably, resistance to metronidazole has been shown to be as high as 70%, fluoroquinolone is up to 27%, and multidrug resistance is 31%. The high rates of resistance is explained by the high frequency of infection in these groups due to lack of socioeconomic support including poor sanitation and contaminated water supply. This case underscores the importance of tailored interventions. Given the high levels of resistance found to metronidazole, alternative therapies including high dose tetracyclines or amoxicillin may be better suited in these populations. Other third line agents such as quinolones can also be considered when H. pylori infection is not eradicated after multiple trials at therapy. Initiating early alternative treatment regimens in the management of these populations at high risk for standard treatment failure should be strongly considered to prevent further complications.

CONCLUSION: As H.pylori cases are increasing in the United States, clinicians should be aware that H. pylori resistance rates to metronidazole and fluoroquinolone are variable geographically but highest in Hmong populations. Our case illustrates recurrent treatment failures of H. pylori leading to use of alternative therapy and surveillance of MALToma. We share this in hopes that it raises awareness about H.pylori treatment resistance in light of increasing cases.

BALANOPOSTHITIS AS A RARE SIDE EFFECT OF SGLT2I THERAPY

Tori Chee. Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4064206)

CASE: A 66-year-old cis-gendered male with a BMI 41 with a history of HTN, HLD, lower extremity lymphedema and diabetes on metformin 1000mg twice daily and Glipizide 5mg once a day with HgbA1c increased from 6.8 to 7.8 over 8 months despite changes in diet and exercise who presented for routine follow-up. Two weeks after addition of Empaglifozin, the patient reported being awakened from sleep with penile swelling, pain, pruritis, and erythema of the prepuce with inability to retract the prepuce. The patient reported no systemic signs of infection, urethral discharge, or dysuria. Minimal relief was achieved with ice and antibiotic cream. The physical exam was significant for an uncircumcised male with swollen glans penis and excess prepuce with fissures without discharge. Empaglifozin was discontinued and the patient was treated with cephalexin and topical clotrimazole. On follow-up, the patient reported the erythema, pain, and pruritis resolved quickly but swelling and phimosis did not fully resolve until 3 months after cessation of therapy.

IMPACT/DISCUSSION: SGLT2 inhibitors have been proven to have benefits morbidity and mortality benefits with multi-organ improvement in function after initiation of therapy. They most notably decrease morbidity/mortality & cardiovascular hospitalizations in both heart failure and chronic kidney disease.

Diabetes has comorbid risk of asymptomatic bacteriuria (ASB), UTI’s, vulvovaginal infections and balanitis. The most common causes are E. Coli, K. Pneumoniae, and Candida spp. Sodium-glucose cotransporters 1 and 2 are located in the proximal renal tubule with SGLT2 being responsible for 90% of glucose re-uptake and SGLT1 for the remaining 10%. Competitive binding at SGLT2 sites causes glucosuria ranging from 20g-80g per day - creating an environment for bacterial and fungal growth.

Balanoposthitis is rare but can lead to phimosis and recurrent GU infections. Proposed mechanisms identified in persons with vaginal epithelium may be applicable to individuals at risk of balanoposthitis: (1) altered immune function with decreased urinary IL-8/IL-6 (2) improved adherence of E. Coli with type I fimbrae to the uroepithelium on glycosylated uroplapkins (3) increased virulence of C. albicans in glucose-rich environments. Risk of balanoposthitis is most likely from retained urine and smegma between the prepuce and the glans penis. Genital infections within the first month of therapy were associated with discontinuation of SGLT2i therapy.

CONCLUSION: To prevent GU infections and treatment discontinuation:

1) Obtain a history of prior GU infection.

2) Education on proper perineal and GU hygiene.

BIOSTATISTICS TO THE RESCUE: AVOIDING A RED HERRING IN A COMMON PRESENTATION OF GENERALIZED LYMPHADENOPATHY

Alexander B. Karol, Kenneth M. Fifer. Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4056232)

CASE: A 60-year-old man with a past medical history of dilated cardiomyopathy presented to the clinic due to six months of progressive generalized lymphadenopathy. He had similar symptoms 15 years prior, and states he had Non-Hodgkin's lymphoma but elected to not pursue treatment and his symptoms resolved. He has never had constitutional symptoms. Review of systems was notable for dry cough and nasal congestion for two weeks. He has not traveled outside the United States and works in landscaping. He self-identifies as Black and has no significant family or other personal medical history and takes no significant medications. Physical exam was notable for non-tender, firm, bilateral 2.5 centimeter cervical and left inguinal lymphadenopathy. Laboratory studies were significant for white blood cell count of 4,100 υ/L with 11% eosinophils. A computed tomography (CT) scan of the neck and a full body positron emission tomography (PET)/CT scan showed extensive bilateral cervical, axillary, inguinal, and mediastinal lymph node enlargement with hypermetabolic lesions in bone, lung, and colon and complete opacification of left maxillary sinus. A left cervical lymph node excisional biopsy was performed and a left maxillary sinus fungal ball was removed during the biopsy, with morphologic features consistent with aspergillosis. Flow cytometry had no evidence of malignancy. Pathology from the biopsy had non-caseating, non-necrotizing granulomas. He was diagnosed with sarcoidosis.

IMPACT/DISCUSSION: This patient has a common presentation of an uncommon disease (27,000 new domestic cases per year) that was confounded by anchoring bias from a self-reported prior diagnosis. To reduce anchoring bias, internists must consider pre-test probabilities, the performance of selected medical testing, and the diagnostic criteria for the underlying diseases on the differential diagnosis. In this case the patient had an elevated pre-test probability since there are positive associations between sarcoidosis and both agricultural occupations and Black individuals. He also had an elevated positive likelihood ratio for sarcoidosis during his workup since mediastinal lymphadenopathy occurs in ~90% of affected patients and aspergillosis is a common complication of advanced sarcoidosis (and may play a role in its etiology). This patient thus warranted a biopsy, since sarcoidosis is a clinical diagnosis of exclusion supported by characteristic clinical and or radiographic findings and a biopsy with noncaseating granulomas.

CONCLUSION:

1. When evaluating new generalized lymphadenopathy in the absence of a histopathologic diagnosis, likelihood ratios, pre-test probabilities, and clinical diagnostic criteria can mitigate anchoring bias.

2. Aspergillosis is a common complication of advanced sarcoidosis and should prompt a clinical-radiographic evaluation for sarcoidosis.

BLISTERS IN THE SUN

Rachna Talluri, Kelly White. Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4065038)

CASE: A 20 year old female developed a painful red rash on her hand. The rash progressed over 1-2 days, developing blisters, bullae, and sharply demarcated areas of redness. The patient denied any history of a similar rash, or exposure to poison ivy or other plants or toxins. The patient denied any systemic symptoms. Past medical history was significant for acne, and she was taking Accutane (isotretinoin) for this. She was not taking any other medications, herbs, or supplements. Patient denies drug use and reports occasional alcohol use. She is a college student in NYC and had recently spent the weekend in Long Island with her girlfriend and denied any other recent travel. The physical exam was remarkable for a red rash on the dorsum of her left hand with large fluid-filled blisters. A bandage was applied to the area and the patient was instructed to look for signs of infection and use NSAIDs for pain control. Upon further questioning, it was revealed that she had been helping in a restaurant by squeezing hundreds of limes. She subsequently walked to the beach and was outdoors for a couple of hours the day before the rash appeared. Based on this history, the patient was diagnosed with photodermatitis due to a mixture of lime juice on her hands followed by sun exposure.

IMPACT/DISCUSSION: Multiple plants can cause photodermatitis, all of which include furocoumarins. The furocoumarins alone are inactive but can induce a photodermatitis reaction after exposure to UVA radiation. Limes are a common cause of photodermatitis, as the juice of limes is often used in many drinks and limes are often squeezed by hand, such as in this case. The typical presentation of this photodermatitis is sharply demarcated red lines where the skin was exposed to the toxin, with overlying bullae and edema. The lesions are not itchy but may be painful and can clinically present similar to a burn. These lesions typically appear 24 hours after exposure to the toxin. When the lesions clear, they are replaced by hyperpigmentation which can last months to a year.

CONCLUSION: It is important to recognize the many types of photodermatitis. May patients may present with a painful rash of unclear etiology. A detailed history and observant physical exam may help the astute internist uncover the diagnosis. Education to avoid future lesions and appropriate treatment can ensure a proper diagnosis.

CAN A NECK SWELLING BE GIANT CELL ARTERITIS ?

Mridula Sree Naagendran¹; Sara Halili³; Saira Cherian². ¹Internal Medicine, UConn Health, Farmington, CT; ²Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; ³UConn Health, Farmington, CT. (Control ID #4058560)

CASE: 64 yr. woman presented with bilateral swelling under the chin. It started as headaches, progressed to swelling, and eye puffiness. Initially treated as sinusitis with amoxicillin with no improvement. After this, she started experiencing fevers, chills, sweating, myalgias, 5 lb. weight loss, and decreased appetite. Physical exam revealed tenderness over bilateral TMJs, restriction in opening mouth and generalized swelling bilaterally underneath the jaw L>R. ESR, CRP were elevated. Lyme antibodies, non-Malaria Parasite Smear, RMSF IgG and IgM, Tick-Borne Disease Panel, Infectious mono screen, and HIV combo antigen/antibody were negative. US neck soft tissue was nonspecific, possibly suggesting reactive or inflammatory change. Patient later presented to the ED with diplopia lasting 10 to 15 seconds. Neurological exam was positive for scalp tenderness and the head MRI showed no acute findings. Subsequent testing for Acetylcholine (AChR) antibody, Bartonella, Toxoplasma IgG, Syphilis EIA, ANA, C3, C4, ENA, urine protein/ creatinine, ANCA/MPO/PR3 were negative. A chest CT was obtained to evaluate for lung opacities, and it showed no evidence for intrathoracic sarcoidosis. Given high suspicion of Giant Cell Arteritis, was treated with steroids with gradual clinical improvement in symptoms and gradual decrease in ESR. She did not undergo biopsy to confirm GCA she had improvement with prednisone.

IMPACT/DISCUSSION: Occurring in only 6.5 % of cases (1), face and neck swelling is less common, and may appear subtly in giant cell arteritis. Giant cell arteritis affects large and medium-sized vessels, including aorta and branches of the external carotid arteries. Histologically, characterized by a granulomatous process causing elastic laminae destruction and adventitial fibrosis.Neck swelling in GCA usually started as waxing, waning pattern due to facial artery spasm and collateralization. The raised inflammatory markers may cause clinicians to suspect infection initially. The vagueness in less common GCA symptoms may result in a delayed diagnosis of GCA, eventually leading to irreversible vision loss. In a review by Friedman (2), 13 of 58 biopsy proven GCA patients with facial swelling, developed visual disturbance. This study concluded that the perception of face enlargement could be a sign of impending visual disruption.

References:

1. Liozon E, Ouattara B, Portal MF, et al. Head-And-Neck swelling: an under-recognized feature of giant cell arteritis. A report of 37 patients. Clin Exp Rheumatol 2006;24:20–5

2.Friedman G, Friedman B. The sensation of facial swelling in temporal arteritis: a predictor for the development of visual disturbance. Postgrad Med J 1986;62:1019-20.

CONCLUSION: Uncommon symptoms include face and neck swelling, trismus, cough, voice changes, sore throat, dysphagia, hearing loss and tongue claudication.

Suspecting GCA early in differentials in elderly with uncommon symptoms and treated with steroids to prevent vision loss

CARDIOGENIC EDEMA PRESENTED AS UNILATERAL BREAST SWELLING

Alexander J. Nagourney, Mohammed I. Alsaud, Laura Bock. Internal Medicine, Mount Sinai Morningside Hospital, New York, NY. (Control ID #4063931)

CASE: This case involves an 85-year-old female with a past medical history of cirrhosis due to hepatitis C, primary sclerosing cholangitis, anemia, chronic kidney disease, and heart failure who presented with acute changes to her left breast. Over the last month she noticed a gradual enlargement of the breast, with progressive skin changes and mild tenderness to palpation. She denied any recent changes in medication. No personal or family history of breast cancer. Her last mammogram was in 2014. Physical exam revealed a left breast that was significantly larger than the right breast. She had skin dimpling and a general firmness to palpation. There was no palpable mass or lymphadenopathy. The exam also showed mild lower extremity edema. Labs showed normal electrolytes and albumin, her kidney and liver function were at her baseline. Given the rapid onset of swelling and appearance of the breast there was concern for breast cancer and the patient was sent for breast imaging. Breast ultrasound revealed left sided skin and parenchymal thickening consistent with cardiogenic edema. Patient was started on torsemide with rapid resolution of the asymmetric swelling.

IMPACT/DISCUSSION: Invasive breast cancer is one of the most commonly diagnosed cancers in the United States with an annual incidence of 297,000. Cardiogenic edema leading to unilateral breast swelling is exceedingly rare but has been described in a case report. The unilateral breast edema in our patient mimicked inflammatory breast carcinoma. Due to the rapid progression and peau d’orange cutaneous changes, it was challenging to overlook the possibility of malignancy. After her ultrasound revealed signs of fluid overload and the torsemide resulted in resolution of symptoms, it was confirmed that the patient’s presentation was cardiogenic. Given the patient had no significant signs of heart failure exacerbation other than breast swelling and mild lower extremity edema, a cardiogenic cause was not immediately obvious. Her breast swelling seemed out of proportion to the fluid status of the rest of her body however it quickly improved with a diuretic. In hindsight, considering a diuretic while the patient awaited imaging would have resulted in faster resolution of symptoms as well as alleviated the patient's discomfort and anxiety regarding the symptoms. In counseling patients with newfound breast abnormalities, it is important to quickly rule out malignancy while not overlooking other possible explanations.

CONCLUSION: This case highlights the importance of obtaining a complete workup before proceeding with invasive procedures.

This case provides insight into the diverse signs and symptoms of cardiogenic edema which allows for the rapid and effective management of this atypical presentation.

CASE REPORT OF A YOUNG MALE PATIENT WITH CHRONIC HEMATURIA

Nausheen Singh, Kelsey B. Bryant. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4064966)

CASE: A 24 year old male patient presented to the primary care clinic to establish care as a new patient. He had moved to the United States from Mauritania a few months prior. He had no significant past medical history but endorsed that he had been having intermittent gross hematuria for the last three years along with intermittent body aches and subjective fevers. He had sought medical attention for this in Mauritania but had not been worked up further or initiated any treatment. He did not take any medications and had no history of alcohol, tobacco, cocaine, or intravenous drug use.

The patient originally presented to urgent care one month prior to being seen in clinic. His chief concerns at that time were fever and body aches. STI testing was negative. He was treated for chlamydia empirically. Lab results were significant for eosinophilia. When the patient was seen in clinic, his urinalysis was significant for red blood cells. Schistosoma antibody testing was sent which came back positive. He completed treatment with praziquantel, dosed 40 mg/kg in two divided doses for one day.

IMPACT/DISCUSSION: Over 200 million people worldwide are affected by schistosomiasis. The three major species are S. Haematobium (Africa, Middle East), S. Mansoni (Africa, South America), and S. Japonicum (East Asia). Typically, S. Haematobium causes infection in the genitourinary tract while S. Japonicum and S. Mansoni affect the intestinal tract.

Schistosomiasis is transmitted through contact with fresh water and infection is typically acquired by swimming in impacted lakes or rivers. Travelers to endemic areas often present with acute infection while individuals living in endemic regions tend to have chronic infection given ongoing exposure.

Genitourinary schistosomiasis generally presents with painless hematuria. In younger patients, the disease may be confused with other common causes of hematuria such as sexually transmitted infections or urinary tract infections. There is significant morbidity associated with untreated schistosomiasis. Clinical disease is caused by the body’s immune response to schistosome eggs. The migrating eggs in the genitourinary tract cause granulomatous inflammation and even ulcers. Longstanding infection has been associated with the development of bladder cancer, infertility, and kidney failure.

Schistosomiasis is a very treatable illness and requires only one day of treatment with praziquantel. However, it can be a difficult diagnosis to make and requires detailed history taking and a broad differential.

CONCLUSION: - Diagnosis of schistosomiasis requires thorough history taking and clinicians should be cautious of anchoring bias, especially in young patients

- Schistosomiasis is a highly treatable illness with significant complications and mortality if left undiagnosed and untreated

CAUSAL OR CONSEQUENTIAL: POORLY CONTROLLED TYPE II DIABETES IN A 72-YEAR-OLD MAN FOUND TO HAVE PANCREATIC ADENOCARCINOMA

Lillian Hallmark¹; Susan B. Glick². ¹Medical College, Rush University Rush Medical College, Chicago, IL; ²Internal Medicine, Rush Medical College, Chicago, IL. (Control ID #4057895)

CASE: A 72-year-old man with a history of type 2 diabetes (DM2) on insulin, HTN, HLD, and nephrolithiasis s/p lithotripsy, presented to his PCP for left upper quadrant pain that radiated across his upper abdomen and awoke him from sleep the night prior. He noted dull abdominal pain for six months that worsened when supine and 16 lbs of unintentional weight loss. He denied loss of appetite, nausea, vomiting, bowel changes, melena, polyuria, polydipsia, heartburn, chest pain, or shortness of breath.

His DM2 diagnosis came 6 years prior (age 66) following an ER visit for polydipsia and polyuria where he had hyperglycemia (400 mg/dL), an anion gap of 22 mEq/L, urine ketones, and isolated leukocytosis (14K). Initial A1c was 10.8%, prompting metformin initiation and lifestyle modification. However, in the past two years his A1c relapsed to 10.3% with increasingly labile blood sugars despite escalating doses of metformin, sitagliptan, dulaglutide and insulin.

Hematology previously suggested the leukocytosis to be benign vs related to diabetes.

Medications included insulin glargine, sitagliptan, metformin, atorvastatin, losartan and potassium.

Family history included DM, HTN and bladder cancer in his father and HTN with multiple strokes in his mother.

Socially, the patient endorsed occasional cigar use (< 1/wk) and 3-4 alcoholic drinks per week.

On physical exam, he appeared well without acute distress. BP 142/74, pulse 77, respirations 16, temp 98F and BMI 25.5. Lungs were clear bilaterally and cardiac exam revealed regular rate and rhythm, normal S1/S2, no murmurs. Abdomen was soft, non-tender, and non-distended without organomegaly or palpable mass. Extremities were non-edematous with 2+ distal pulses.

Labs showed leukocytosis unchanged from prior. CT abdomen revealed a hypo-enhancing lesion in the pancreatic body/tail encasing the splenic vasculature with at least 6 lesions in the right hepatic lobe concerning for hepatic metastasis. Biopsy revealed well-differentiated adenocarcinoma of the pancreas. The patient was referred to oncology and started on FOLFIRINOX chemotherapy for stage IV pancreatic cancer (PaC).

IMPACT/DISCUSSION: This patient’s refractory diabetes despite medication adjustment raises the question of whether DM2 is a risk factor or a manifestation of PaC. 80-85% of patients are hyperglycemic in the pre-symptomatic phase of PaC, with diabetes presenting 2-3 years prior to unintentional weight loss, abdominal pain, or malaise. Patients over age 50 diagnosed with new onset diabetes are considered higher risk of having PaC than the general population. Other risk factors for PaC include a family history of PaC, smoking, age, and obesity.

CONCLUSION: Continued research is required to identify screening biomarkers for PaC in high-risk individuals with diabetes, hyperglycemia or insulin resistance. Physicians can recognize patients at higher risk for PaC by onset of diabetes over age 50, family history, labile blood sugars despite medication adjustment and unintentional weight loss.

CHAGAS AND THE BROKEN HEART SAGAS - CARDIOMYOPATHY SECONDARY TO CHRONIC CHAGAS DISEASE

Effie Mathew. Internal Medicine, Boston Medical Center, Boston, MA. (Control ID #4064813)

CASE: A 45 year old male with a history of hypertension (HTN) presented to the emergency department for 2 months of gradually worsening lower extremity edema, orthopnea, and dyspnea on exertion. The patient was originally from El Salvador and immigrated to the USA 20 years ago. He reported rare alcohol intake (<1 beer per month), with no other drugs. He had no family history of sudden cardiac death or premature ASCVD. He took losartan 50mg daily for HTN.

Physical exam was significant for tachycardia, abdominal distension, and 2+ bilateral lower extremity edema. Labs showed BNP elevation to 1700 and stable Hs-troponin elevation (14 to 15). ECG showed tachycardia with no ST-segment changes. Chest x-ray showed pulmonary vascular congestion. TTE demonstrated a dilated left ventricle, reduced LVEF of 15% with diffuse global hypokinesis and grade 3 diastolic dysfunction. The patient was admitted to the hospital for aggressive diuresis, resulting in 10kg weight loss and reported improvement in his symptoms by the time of discharge.

As part of the patient’s work up for new-onset heart failure, TSH was within normal limits and HIV testing was negative. Left heart catheterization showed no evidence of coronary artery disease. Sleep study was non-concerning for obstructive sleep apnea. Given patient’s country of origin, T. cruzi IgG antibody was sent and resulted positive. Secondary confirmatory testing by the CDC was also positive.

IMPACT/DISCUSSION: Chronic Chagas disease (CCD) is a cause of non-ischemic cardiomyopathy. Its pathogenic agent, T. cruzi, is a parasite endemic to Central and South America, and infects humans through vector bite wounds. CCD is diagnostically confirmed by identifying IgG antibodies to T.cruzi by both ELISA and IFA; one single test is not sufficient in specificity for confirmatory diagnosis. Benznidazole is first-line therapy because of its better side effect profile, in comparison to nifurtimox. However, the decision on therapy for patients with cardiac manifestations depends on severity of heart failure; patients with ACC Stage C or D heart failure, as in this clinical vignette, have not been shown to benefit from treatment. Screening for T. cruzi infection should be considered in patients from endemic areas; appropriate treatment for patients in the indeterminant phase of disease – between acute and chronic manifestations– prevents cardiac and gastrointestinal complications.

CONCLUSION: In select patient populations, CCD should be recognized as a cause of non-ischemic cardiomyopathy. Treatment at late-stage manifestations of the disease has not shown clinical benefit; therefore, screening programs for patients from endemic areas should be considered and implemented on a larger scale in relevant communities.

CHANGING TREATMENT PARADIGMS RAISE THE STAKES FOR EARLY DIAGNOSIS OF T1DM

Neil A. Rana¹; Debra S. Leizman². ¹School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; ²medicine, University Hospitals, Cleveland, OH. (Control ID #4060748)

CASE: A 24-year-old male presented with 5 days of progressive xerostomia, polydipsia, polyuria, and fatigue. He denied any recent illness and was not taking any medications. Past medical history was notable for GERD with concern for eosinophilic esophagitis during childhood, allergic rhinitis, and childhood eczema. His family history was notable for type 2 diabetes in both paternal grandparents, and social history was noncontributory. Labs revealed metabolic acidosis (pH 7.30) with an elevated serum glucose (409) and beta-hydroxybutyrate (7.86). He was diagnosed with diabetic ketoacidosis and responded well to fluids and insulin. Further studies showed an elevated HbA1c (11.6), low C-peptide (0.4), and triple antibody positivity (islet antigen-2, anti-GAD, zinc transporter 8) indicative of new-onset type 1 diabetes. Further questioning revealed the patient had an elevated fasting glucose (125) and prediabetes-range HbA1c (6.3) on routine screening at a primary care visit 9 months ago. Although he had a BMI of 24.07, ate a balanced diet, and was physically active, he was counseled on dietary modifications and weight loss at the time. He achieved 10 lb of intentional weight loss with repeat testing 4 months later showing a fasting glucose of 97; however, HbA1c, while improved, remained in the prediabetes range (5.9). He received no further testing in the ensuing 5 months before presenting with DKA.

IMPACT/DISCUSSION: This case highlights the importance of maintaining a high index of suspicion for type 1 diabetes in patients presenting with new dysglycemia that lack the traditional risk factors for insulin resistance. To date, type 1 diabetes is predominantly diagnosed after symptoms of hyperglycemia become apparent (i.e. DKA), as in this case. However, the disease is preceded by two asymptomatic phases: in stage 1, disease-specific autoantibodies develop followed by the development of dysglycemia in stage 2. In this case, although the patient had a significant family history, he otherwise lacked the traditional factors of type 2 diabetes like age, obesity, and physical inactivity. Further investigation with the first signs of dysglycemia in the outpatient setting would likely have shown antibody positivity consistent with stage 2 of type 1 diabetes. Identifying patients at this stage has newfound clinical implications in the wake of FDA approval of teplizumab in November 2022, a drug that delays onset of stage 3 (symptomatic) type 1 diabetes by months to years.

CONCLUSION: Internists should maintain a high level of suspicion for type 1 diabetes when evaluating patients presenting with new dysglycemia. Given the cumulative morbidity over time with type 1 diabetes, identifying patients in the preclinical stages and delaying disease onset with appropriate use of teplizumab are paramount to improved outcomes.

CHECKPOINT FOR CHOLANGITIS: A RARE CASE OF IMMUNOTHERAPY-RELATED CHOLANGIOPATHY IN BRCA POSITIVE BREAST CANCER

Sanjna Rajput¹; Mariya Pogorelova². ¹Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4044704)

CASE: A 63-year-old female, BRCA1 positive with history of right sided triple negative invasive ductal carcinoma (IDC), s/p lumpectomy and adjuvant radiation with local recurrent triple negative IDC, PDL1 testing >70% presented with significant elevation of alkaline phosphatase (ALP). She had been on pembrolizumab for 17 months as part of her cancer treatment therapy. Patient experienced abdominal pain, nausea, vomiting, and loss of 25 lb. ALP was initially elevated to 215, peaking eventually at 1719 with mainly liver fraction, and transaminases were moderately elevated with peak at 142 ALT and 115 AST. Abdominal ultrasound was unrevealing, CTAP showed irregular areas of biliary dilatation, MRCP showed intra and extrahepatic ductal dilation with stricture of the distal CBD. EUS liver biopsy showed chronic portal inflammation and bile ductular proliferation, lymphocytic cholangitis, bile duct injury and patchy pericellular, periportal and focal bridge fibrosis. Cytology, FISH and biliary biopsy was negative. Given cholestatic pattern, imaging and histopathology findings, immune checkpoint inhibitor (ICI) toxicity was suspected, patient was started on prednisone 80 mg with improvement of transaminitis and ALP.

IMPACT/DISCUSSION: ICIs are monoclonal antibodies that target inhibitory receptors on T cells and have shown improved patient survival in advanced tumors. Hepatotoxicity is seen in 0-30% of ICI patients, including the more common hepatitis and less common cholangitis. Cholangiopathy has a more gradual onset with dominant elevation in ALP relative to transaminases. A cholestatic liver injury pattern should trigger further imaging and NCCN recommends consulting oncology and hepatology. Large-duct cholangitis/secondary sclerosing cholangitis with findings of CBD dilation, stenosis, and wall thickening is seen with higher ALP and later onset time as compared to small duct cholangitis with findings of portal inflammation, bile duct injury and ductular reaction. MRCP elucidates biliary tree anatomy and ductal changes. It is important to differentiate between large-duct cholangitis and autoimmune cholangitis which have similar imaging findings. Onset of ICI cholangitis varies greatly, studies reporting timeline between 1 week to 2 years, and onset of ICI hepatitis is typically more acute. Immunosuppression therapy of primarily steroids is the mainstay of therapy to improve LFT elevation, however minority of cases are expected to completely normalize. ICI cholangitis is found to be more resistant to immunosuppression therapy than hepatitis.

CONCLUSION: Clinicians should consider ICI cholangiopathy in patients with ICI use and gradual development of cholestatic pattern of liver enzymes. It should be differentiated from autoimmune cholangitis and malignancy via labs, imaging and pathology. Recommended treatment is steroids, although resolution may be slow and incomplete. Early identification of ICI toxicity is essential, NCCN recommends involvement of oncologist and liver specialist.

CHEST PAIN: EXCLUDING THE WORST, NOT MISSING THE DIAGNOSIS

Mishael Khan, Swati Shroff. Internal Medicine, Jefferson Health, Wayne, PA. (Control ID #4063959)

CASE: A 60-year-old woman with a history of prediabetes, hyperlipidemia, and remote smoking history,presents to primary care with left shoulder soreness and sharp chest pain. Five days prior, she experienced left shoulder soreness prior to going to bed. She woke up the next morning and immediately developed sharp, substernal, severe chest pain which lasted 30 seconds. The chest pain is not associated with dizziness, diaphoresis, nausea, exertion, or shortness of breath. She cannot identify any triggers or associated factors. Medical history included prediabetes (last HgbA1c 5.8), hyperlipidemia (last LDL 108), and she is overweight (BMI 27.3). She has a 20 pack-year smoking history and quit 28 years ago. She does not take any medications. In clinic, she is hemodynamically stable and not experiencing symptoms. Her cardiovascular, pulmonary, and musculoskeletal exams are within normal limits. ECG shows normal sinus rhythm with a left bundle branch block; there are no prior ECG available for comparison. Troponin ordered in clinic is < 6ng/L. Transthoracic Echocardiogram shows an EF of 55% without segmental wall motion abnormalities. Nuclear stress test reveals a moderate anteroseptal apical infarct with peri-infarct ischemia in the left ventricle.

IMPACT/DISCUSSION: The ECG and stress test results concerning for coronary artery disease (CAD), the transient nature of her chest pain and lack of association with exertion were not consistent with typical anginal chest pain. The left bundle branch block and stresss test findings were concerning for ischemia. After vasospasm was diagnosed in this patient, Cardiology attributed the ECG and stress test findings to age related conduction system disease and the area of ischemia on nuclear stress test was thought to be a false positive result given the lack of wall motion abnormalities on echocardiogram. Distinguishing coronary vasospasm from CAD is challenging. Both can manifest as chest tightness, squeezing ,and pressure. Distinguishing features that should raise suspicion for vasospasm include symptoms that occur late at night and in the early morning and at rest rather than with exertion. While ECGs may show ST elevations or depressions during active vasospastic episodes, they are often normal between episodes. A diagnosis of coronary vasospasm requires chest pain to be nitrate-responsive with at least one of the followings: rest angina, reduced exercise tolerance in the morning, symptoms triggered by hyperventillation, and episodes suppressed by calcium channel blockers. Treatment includes calcium channel blockers and long-acting nitroglycering to prevent vasoconstriction.

CONCLUSION: Cardiology is consulted and starts aspirin 81mg and a high intensity statin. Left heart catheterization is performed and shows 60% stenosis of the LAD which improves to 20% post nitroglycerin, consistent with coronary artery vasospasm. Cardiology starts the patient on Imdur 30 mg daily, and she has not experienced any recurrence of chest pain.

CHRONIC TOPHACEOUS GOUT AND MICROCYTIC ANEMIA: IS HEMOGLOBIN H THE MISSING LINK?

Shreena Kamlesh Gandhi¹; Samvid Kotia²; Timothy Shaver¹. ¹Internal Medicine, The University of Kansas School of Medicine Wichita, Wichita, KS; ²Diagnostic Radiology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India. (Control ID #4064546)

CASE: We present the case of a 60-year-old Asian male of Vietnamese heritage who visited the clinic due to chronic tophaceous gout.

Upon discussing his medical history, he mentioned experiencing gout episodes and tophi formation since a young age but had not previously undergone a comprehensive evaluation for triggers. His past medical records indicated hypertension and anemia. He denied having obesity, hyperlipidemia, diabetes, chronic kidney disease, a red meat-heavy diet, or excessive alcohol consumption. He was started on allopurinol for hyperuricemia. His labs and imaging studies were otherwise at baseline.

The persistent microcytic anemia on follow-up visits raised suspicion of an underlying hemoglobin disorder since he had had negative screening colonoscopies and failed to respond to oral iron supplements. Hemoglobin electrophoresis confirmed the presence of hemoglobin H. The patient and his family were informed about the diagnosis. Family members were advised to undergo testing, and if positive, to begin early urate-lowering therapy.

IMPACT/DISCUSSION: Hemoglobin H [HbH] represents a rare variant of alpha thalassemia, a genetic disorder that stems from reduced production of alpha globin chains, disrupting the balance required to form normal hemoglobin molecules. This imbalance leads to the formation of unstable HbH molecules, resulting in hemolysis and moderate to severe microcytic hypochromic anemia. It's more prevalent among individuals of Southeast Asian, Middle Eastern, and Mediterranean descent, estimated at a birth prevalence of 1/14,000 among southeastern ethnicities in the USA.

Individuals with these genetic hemolytic anemias frequently present chronic hyperuricemia leading to tophi formation. This is likely due to heightened cellular turnover, changes in purine metabolism, and renal dysfunction associated with these conditions. Though a clear link remains elusive, reported instances with Syracuse hemoglobinopathy and sickle cell disease hint at such an association. Our case stands as the first report connecting HbH with tophaceous gout.

Recognizing this association is vital, necessitating a proactive approach in testing for hemoglobinopathies among patients presenting with tophi, gout flares, and microcytic anemia. This suspicion should be high among individuals of Southeast Asian heritage. Early intervention based on this knowledge can prevent joint damage and deformity from tophi.

CONCLUSION: Consider hemoglobinopathies in the assessment of patients experiencing repetitive gout flares or chronic tophaceous deposits alongside an underlying chronic microcytic anemia unresponsive to iron therapy.

Suspicion should be high in patients of Southeast Asian heritage.

Early uric acid lowering therapy initiation can prevent tissue damage resulting from tophi.

CUTANEOUS COCCIDIOIDOMYCOSIS PRESENTING AS FACIAL RASH

Nicole Remmert¹; Sivateja Pati¹; Hannah Chaudhury¹; Pranav Ganta²; Pablo Feuillet³; Barath Rangaswamy⁴. ¹Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²Harvard College, Cambridge, MA; ³Infectious Disease, MCH ProCare, Odessa, TX; ⁴internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX. (Control ID #4064382)

CASE: Patient is a 38-year-old man with obesity, who was referred to infectious disease (ID) due to a cutaneous coccidioidomycosis infection of his face. The patient initially presented to his PCP with symptoms of fatigue, knee pain, and a facial rash for a couple months. Initial treatment involved a course of oral antibiotics, yielding no improvement. Subsequently, the patient sought evaluation at a dermatologist's office for multiple lesions on his face and scalp. Another round of oral antibiotics and topical mupirocin ointment were prescribed. The lesions were biopsied, and a culture was obtained that resulted positivity for Coccidioides immitis. He was then referred to ID consultant. Physical exam revealed a scaling erythematous rash located on the right malar cheek, forehead and scalp. Vitals were stable. A chest CT was positive for multiple pulmonary nodules consistent with a history of coccidioidomycosis infection. Lab results revealed a cocci IgM 1.2, IgG 8.8, and an antibody by complement fixation of 1:128. The patient was started on oral fluconazole 200 mg daily, then increased to 400 mg daily. Patient started having improvement of his skin lesions. Due to his body mass index, the dosage had to be increased to 400 mg twice daily which he tolerated.

IMPACT/DISCUSSION: Coccidioidomycosis is a fungal infection caused by the inhalation of Coccidioides immitis spores that are found in areas of dry desert soil. The geographic predominance of cocci is largely throughout the Southwestern United States with a large prevalence in Arizona and California. After inhalation of the spores, the infection can spread hematogenously or through the lymphatics of any organ. Due to this, the clinical presentation of coccidioidomycosis can vary greatly. A large portion of those infected will be asymptomatic or have a mild respiratory illness and others will develop a progressive pulmonary infection or extrapulmonary dissemination. The most common extrapulmonary areas of dissemination include skin, lymph nodes, bones, joints and the central nervous system. Cutaneous lesions can present as ulcers, papules, nodules and pustules. Owing to this diversity, there is a propensity for misdiagnosis and subsequent inappropriate treatment, often misconstruing them as bacterial cellulitis, atopic dermatitis, tinea corporis etc. Diagnosing cutaneous cocci includes biopsy of the lesion which can show spherules within muti-nucleated giant cells, and/or culturing the lesion. Fluconazole can be used for mild to moderate diseases, while liposomal amphotericin B plus a triazole antifungal is indicated in severe or refractory cases.

CONCLUSION: We report an unusual presentation of cutaneous coccidioidomycosis as facial rash. Clinicians, especially in endemic areas, should be aware of the differing presentations of Coccidioides infections. A thorough understanding of the diagnostic workup and management avoids diagnostic delays and mismanagement.

DECEPTIVE DIABETES: AUTOIMMUNE HEMOLYTIC ANEMIA MASQUERADING AS IMPROVED GLYCEMIC CONTROL

Moyan Sun, Vikas Kilaru, Abijha Boban, James Murphey. Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #4058016)

CASE: A 72-year-old man with a history of type 2 diabetes mellitus (T2DM) and alopecia areata is evaluated in the emergency department (ED) for two weeks of exertional lightheadedness and dyspnea. In the preceding three months, his glycated hemoglobin (HbA1c) fell from 4.2% to undetectable levels, but his morning fasting glucose consistently ranged between 150 to 175 mg/dL. This dissonant finding prompted further outpatient work-up, which revealed new-onset anemia with hemoglobin of 10.4 g/dL, total bilirubin of 4.0 mg/dL, and undetectable haptoglobin. Due to concern for hemolytic anemia, he was referred to hematology but required emergent evaluation after the development of his lightheadedness and dyspnea. In the ED, vitals were unremarkable, but he had scleral icterus with a pale complexion on physical examination. Laboratory testing was notable for total bilirubin of 5.2 mg/dL, hemoglobin of 6.2, immature reticulocyte fraction of 30.6% (reference range 2.3-13.4%), LDH 305 U/L, haptoglobin < 1.0 mg/dL, direct globulin test positive for IgG with warm autoantibody. He was diagnosed with warm autoimmune hemolytic anemia and transfused three units of packed RBC. Additionally, he was treated with IV corticosteroids and IVIG for two days with improved Hgb to 7.8. Additionally, his symptoms resolved before discharge, and he is scheduled for a close follow-up with the hematology clinic.

IMPACT/DISCUSSION: Warm autoimmune hemolytic anemia (AIHA) arises from autoantibodies catalyzing red blood cell hemolysis at body temperature, with an estimated prevalence of 1 per 1,000,000 individuals and a variable clinical course spanning from asymptomatic hemolysis to fulminate hemolysis. This rarity and the diverse clinical presentations pose challenges in recognizing AIHA. HbA1c is the primary clinical test for diagnosing type 2 diabetes mellitus (T2DM) and monitoring treatment. Beyond reflecting a patient's glycemic control over the preceding 8 to 12 weeks, HbA1c serves as a predictor of future diabetic complications. However, like all laboratory tests, HbA1c is susceptible to false results and necessitates consideration within the broader clinical context. Notably, hemolysis, leading to a decreased average red blood cell lifespan, can yield falsely low HbA1c levels. The ongoing decline in our patient's HbA1c, despite a consistent measure of fasting glucose, raised concerns, prompting a thorough investigation. While the recognition of hemolysis was timely, the progression of AIHA demanded immediate evaluation and treatment.

CONCLUSION: This case underscores the limitations of medical tools when caring for patients. Despite our patient's HbA1c masquerading as improved control of his T2DM, his entire clinical picture pointed otherwise. Moreover, this case highlights that although medicine continues to grow with respect to data points and laboratory values, the intricacies of each patient's clinical picture remain a challenge that physicians must overcome.

DEMYSTIFIED: AN UNCOMMON CASE OF DIFFUSE DERMAL ANGIOMATOSIS IN THE BREAST

Maaz Ali²; Mahad Muhummad²; Syed F. Hussaini²; Nabeel Akhtar¹. ¹Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA; ²Penn State College of Medicine, Hershey, PA. (Control ID #4049536)

CASE: The patient is a 49-year-old morbidly obese female with insulin-dependent Type 2 diabetes mellitus (Hb A1c 11.8) complicated by neuropathy and gastroparesis, hypertension, and hypercholesterolemia who presented to her primary care provider for evaluation of a right breast lesion. The patient was in her usual state of health when she initially found it 2-3 weeks ago. It progressively became more open, firm with crustiness, and pruritic, and it did not improve with Neosporin. Upon evaluation, the patient was afebrile and hemodynamically stable on room air. On physical examination, there was an irregularly shaped hyperkeratotic and hyperpigmented plaque with surrounding hypopigmentation on the right breast areola between 7 and 8 o' clock with respect to the nipple. The breast was not warm to touch, and the lesion was not tender to touch and did not have any discharge. There was no concern for an infection or dermatitis; antibiotics or topical steroids were not prescribed. Instead, there was concern for malignancy, and mammogram was ordered, which resulted negative. Dermatology was electronically consulted and recommended in-person evaluation. Dermatology completed a punch biopsy, which showed evidence of diffuse dermal angiomatosis (DDA). Wound care and diabetes education was set up for the patient. The patient has not returned to clinic since then.

IMPACT/DISCUSSION: DDA is a rare skin disease due to a benign diffuse proliferation of capillary vessels in the dermis. It usually presents as a reticulated erythematous to violaceous patch with indurated plaques and occasionally shallow ulceration. It commonly involves the limbs, although there are less than 40 reported cases of occurrence in the breast. Risk factors include atherosclerotic disease, tobacco use, iatrogenic arteriovenous fistula, and monoclonal gammopathy. The pathogenesis is not understood, but it is thought that tissue hypoxia is a significant contributor. Diagnosis is via skin biopsy that shows proliferation of blood vessels in the dermis and lymphohistiocytic inflammation. Management includes improving relative ischemia and tissue hypoxia by reducing cardiovascular risk factors and offering supportive care. Our patient was obese and had uncontrolled diabetes mellitus with microcomplications likely causing poor vascularity. The patient could benefit from weight loss and diabetes control.

CONCLUSION: DDA is a rare dermatological condition that can uncommonly develop in the breast. It clinically appears as reticulated patches with indurated plaques sometimes with ulceration. It can be seen in patients with cardiovascular risk factors. Primary care providers must know DDA's clinical appearance and risk factors to prevent it from developing in their patients.

DETECTING BICUSPID AORTIC VALVE STENOSIS: INSIGHTS FROM A YOUNG PATIENT’S DIAGNOSIS

Pooja Singh¹; Nnenna Oluigbo². ¹Internal Medicine, MedStar Washington Hospital Center, Washington, DC; ²Medicine, MedStar Washington Hospital Center, Washington, DC. (Control ID #4048905)

CASE: 39-year-old male with a past medical history of hypertension and pertinent family history of early death in his mother and grandmother due to presumptive cardiac causes, presented to his primary care physician for evaluation of a history of chest pain. The chest pain was described as an intermittent, chest pressure/tightness, which occurred both at rest and with exertion. On exam he was found to have a systolic murmur with radiation to the carotids. In-office ECG showed T-wave inversions in the inferolateral leads. A stress echocardiogram was ordered but not completed as the pre-exercise images showed severe bicuspid aortic stenosis with calcification. He was promptly referred to cardiology and subsequently seen by cardiothoracic surgery. He underwent a successful surgical aortic valve replacement with a mechanical valve and anticoagulation was initiated. The patient is now followed closely by his primary care physician, cardiologist, and cardiothoracic surgeon.

IMPACT/DISCUSSION: This case highlights the need to screen family members of a patient with known history of bicuspid aortic valve (BAV) for possible cardiovascular malformations in the primary care setting. The 2020 ACC/AHA guidelines recommends considering screening first degree relatives of patients with BAV with a transthoracic echocardiogram (grade 2B recommendation). Previous literature supports this initiative, with one prospective study demonstrating 9% of family members of a patient with known BAV being newly diagnosed with a BAV. This study also showed an autosomal dominant inheritance of a BAV. Another study demonstrated the heritability of a BAV or other cardiovascular malformations were 89% and 75%, respectively. In another study, screening patients in a general hospital, yielded a diagnosis of BAV in 6% of the participants and aortic dilatation in 7.5% of participants. BAV is also the most common congenital heart defect with an incidence of 0.5 -1.4% and a male predominance of approximately 3:1. The persuasiveness of this data should urge the primary care physician to dive deeper into a patient’s family history in order to uncover possible inherited BAV or other cardiac conditions. Prompt recognition and knowledge of inheritability can lead to surveillance echocardiograms to avoid future complications, or immediate intervention if necessary.

CONCLUSION: Screening first degree relatives of patients with BAV is important, as those with BAV have increased an association with aortic stenosis, aortic regurgitation, and infective endocarditis. Prevalence of the BAV has also increased in recent years with the development and advancement of echocardiography. With early recognition, complications later in life can be avoided.

DEVELOPEMENT OF PURE RED CELL APLASIA AS A RARE COMPLICATION OF LONG TERM THERAPY WITH ADALIMUMAB (HUMIRA)

Jenny Hsu. Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #4063107)

CASE: A 70 yo female with a history of rheumatoid arthritis presented to the ED with worsening fatigue, shortness of breath, and tachycardia. She was found to have a hemoglobin of 5.6, low reticulocytes, with normal platelets and leukocytes. The prior month she had a stable hemoglobin of 11.4. During her initial admission she declined bone marrow biopsy and other invasive testing so was transfused and discharged with outpatient Hematology follow up. Subsequently, serologic testing was done to rule out viral causes, nutritional deficiencies, and radiographic studies were done to rule out neoplasms. Without a definitive diagnosis, Hematology offered treatment with steroids but patient refused due to beliefs steroids had harmed her in the past. Because she would not agree to bone marrow biospsy and any therapy aside from transfusions, Hematology declined to arrange any more transfusions. Her primary internist assumed the laboratory monitoring and transfusions arrangments. The patient required 2 units of PRBCs nearly every 2 weeks. Her Humira had been continued throughout this time as she had been managed with this for over 10 years without issue. With no other options, her primary eventually asked the patient’s rheumatologist to find an alternative to Humira. Eight months after her initial presentation, she transitioned to Orencia. Approximately 2 months later her reticulocyte count started to increase from the 0.2 range, and the frequency of transfusions decreased. By 14 months she no longer required transfusions and was able to achieve a hemoglobin of 12 at 18 months.

IMPACT/DISCUSSION: Acquired pure red cell aplasia is rare with a reported incidence of 1-2 cases per million per year. Potential causes include viral etiologies such as Parvovirus B19. It can be associated with autoimmune dieases such as RA which this patient has however her symptoms have been stable. Other causes include neoplastic causes such as Thymoma and lymphoproliferative disorders. If other treatable causes are not found, treatment usually includes immunosuppression with Cytoxan and corticosteroids. TNF-alpha inhibitors such as adalimumab have rarely been reported to cause aplasitc anemia as well as pure red cell aplasia. In this case, Humira seemed to be a less likley cause as the patient had been on Humira for over 10 years resulting in some delay in discontinuation of this agent. Length of treamtent should not dissuade against a trial of discontinuation of a medication.

CONCLUSION: The number of biologics to treat autoimmune diseases have multiplied. Drug toxicity despite long term use of a medication should be considered whenever hematologic disorders or other side effects develop.

DIAGNOSING PERNICIOUS ANEMIA IN A PATIENT WITH FACIAL NUMBNESS

Niveda M. Rao²; Jessica Chen¹. ¹Internal Medicine, University of California San Diego, La Jolla, CA; ²School of Medicine, University of California San Diego, La Jolla, CA. (Control ID #4062616)

CASE: A 56-year-old Asian healthy female with a history of hypothyroidism presented with intermittent left facial and scalp numbness for few days. The patient denied pain, trauma or weakness of the affected area, or vision or hearing loss. Left upper and lower extremity numbness developed subsequently. She was an avid runner and a scientist. The physical exam was unrevealing. The brain, C-spine, and trigeminal nerve MRIs, and electromyelogram were unremarkable. Mean corpuscular volume (MCV) was 97.6 μm³ (ref 79–95) without anemia, vitamin B12 level <150 pg/mL (ref 232–1245), methylmalonic acid (MMA) 0.50 μmol/L (ref 0.00-0.40), and positive intrinsic factor antibody, suggestive of pernicious anemia (PA). Esophagogastroduodenoscopy showed chronic atrophic gastritis with moderate chronic inflammation.

IMPACT/DISCUSSION: Pernicious anemia (PA) is a type of megaloblastic anemia caused by a deficiency of vitamin B12 due to the idiopathic development of auto-antibodies to the parietal cells within the stomach that produce intrinsic factor (IF). It can be triggered by end-stage atrophic body gastritis from long-standing H. Pylori infection, or the development of anti-intrinsic factor antibodies and anti-parietal cell antibodies. IF is essential for the absorption of vitamin B12 in the small intestine. The deficiency can lead to fatigue, weakness, glossitis, pale or jaundiced skin, shortness of breath, and neuropsychiatric symptoms including subacute combined degeneration. This condition affects around 0.1% of the world population and has a predominance in older adults of European descent with co-occurring autoimmune disorders. Studies show 40% of PA patients also have autoimmune thyroid disease, as this patient, and 10% have type-1 diabetes mellitus, some with vitiligo.

Diagnostic criteria include elevated MCV, MMA, presence of anti-IF or anti-parietal cell antibodies, and endoscopy with biopsy to assess gastric mucosal damage. Treatment involves lifelong vitamin B12 supplementation with intramuscular injections to ensure effective absorption in the absence of IF. Patients typically experience full resolution of symptoms with supplementation, as seen in this patient.

The classic PA patients present with weakness, fatigue, coordination problems, gait instability, glossitis, numbness of extremities, in a frailer state. This patient was atypical because she was a healthy avid runner who consumed a balanced diet and did not have alcohol intake, gastrointestinal disease, or H. Pylori infection. The elevated MCV led to further investigation, and eventually led to PA diagnosis.

CONCLUSION: It is important to recognize facial numbness can be the presentation of vitamin B12 deficiency and pernicious anemia.

Pernicious anemia can present in healthy, generally asymptomatic patients.

DIAGNOSING POLYMYALGIA RHEUMATICA WITH NORMAL ESR

Niveda M. Rao¹; Jessica Chen². ¹School of Medicine, University of California San Diego, La Jolla, CA; ²Internal Medicine, University of California San Diego, La Jolla, CA. (Control ID #4062729)

CASE: A 72-year-old Caucasian female with no significant rheumatologic or autoimmune history, presented to primary care clinic with several weeks of unprovoked progressive symmetrical bilateral shoulder and hip pain with morning stiffness. She had problem holding a cup, combing hairs, raising arms, and flexing hips due to pain. Several months ago, she was able to ski, walked several miles a day. She denied having fever, chills, recent infection, rash, trauma, shortness of breath, cough, blurred vision, headache, leg swelling or jaw claudication. Physical exam revealed diffuse symmetrical bilateral shoulder tenderness with poor effort in raising arms and walking up one step. She had no clinical evidence of osteoarthritis or inflammatory arthritis in fingers, wrists, or elbows. TSH, CPK, ANA, RF were normal. Her C-reactive protein (CRP) was slightly elevated at 1.8 mg/dL (ref <0.5), but ESR was normal at 19 mm/hr (ref 0-30). Her shoulder MRI revealed significant subacromial bursitis, suggestive of PMR. Electromyelogram was unremarkable.

Despite patient having a normal ESR, her clinical symptoms, examination, and imaging study were very suggestive of PMR. Patient was started on a trial of prednisone 15 mg daily by rheumatologist. She quickly responded to daily prednisone and was able to taper off prednisone slowly over fifteen months without symptom recurrence.

IMPACT/DISCUSSION: Polymyalgia rheumatica is an inflammatory proximal muscle disease characterized by morning stiffness, bilateral pain of shoulders and hip girdles. It may be associated with constitutional symptoms, such as mild fever, fatigue, malaise. PMR affects older Caucasian adults (mostly between age 70-80), of Scandinavian or northern European descent. Women are two to three times more likely to be affected. Current diagnostic criteria include age >50, proximal muscle pain ≥1 month, morning stiffness >1 hour, and elevated ESR and/or CRP. ESR and CRP are acute phase reactants that indicate inflammation within the body, and are elevated in a majority of PMR patients due to proximal muscle inflammation and possible associated systemic symptoms, such as fever. PMR patients have great variability of ESR elevation, ranging from mild (<40) to markedly increased (>100), seen in 20% of patients. Studies show ESR and CRP are usually elevated, although only one of them may be elevated. Recent literature has shown 7-22% of PMR patients can have normal ESR and CRP.

This patient fit the demographic and clinical symptoms of PMR despite negative inflammatory markers. PMR is also characterized by quick response to 15-20 mg prednisone daily in few days as in this patient.

CONCLUSION: It is important for primary care providers to recognize that PMR can present without elevation in ESR.

PMR is a clinical diagnosis that can be treated quickly with 15-20 mg of prednisone if suspected.

DIFFUSE LARGE B-CELL LYMPHOMA WITH INITIAL PRESENTATION OF HYPERCALCEMIA

Nisha Patel, Jack McHugh. Department of Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4062493)

CASE: A 76-year-old female with past medical history significant for papillary thyroid cancer, post-thyroidectomy hypoparathyroidism, osteoporosis, breast cancer, colon cancer, and hypertension was found to have hypercalcemia (Ca²⁺ 13.5 mg/dL). Her calcium carbonate was held and her ergocalciferol dose was reduced, with improvement in calcium to 10.8 mg/dL. She was advised to hydrate aggressively and was re-initiated on half her previous dose of calcium carbonate. Hypercalcemia again worsened to 12.3 mg/dL one week later. Further workup was significant for low parathyroid hormone (PTH < 6 pg/mL), and elevated 25-hydroxyvitamin D (215 ng/mL), lactate dehydrogenase (LDH 291 U/L), platelets (420 x10⁹/L), and 24-hour urine calcium (243 mg/24h). Her phosphorus, PTH-related protein (PTHrP), and 1,25-hydroxyvitamin D levels were normal. Given her significant cancer history, nuclear medicine bone scan was obtained which showed no findings of osseous metastatic disease, with mild radiotracer uptake in the left iliac bone that was felt to be benign. Two weeks later, the patient began reporting back and abdominal pain, fevers, and night sweats. CT abdomen revealed a 9 mm left renal mass with central mesenteric and retroperitoneal abdominal lymphadenopathy. Full body PET scan revealed diffuse uptake above and below the diaphragm with extra-nodal involvement of the right iliac bone and several vertebral bodies. Fine-needle aspiration of the right iliac bone was positive for DLBCL, with bone marrow biopsy demonstrating involvement of 60% of bone marrow. The patient was treated with six cycles of R-CHOP, and had a complete response to therapy.

IMPACT/DISCUSSION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma, accounting for about 25% of cases. It is particularly aggressive and typically presents with a rapidly growing and painless mass, as well as B symptoms such as fever, night sweats, and weight loss. Hypercalcemia is frequently present in patients with DLBCL, but this case is unique as it is rarely seen as the first presentation of disease.

After PTH-mediated causes, the most common etiology of hypercalcemia is malignancy. In this case, drug-induced hypercalcemia was suspected initially, however the presence of elevated serum LDH was a clue to systemic malignancy. Hypercalcemia of malignancy is most often mediated by humoral secretion of PTHrP or by local osteolysis. Lymphoma-related hypercalcemia is associated with adverse clinical outcomes but can respond well to early treatment, highlighting the importance of considering malignancy early on in the differential for PTH-independent hypercalcemia.

CONCLUSION: In cases where drug-induced hypercalcemia is suspected, there is risk of premature diagnostic closure if an advanced work-up for hypercalcemia is not initially pursued. Differential diagnosis for hypercalcemia should always include malignancy, with early testing of PTHrP, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D levels for unclear diagnoses.

DIG DEEPER: WHEN CELLULITIS DOES NOT IMPROVE WITH SEVERAL COURSES OF ANTIBIOTICS

Armelia Sani¹; Jessica Chen¹; Miriam Hakim¹; Ashley S. Watt². ¹Internal Medicine, University of California San Diego, La Jolla, CA; ²Public Health, California Polytechnic State University, San Luis Obispo, CA. (Control ID #4064080)

CASE: A 70-year-old male with DM, NASH, hyperlipidemia, and HTN presented with a 6-month history of a swollen, mildly erythematous right middle finger. Symptoms started after he cut his finger while gardening without gloves and was exposed to garden material. Initial x-ray did not reveal a foreign body or bony abnormality. He was treated with two 7-day courses of cephalexin followed by a 7-day course of doxycycline. The swelling persisted for 2 months. An ultrasound was obtained showing a heterogeneous echogenicity of the soft tissues superficial to the flexor tendon sheath, consistent with cellulitis. He was given another 7-day course of doxycycline followed by a 7-day course of amoxicillin-clavulanate and trimethoprim-sulfamethoxazole. Although his pain resolved, the swelling waxed and waned without complete resolution. An MRI was done 3 months after initial presentation, revealing a collection of soft tissue inflammation versus a developing abscess. He was taken to the OR for exploration. His finger culture grew out Mycobacterium salmoniphilum, at which point the patient endorsed frequently cleaning the pond in his backyard without gloves. He was treated with ciprofloxacin, clarithromycin, and trimethoprim-sulfamethoxazole, and then transitioned to IV tobramycin based on culture sensitivities for total of 3 months of treatment. He had complete resolution of his right middle finger swelling.

IMPACT/DISCUSSION: This case illustrates an uncommon and atypical skin and soft tissue infection (SSTI) of the hand with Mycobacterium, and the importance of investigating further when a superficial hand infection is recalcitrant to numerous courses of antibiotics. Superficial hand infections affect skin and subcutaneous tissue, and are easy to diagnose clinically. Treatment is usually non-operative with oral antibiotics. As our case demonstrates, it is important to suspect a deep infection when symptoms persist despite treatment. Pursuing imaging such as US, MRI, or CT will evaluate for findings that may require surgical intervention. The type of imaging is driven by clinical presentation and concern for complications such as deep tissue infection, tendon involvement, foreign body, soft tissue gas, and periosteal abnormalities. Furthermore, when standard antibiotics fail, atypical microbes are important to consider as a cause of infection. Our patient was infected with M. salmoniphilum, a Mycobacterium often associated with soft tissue infections following traumatic injury with water exposure.

CONCLUSION: ● When the treatment course for a SSTI is characterized by lack of improvement, recognizing the possibility of a deep and/or atypical infection, reviewing potential exposures, and pursuing further imaging evaluation are important for successful treatment.

● Atypical microbes are important to consider as a cause of infection if standard antibiotics fail to resolve infection.

DON’T “DROP” THE BALL: DIAGNOSING AND TREATING GUTTATE PSORIASIS

Anne Barnes, Dillon Nussbaum, Jillian S. Catalanotti. Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4028524)

CASE: A 43-year-old man presented to primary care clinic for evaluation of an erythematous, pruritic rash that began three weeks prior. The rash began on his arms and progressed to his legs, shoulders, and trunk. He denied preceding illness, medication changes, recent travel, or new sexual contacts. He had a history of shingles seven years prior and no history of psoriasis or eczema. Before this presentation, he had been seen at an urgent care clinic and treated with five days of prednisone without improvement.

Physical examination revealed normal vital signs and numerous well-circumscribed, drop-shaped, erythematous, mildly scaling papules, approximately 0.5 to 1 cm in diameter. Papules were concentrated on his arms and trunk, with a few on his legs.

He was referred to dermatology for further evaluation. The dermatologist performed KOH prep and ordered RPR and anti-DNase B antibody tests. KOH prep and RPR were negative.Anti-DNase B antibody titers were elevated, suggesting a diagnosis of guttate psoriasis triggered by a recent streptococcal infection. He was prescribed five days of azithromycin with resolution of rash.

IMPACT/DISCUSSION: Guttate psoriasis is a relatively rare subvariant of psoriasis that most often occurs in children and adolescents. Typical onset occurs 1-2 weeks after a streptococcal infection. It is an eruptive form of psoriasis characterized by rapid appearance of numerous discrete, erythematous, sometimes pruritic papules, generally less than 1 cm in diameter and most often occurring on the trunk and proximal limbs. Like other forms of psoriasis, scraping lesions off reveals pinpoint bleeding, known as the Auspitz sign.

When guttate psoriasis is preceded by streptococcal infection, treatment of the infection with antibiotics can resolve the rash. UVB phototherapy is another effective treatment. Without treatment, lesions may resolve spontaneously within a few weeks. The occurrence of guttate psoriasis may also herald the development of chronic psoriasis in the future.

This case of guttate psoriasis occurred in an adult who denied preceding illness, making diagnosis difficult. The differential diagnosis of erythematous, discrete papules includes drug eruptions, pityriasis rosea, pityriasis lichenoides chronica, tinea corporis, nummular eczema and secondary syphilis. Work-up may include review of recent medication changes, KOH prep of a lesion, syphilis testing, and throat culture or titers for recent streptococcal infection, such as antistreptolysin O, anti-DNase B, or streptozyme. Biopsy is typically unnecessary.

CONCLUSION: Guttate psoriasis is a variant of psoriasis that typically occurs after Group A streptococcal infection, most often in children and adolescents. Differential diagnosis for psoriasiform lesions s is broad, requiring a complete history and targeted testing. When preceded by streptococcal infection, guttate psoriasis may be treated with appropriate antibiotics, however some patients require UVB phototherapy or progress to chronic psoriasis.

DULOXETINE-INDUCED SIADH IN AN ELDERLY PATIENT

Jessica A. Erickson¹; Mike K. Cheng². ¹Division of General Internal Medicine, UCSF Medical Center, San Francisco, CA; ²Medicine, University of California San Francisco, Oakland, CA. (Control ID #4064446)

CASE: An 80-year-old man with HTN, BPH, pre-diabetes, HLD, anxiety and insomnia presented with 2 weeks of fatigue, confusion, short-term memory loss, “brain fog,” visual hallucinations, and muscle cramps. He denied recent illness, fever, chills, substance use, GI or urinary symptoms, diet changes, travel, or sick contacts. Recent medication changes included starting duloxetine 2 weeks earlier for anxiety. Examination revealed impaired mental status and confusion, with frequent repetition, and orientation to person and place only. Same-day labs (CBC, BMP, LFTs) were notable for Cr of 1.6 and Na of 117. The patient was hospitalized for treatment of duloxetine induced SIADH with severe hyponatremia and new AKI. Additional workup for causes of sodium wasting was negative (TSH and cortisol within normal limits), duloxetine was discontinued, and Na levels were corrected with fluid restriction over the course of 3 days. At discharge, the patient’s sodium was 133, and he had returned to his baseline mental status, with a plan to avoid SNRIs/SSRIs in the future.

IMPACT/DISCUSSION: This case highlights the risk of SIADH from SNRI use, particularly in the elderly. Mood disorders affect approximately 1 in 8 older adults, with antidepressants commonly prescribed and generally well-tolerated. While practitioners are well-versed in counseling patients about mood, sleep, GI, and sexual side effects from SSRI/SNRI initiation, the risk of hyponatremia, especially in older populations, merits attention. While the incidence of SIADH with SSRIs ranges widely from 0.5%- 32%, less data exists linking SNRIs with hyponatremia, and only a few case reports and observational studies suggest an association with duloxetine. Risk factors for SIADH after SSRI/SNRI initiation include older age, female gender, low body weight, concomitant diuretic use, and low baseline sodium. Notably, older patients may develop rapid-onset hyponatremia, with case reports demonstrating hyponatremia after only two doses of duloxetine. The mechanism by which duloxetine causes SIADH is likely an increase in ADH secretion by enhancing serotonin action on 5-HT receptors or by sensitizing kidneys to ADH. Key symptoms of hyponatremia include nausea, headache, confusion, fatigue, weakness, memory and mood changes, and muscle cramps. Symptoms can develop within the first day to months after treatment initiation and should resolve with medication discontinuation. Patient counseling, early detection, and medication discontinuation are vital, as severe hyponatremia poses risk of seizures and coma.

CONCLUSION: Additional counseling on hyponatremia symptoms or electrolyte monitoring after SNRI initiation should be considered in at-risk patient populations.

Risk factors for SSRI/SNRI-induced SIADH include elderly, female, low BMI, diuretic use, and low baseline sodium.

SSRI/SNRI- induced hyponatremia onset ranges from 1-2 days in older at-risk populations, up to months after treatment initiation and should improve with medication cessation.

DUODENAL-TYPE FOLLICULAR LYMPHOMA IN A YOUNG FEMALE WITH A HISTORY OF H. PYLORI INFECTION

Andrew Barr^1,2; Chelsea Takamatsu^1,2; Clinton Wu^1,2; Kenneth Barker^1,2. ¹Internal Medicine, Banner - University Medical Center Tucson, Tucson, AZ; ²Department of Medicine, The University of Arizona, Tucson, AZ. (Control ID #4064267)

CASE: We discuss a 33-year-old woman with a prior H. Pylori infection presenting to our clinic to establish care. Our visit focused on her recurrent, extended bouts of nausea associated with watery diarrhea and non-bloody, non-bilious emesis, culminating in an unintentional 20-pound weight loss over six months. Physical examination revealed alarming distress and epigastric tenderness.

An urgent esophagogastroduodenoscopy (EGD) performed the following day unveiled gross findings of several white nummular spots within the duodenum, which were biopsied. There was no biopsy evidence of active H. Pylori infection or mucosal ulceration; however, pathology results were consistent with follicular lymphoma. To confirm our diagnosis of duodenal-type follicular lymphoma (DTFL), a bone marrow biopsy was negative for lymphoid malignancy and a positron emission tomography (PET) scan demonstrated no metastatic or localized F-fluorodeoxyglucose (FDG) uptake to the duodenum. Our patient received Rituximab with rapid symptomatic improvement and repeat PET imaging again void of any duodenal FDG uptake.

IMPACT/DISCUSSION: Most DTFL cases affect asymptomatic older patients whose diagnoses were incidentally discovered during routine endoscopic procedures. One similar DTFL case exists in a symptomatic 30-year-old male, raising the question of whether earlier onset DTFL manifests with more symptoms. Potential predisposing factors shared by this young male and our patient may explain this malignancy arising decades prior to other cases. This consideration highlights the importance of clinicians maintaining a lower threshold to obtain urgent EGDs for young patients with debilitating gastrointestinal and non-specific constitutional symptoms.

Not only will the common empiric proton pump inhibitor trial delay diagnosis but also limit EGD biopsy accuracy for DTFL and H. pylori diagnoses. In fact, there are cases of H. pylori infection coexisting with DTFL, but there are no reports of DTFL diagnosis after treated H. Pylori infection, as in our patient. Pathophysiologic and genetic similarities between MALT lymphoma and DTFL may imply a similar H. pylori malignancy risk for DTFL, as for MALT lymphoma. Interestingly, cases of DTFL eradicated with H. pylori treatment propose potential antibiotic therapeutic options as well. Yet, the possibility of false negative endoscopic biopsies after non-invasive H. pylori testing and treatment further reinforces obtaining prompt diagnostic EGDs.

CONCLUSION: This case demonstrates the need for earlier diagnostic EGDs, particularly in younger patients with more significant gastrointestinal and non-specific constitutional symptoms, to best identify the true prevalence of DTFL without interfering with - and delaying - diagnosis. This will ultimately allow for larger therapeutic studies with the goal of best determining patients that are at greater risk for DTFL, exploring the possible association with H. pylori infection, and establishing proper evidence-based treatment guidelines.

DYSPNEA IN A HEALTHY ACTIVE 74 YEAR OLD MALE AFTER RECENT MILD COVID INFECTION

Carmel Malvar¹; Beemnet Amdemicael²; Jessica Chen³; Bernice Ruo¹. ¹Medicine, University of California San Diego, La Jolla, CA; ²School of Medicine, University of California San Diego, La Jolla, CA; ³Medicine, Universityo California at Sa Deig, San Diego, CA. (Control ID #4062752)

CASE: A 74 year old male presented to clinic with one week of dyspnea on exertion. The patient had tested positive for COVID two weeks ago, with initial symptoms of fever, headache and cough, which improved without prescription medications.

The patient described a mild but improving dry cough. He felt short of breath after walking short distances despite biking daily prior to COVID infection. His vital signs were within normal ranges. The lung exam was clear to auscultation bilaterally and no lower extremity edema was present. The patient’s oxygen saturation decreased from 98% to 90% after walking approximately 50 feet but he was able to recover after resting in less than five minutes. The commonly used Well’s score for PE was 1.5 which suggested low risk for PE.

Further work-up included a D-dimer which was found to be remarkably elevated at 7,500 ng/mL (normal reference range <241). CT angiography was obtained and demonstrated bilateral acute segmental and subsegmental PE with associated right heart strain and small bilateral pulmonary infarcts. The patient was referred to the Emergency Department and obtained an echocardiogram which was notable for mild right ventricular enlargement and moderate pulmonary artery pressure elevation. The patient was started on a direct oral anticoagulant and his dyspnea on exertion improved within a few days.

IMPACT/DISCUSSION: Common risk factors for PE include obesity, immobilization, cigarette use, cancer, surgery, pregnancy, and a prior history of PE or a known hype-coagulable disorder. In up to 30% of patients with PE, there are no detectable provoking factors (1). This case illustrates the role of COVID-19 as a risk factor for pulmonary embolism. Prior studies have shown that the risk of PE is increased for six months after COVID-19 infection (2).

After obtaining clinical history and physical examination, determining the pretest probability of PE is the next step in diagnosis. Conventional scoring systems for the risk stratification of PE include the Well’s criteria, a multi-point rule which has been found to have a sensitivity of up to 96% (3). However, the Well’s score has been noted to be non-discriminatory in predicting the risk of acute PE in COVID-19 patients (4,5). Previous studies have demonstrated the role of D-dimer in the assessment of COVID-19 patients for initial screening of PE although there are still no clear prediction schemes (3).This case supports the utility of obtaining D-dimer in patients presenting with acute dyspnea in the setting of a recent COVID-19 infection and a low-risk Well’s score.

CONCLUSION: - Recent infection with the COVID-19 virus is a risk factor for pulmonary embolism

- Obtaining a D-dimer is beneficial in ruling out pulmonary embolism in individuals recently infected with COVID-19 as history and physical exam may be atypical and Well’s score may have poor predictive value

EARLY RECOGNITION AND MANAGEMENT OF IMMUNE CHECKPOINT INHIBITOR-INDUCED (ICI) INFLAMMATORY ARTHRITIS

Regina Koch¹; Michael Mueller². ¹Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²General Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4063909)

CASE: A 56 y.o. woman with pancreatic adenocarcinoma status post Whipple procedure and radiation, on pembrolizumab for 8 months, presented with bilateral knee pain, warmth, and edema for one week. Physical exam showed active synovitis of the right knee and a right Baker’s cyst. Plain radiographs showed large bilateral effusions. Aspiration of the synovial fluid showed an inflammatory infiltrate of 9500 nucleated cells with 50% neutrophils. Laboratory studies revealed an ESR of 55mm/hr (normal: < 30mm/hr) and CRP of 46mg/dL (normal: < 8mg/dL). Rheumatoid factor and anti-CCP were negative. Given concern for ICI-induced inflammatory arthritis, pembrolizumab was stopped. She started prednisone 30mg daily with improvement in symptoms, but failed multiple attempts at taper over the course of 3 months. The addition of hydroxychloroquine did not yield any clinical benefit, and additional attempts to taper prednisone failed. She received bilateral glucocorticoid knee injections, with marked improvement in her pain and resolution of her synovitis. Over the next 4 months, she successfully tapered to prednisone 5mg daily, with full resolution of her synovitis. She continues on prednisone long-term. Notably, after 18 months without pembrolizumab, she had no radiologic evidence of tumor progression. The decision was made to forgo further immunotherapy in favor of active disease surveillance with CT every 3 months.

IMPACT/DISCUSSION: Inflammatory arthritis is a well-described complication of ICI therapy that typically manifests within 3 months of initiating therapy. However, delayed onset, as seen in our case, is common, and clinicians should consider ICI-arthritis in any patient with new inflammatory arthritis within two years of initiating immunotherapy. A minority of cases fulfill diagnostic criteria for well-defined disease patterns, including RA and psoriatic arthritis. But the most common presentation is undifferentiated inflammatory polyarthritis, oligoarthritis, or monoarthritis. Initial evaluation should include ESR, CRP, RF, and anti-CCP. If this evaluation is unrevealing, suspicion for ICI-arthritis should remain high because normal inflammatory markers and negative serology are common. Management is dictated by arthritis severity according to CTCAE criteria. Grade 1 arthritis (synovitis and mild pain) is managed with NSAIDs, and ICI therapy is continued. Grade 2 arthritis (moderate pain limiting instrumental ADLs) requires NSAIDs, prednisone 20mg, and rheumatology consult. In cases such as ours with predominantly large joint involvement, intra-articular glucocorticoids are highly effective in improving symptoms and minimizing systemic steroid exposure. ICI-toxicity rarely affects more than one organ system, so diagnosis of ICI-arthritis should not prompt screening for other ICI-toxicity

CONCLUSION: ICI-arthritis has a broad spectrum of phenotypes and should be considered in any patient on immunotherapy with new arthralgias. CTCAE criteria help guide management in the outpatient setting.

EXPLORING NON-PHARMACOLOGICAL INTERVENTIONS IN POLYMYALGIA RHEUMATICA: A CASE OF DIETARY MANAGEMENT

Damaris Figueroa¹; Kudret Arslan¹; Kadijha Merchant¹; Delaram Moazami². ¹Internal Medicine, Capital Health System Inc, Trenton, NJ; ²Internal Medicine, Capital Health, Trenton, NJ. (Control ID #4027390)

CASE: A 71-year-old woman, with a medical history including hypertension, hypothyroidism, osteoarthritis, sleep apnea, prediabetes, and macular degeneration, presented with a gradual onset of neck pain. Subsequently, she developed right wrist pain and swelling, initially responsive to Medrol Dosepak. Recurrent symptoms, including headaches and left temple tenderness, prompted further examination revealing stiffness in both hips, difficulty rising from a seated position, and tender, swollen wrists with numb fingers.

Laboratory investigations unveiled thrombocytosis (419 x10e3/uL), an elevated White Blood Cell count (10.37 x10e3/uL), increased C-reactive protein (35 mg/L), and erythrocyte sedimentation rate (21 mm/HR). Rheumatologic evaluations excluded alternative diagnoses, and negative ANCA serologies supported the diagnosis of PMR, with a potential association with GCA due to temporal symptoms. Referral to a Rheumatologist recommended a standard prednisone regimen (20 mg daily). However, owing to apprehension regarding glucocorticoid therapy, the patient chose to pursue an exclusive non-pharmacological approach. Implementing a plant-based diet with occasional lean white meat, she abstained from prednisone.

Over a four-month period, symptomatic improvement was observed, paralleled by a substantial reduction in C-reactive protein from 35 mg/L to 4 mg/L. Temporal symptoms also resolved without the initiation of glucocorticoids. The patient continued to decline prednisone but agreed to Ibuprofen as needed for pain relief.

IMPACT/DISCUSSION: Polymyalgia rheumatica (PMR) stands as a prominent inflammatory rheumatologic disorder primarily managed with glucocorticoids, despite concerns regarding associated adverse effects and limited evidence supporting significant impacts on prognosis or the prevention of progression to Giant Cell Arthritis (GCA). The implementation of exclusive lifestyle medicine and its multiple proven benefit including increased patient and physician satisfaction, decreased healthcare and patients costs, aligned with lack of short and long term side effects, in the management of such rheumatologic diseases remains an area warranting investigation.

CONCLUSION: This case underscores the potential efficacy of lifestyle medicine, specifically a dietary approach, as both a primary and adjunctive therapy for PMR. The observed reduction in inflammatory markers aligns with symptomatic improvement, challenging the conventional glucocorticoid-centric approach. The patient's sustained adherence to a non-pharmacological strategy suggests that comprehensive investigations are warranted to elucidate the mechanistic underpinnings and broader applicability of lifestyle interventions in managing inflammatory rheumatologic diseases. Future research efforts should prioritize establishing a robust evidence base to guide clinicians and empower patients seeking alternatives to conventional pharmacological interventions.

FINDING THE DISEASE: FATIGUE AND WEIGHT LOSS IN A 71-YEAR-OLD MALE

Julie Jin¹; 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 #4057090)

CASE: A previously healthy 71-year-old male presented to the ED with one month of fatigue and 20 lb. weight loss. He had significant fatigue with activities of daily living, dysgeusia impairing appetite, decrease in weight from 270 lb. to 250 lb. in a month, night sweats, and subjective fevers. He also had two broken crowns which needed replacing.

Past medical history was notable for MGUS and prostate adenocarcinoma. He was retired, monogamous with his wife, and lived in a rural area. He had no pets and did not travel or have outdoor hobbies. He did not smoke, drank rarely, and did not use illicit substances. Of note, his father, sister, maternal grandmother, and paternal uncle all passed away from multiple myeloma. He did not take any medications and was up to date on cancer screening and vaccinations. Physical exam was unremarkable.

Prior to presentation, he had extensive workup through his PCP notable for ESR 80s, CRP 90s, ferritin 1,088, mild leukocytosis, and anemia of inflammation. Infectious, rheumatologic, and malignant labs were normal. ECG, peripheral blood smear, and blood cultures were unrevealing. CXR, CT head, CT chest, and CT A/P were unremarkable. Bone marrow biopsy was supportive of MGUS. K:L ratio, SPEP, and free light chains were consistent with prior testing.

Further laboratory testing showed WBC 12.7, Hgb 11.1, ESR 140, CRP 126, and aldolase 9.8. Further infectious, rheumatologic, and malignant labs were negative. Rheumatology was consulted and recommended MRI/MRA of the brain to assess for giant cell arteritis which was unremarkable and temporal artery biopsy. Panorex showed dental caries and TTE did not note valvular abnormalities. Heme/onc and infectious disease were also consulted, and ID recommended PET-CT of the whole body. This showed a soft tissue lesion in the medial intramuscular compartment of the distal left thigh suspicious for an infectious/inflammatory process. A soft tissue biopsy of the lesion was performed and the patient was discharged home. The biopsy showed high-grade spindle cell sarcoma, unclassified.

IMPACT/DISCUSSION: The clinical definition of fever of unknown origin (FUO), as defined by Petersdorf and Beeson in 1961, is a temperature of 101°F or higher for three weeks without a diagnosis despite one week’s investigation in the hospital. Three general categories account for the majority of cases: infections, malignancies, and systemic rheumatic diseases. If cases remain undiagnosed, nuclear medicine testing to image the whole body can localize a site for more specific evaluation. This can be done with labeled WBC or gallium scans, and FDG-PET. FDG-PET appears more sensitive than WBC scans for identifying anatomic sites of inflammation, infection, and malignancy. Biopsies can be performed for further histopathological evaluation.

CONCLUSION: Workup for FUO should include infectious, rheumatologic, and malignant workup.

FDG-PET scan has a role diagnosis in cases of FUO.

FISH BONE SIGMOID COLON PENETRATION IN A JAPANESE ELDERLY WOMAN CONCERNED ABOUT OSTEOPOROSIS: UNMET CULTURAL NEEDS IN DELIVERING INFORMATION TO PATIENTS

Yuki Ohnishi^1,2; Hiroyuki Otsuka¹. ¹Internal Medicine, Kokuho Sosa Shimin Byoin, Sosa, Chiba, Japan; ²General Internal Medicine, Iizuka Byoin, Iizuka, Fukuoka, Japan. (Control ID #4038225)

CASE: A 86-year-old Japanese woman with ascending colon cancer status post surgery presented with the gradual onset of severe lower abdominal pain. She described the pain come and go and reported no nausea, vomiting, and diarrhea. Her temperature was 101.48°F,blood pressure 120/75 mmHg, heart rate 78 beats per minute, respiration rate 18 per minute. The physical examination revealed a mass right next to the umbilicus and abdominal tenderness in the right lower abdomen without rebound tenderness. She shared she was eating fish dishes everyday due to the intense fear of bones becoming fragile and brittle and the words from her previous primary care doctor “Eating plenty of fish is good for strengthening your bones.”.

Laboratory tests showed normal white blood cell count and C-reactive protein level. A contrast-enhanced CT scan revealed thickened sigmoid colon wall with a 4-centimeter linear, high-density foreign body, but no free air. Emergent colonoscopy was performed, which demonstrated a sea bream-like fish bone 4 centimeter in length stuck in the sigmoid colon wall.

The post-endoscopic course was uneventful. After conservative treatment with fasting and antibiotic administration for 5 days, the patient restarted feeding without any problems and was discharged home on the 9th day after the colonoscopy.

IMPACT/DISCUSSION: Many gastrointestinal foreign bodies are naturally excreted, and causing perforation or penetration is considered to be less than 1%. As a cause of gastrointestinal perforation and penetration due to accidental ingestion of foreign bodies, fish bones are considered common in Asian countries and tend to be more prevalent in the elderly. In the case of lower gastrointestinal perforation, surgery is often necessary, but in this case, treatment was achieved solely by endoscopic removal.

In this case, the patient maintained a diet heavily focused on fish due to the fear of osteoporosis. Japan ranks sixth in the world for the highest fish consumption. The patient's cultural affinity for fish, combined with unmet information needs about the nature of osteoporosis and self-management, may have triggered a diet overly centered on fish.

Fish is an essential source of vitamin D, a crucial nutrient for preventing osteoporosis. However, the risks of osteoporosis and that of fractures do not necessarily correlate. Factors such as incidents of falls also play a role in determining fracture occurrence. Therefore, it is crucial for primary care physicians to emphasize the importance of a balanced diet with various types of ingredients, including awareness of frailty and sarcopenia prevention, and to communicate the significance of exercise therapy to patients.

CONCLUSION: The observed racial and ethnic differences in the information demands of patients with osteoporosis highlight the need for reevaluating information delivery to patients. Primary care physicians should place more emphasis on offering information that is culturally sensitive and tailored to individual patients' needs.

FLUCTUATING LDL-C IN AN ADULT PRIMARY CARE CLINIC

Ryan Truitte, Danielle M. Delucchi. Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4064684)

CASE: A 45 year old female with history of well controlled hypothyroidism, who lives an active lifestyle and eats a balanced diet, presented to establish care. She was not on any medications other than Synthroid. Review of systems was pertinently negative for any chest pain, exertional dyspnea, skin changes or joint/tendon aches. In reviewing her family history she knew that her father suffered a stroke at age 60 and had high cholesterol. Lab work from the previous year revealed total cholesterol of 447, & LDL of 350. Her LDL demonstrated considerable variability ranging from 154 to 350 in the past. Lipid panel was repeated showing total cholesterol of 214, LDL 141. Given her history of multiple LDL readings well over 190 our suspicion for heterozygous familial hypercholesterolemia was high. It was decided to pursue aggressive LDL goal of <70 and ApoB level < 80 with Statin +/- Ezetimibe.

IMPACT/DISCUSSION: The prevalence of heterozygous FH is estimated at 1:250 individuals. Untreated, these individuals have 30-50% risk of fatal or non-fatal cardiac event by the age of 50 in men and 60 in women and have an estimated 13% higher risk of MI. It is important for primary care physicians to catch these high-risk individuals, and start treatment as soon as possible, to reduce the risk of cardiovascular disease. In this patient, an LDL of 141 would not be have been suspicious of heterozygous FH. Had the patient not had other extremely elevated LDL values in the past, and her father’s family history, this disease might not have been caught. It is worth obtaining an in-depth family history for cardiovascular disease and risk factors in all young patients with elevated LDL, and, based on that result, more frequent lipid testing to identify these individuals at high risk. CT Coronary Calcium Score is a newer diagnostic test to evaluate cardiovascular risk in individuals > 50 where physicians suspect they might have this condition, but was not caught at an earlier age.

Current ACC guidelines for high risk cardiovascular population, including those with heterozygous FH, recommend a LDL goal of <70 or 50% reduction from baseline. Newer studies are suggesting using Apo B levels (goal < 80 in most cases) instead of LDL levels as a more sensitive test for cardiovascular risk. Although statins are first line therapy for LDL lowering therapy, Ezetimibe and PCSK-9 Inhibitors are the recommended add-on therapy if your patient is unable to reach LDL goals with a statin alone.

CONCLUSION: Detailed Family History of any cardiovascular disease or risk factors should be obtained in any patient with elevated LDL. Guidelines recommend lowering LDL <70 using statins first line, followed by ezetimibe and/or PSK9 inhibitors for those high risk of heart disease, including heterozygous familial hyperlipidemia. Apo B and CT coronary Calcium Scores are new diagnostics tests that can aid with management

FLUID MYSTERIES: UNRAVELING THE DIAGNOSTIC ODYSSEY OF MALIGNANT ASCITES IN A 35-YEAR-OLD WOMAN

Sean C. Selko, Richmond S. Doxey, Anne Cioletti. Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4064621)

CASE: A 35-year-old Somalian female with history of asthma and mild developmental delay presented to an outside hospital with 1 month of abdominal distention and constipation. She denied weight loss, fevers, night sweats. She moved to the United States at age 19 and has had no recent travel. She denies alcohol and tobacco use. Notably, her family history included multiple instances of colon and cervical cancer in first degree relatives.

Physical examination revealed diminished left lung sounds and a distended, slightly tender abdomen with shifting dullness. CT of the chest, abdomen, and pelvis demonstrated left sided pleural effusion, large-volume ascites, and dilated loops of bowel without masses. A paracentesis was performed revealing serum ascites albumin gradient (SAAG) <1.1 g/dL, total protein of 5.2 g/dL from ascitic fluid, white blood cell counts >1000 cells/mm3, and cytology negative for malignancy. Additional workup with negative QuantiFERON TB Gold, ANA with a titer of 1:80, normal echocardiogram, and above normal dsDNA antibody was performed, and the patient was discharged with a rheumatology referral.

Upon establishing in primary care 2 months after hospitalization, she continued to have abdominal distention, pain, ascites, and constipation. She was sent to the emergency department for an urgent CT scan of her abdomen, which demonstrated a heterogenous 7.7 cm mass in the uterus and extensive peritoneal carcinomatosis. After additional workup, she was diagnosed with stage IVA high grade serous carcinoma of tubo-ovarian origin.

IMPACT/DISCUSSION: When evaluating ascites suspected as due to non-portal hypertension causes (<15% of cases), one must remember that the sensitivity of cytology for the detection of malignancy-related ascites (7-10% of total ascites cases) ranges from 58-75%, giving it a poor positive predictive value. While malignancy-related ascites is rare, it remains more common than rheumatological causes of ascites, which usually present with nephrotic syndrome. Additionally, given the clinical context of this patient’s initial presentation, one could posit the likelihood of malignant-related ascites is high.

All of this, along with recognition of the poor prognosis that malignant-related ascites carries, warrants close follow-up with repeat cytological testing or imaging sooner.

CONCLUSION: - Ascitic fluid cytology has limited sensitivity for the diagnosis of malignant-related ascites.

- A patient’s demographics and history should be strongly considered in the likelihood of a given diagnosis.

- When diagnostics and clinical suspicion do not align with a morbid diagnosis, repeat testing is warranted.

FLU SHOT FALLOUT AND THE UNSEEN CULPRIT OF SHOULDER BURSITIS

Juan Sosa¹; Kadijha Merchant¹; Valeria Turcan². ¹internal medicine, Capital Health, Trenton, NJ; ²Internal Medicine, Capital Health Regional Medical Center, Trenton, NJ. (Control ID #4063584)

CASE: A 39-year-old female presented with intense pain and tenderness at the injection site in her right shoulder. The patient reported receiving the flu shot ten days ago, and since then, she has experienced right upper arm pain and a tingling sensation extending from the shoulder to the elbow. The pain onset occurred immediately after the injection. The patient's relevant medical history included only chronic gastritis. Additionally, there was no history of trauma, and her physical activities consisted of walking and treadmill use. On examination, there was mild tenderness to palpation and a range of motion, but no visible wound, redness, or swelling. A two-view shoulder X-ray showed no concerning findings. The patient was discharged with Ibuprofen and Tylenol as needed for pain. However, the patient returned to the outpatient clinic twenty days post-vaccination with persistent pain in the right shoulder, reduced range of motion, and an inability to perform daily activities. On physical examination, mild swelling was noted in the upper arm, and localized tenderness was observed around the top of the humeral head and deltoid. Due to continuous symptoms, a shoulder MRI conducted four weeks post-vaccination supported a diagnosis of subacromial-subdeltoid bursitis with a small amount of fluid in the subacromial-subdeltoid bursa.

IMPACT/DISCUSSION: Shoulder pain after injection should not be underestimated and classified as mild muscle soreness or a psychological symptom. The diagnosis of bursitis was established based on the patient's rapid-onset pain following intramuscular vaccine administration. The patient had no prior history of chronic pain or inflammatory diseases in the affected shoulder, and the findings were consistent with a local immune-mediated inflammatory reaction. A potential cause is the incorrect administration of the vaccine at a higher or deeper location than recommended, leading to the vaccine being inserted into the glenohumeral joint. The administered vaccine contained both antigenic and non-antigenic components, each capable of initiating a response.

CONCLUSION: Although adverse reactions at vaccination injection sites are typically mild and transient, the medical literature reports several cases of bursitis and other shoulder injuries. Based on the literature review, the prevalence of subdeltoid or subacromial bursitis and other shoulder lesions may exceed current estimations, with a predilection for women. While the etiology may involve antigens or adjuvants in vaccines triggering immune or inflammatory responses, a more probable cause is improper injection technique, including location, angle, depth, and needle size. Consequently, vaccination-related shoulder injuries appear preventable.

FREQUENT FAINTS: UNDERSTANDING GITELMAN SYNDROME

Saloni Agrawal¹; 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 #4029042)

CASE: A 53 year old woman with chronic hypokalemia presented to the ED with recurrent syncope since 2021. In the weeks leading up to ED presentation, she had 5-6 episodes of syncope brought on by laughing, coughing and emotional distress. Each episode lasted several minutes with no post-ictal period. She denied any olfactory or visual auras. These episodes were witnessed and she did not have any jerking movements, tongue lacerations, or injuries.

In the last year she noted frequent headaches and transient periods of palpitations lasting minutes. She denied use of cigarettes, alcohol, or drugs. She reported eating a high potassium diet due to history of hypokalemia without a specific diagnosis dating to childhood. She took no medications. Family history was significant for hypokalemia in her sister.

On presentation, her blood pressure was 97/62 with negative orthostatic vital signs. Labs were notable for K 2.5, Mg 1.4, HCO3 28. EKG was notable for stable RBBB. The patient underwent cardiac and neurological evaluations including cardiac monitoring, TTE, CT Head and MRI of the head and neck. Genetic testing was sent for Gitelman and Bartter syndrome and four weeks later she was diagnosed with Gitelman syndrome. She was started on high dose potassium and magnesium supplementation and did not have further syncopal episodes.

IMPACT/DISCUSSION: Gitelman syndrome is an inherited disorder resulting in defective NaCl resorption in the distal convoluted tubule. It is an uncommon hypokalemic and hypomagnesemic tubulopathy which often presents with unexplained metabolic alkalosis and a normal or low blood pressure. It presents with muscle weakness or cramps, fatigue, salt craving, thirst and polydipsia. Less commonly, it presents with palpitations secondary to prolonged QT intervals from electrolyte abnormalities.

This case highlights a unique presentation of Gitelman syndrome. Syncope is a common initial reason for admission in our general patient population and few case studies exist which describe episodes of recurrent syncope in patients diagnosed with Gitelman syndrome. Here, we demonstrate that in patients presenting with recurrent syncope and electrolyte abnormalities, specific genetic causes should also be considered. This allows for timely diagnosis and patients can be expeditiously treated to avoid risk of morbidity.

Medical therapy is directed at correcting electrolyte abnormalities with oral supplementation and hypovolemia with close monitoring every three or four months with a nephrologist. Patients unresponsive to supplementation require potassium-sparing diuretics, NSAIDs or ACE inhibitors. Kidney transplantation is recommended in patients who develop severe chronic kidney disease.

CONCLUSION: 1. Syncope is a unique presentation of Gitelman syndrome

2. Gitelman syndrome presents with hypokalemia, hypomagnesemia, metabolic alkalosis and normal or low blood pressure

3. Treatment of Gitelman syndrome involves correction of electrolyte abnormalities and hypovolemia

FROM THE LENS OF A PSEUDO-CARDIOLOGIST: WHAT EVERY PRIMARY CARE PHYSICIAN NEEDS TO KNOW

Mathew Karivelil¹; Kinley Buckley¹; Luke Casals¹; Reza Atras²; Kevin O'Brien¹; ¹Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL; ²Department of Emergency Medicine, Mount Sinai Morningside Hospital, New York, NY. (Control ID #4062887)

CASE: Mr. P is an 83-year-old male with a history of severe aortic stenosis, hypertension, and prediabetes who was seen in primary care clinic five days following TAVR procedure. He complained of swelling in the right groin with minor pain. The exam was notable for extensive ecchymoses around the catheter insertion site, 2+ bilateral femoral pulses, and a right-sided femoral bruit. Vitals and labs were unremarkable with a stable hemoglobin. On chart review, the patient tolerated the procedure well and was discharged without complication.

His primary care physician (PCP) ordered a color doppler ultrasound (DUS) of the right groin which revealed a 1.9 x 1.8 X 1.9 cm femoral pseudo-aneurysm (PSA) with a long and wide neck. He was re-admitted to the hospital for thrombin injections. Follow-up PCP visits noted improvement in pain and swelling.

IMPACT/DISCUSSION: In today's healthcare landscape, there is an emphasis on reducing hospital length of stay with overall evidence indicating stable patients undergoing percutaneous coronary intervention (PCI) can be discharged after six hours of monitoring. PSA may be easily overlooked during this period, as common occurrence of post-procedural hematoma can obscure presentation. Thankfully, rapid primary care follow-up may uncover missed PSA. Therefore, it is necessary to enhance PCP awareness for recognition, diagnosis, and therapeutic approaches to PSA.

History and physical exam remain the hallmark of diagnosis of PSA. This patient’s physical exam findings of a pulsatile mass, ecchymosis, bruit, and palpable thrill increased suspicion for PSA. Color doppler ultrasound (DUS) is the preferred imaging modality with a sensitivity of 92 – 96%. Findings include swirling color flow seen in a hypoechoic structure adjacent to the affected artery, color flow within a tract leading from the artery (PSA neck), and “to-and-fro” doppler waveform in the PSA.

Management of PSA is guided by size of the defect. PSA measuring less than 2 – 3 cm can be managed conservatively. PSA greater than 3 cm typically require intervention. Treatment options include US-guided thrombin injection (UGTI), embolization, covered-stent deployment, or surgical repair.

CONCLUSION: Prompt recognition of post-PCI complications in primary care follow-up is necessary to prevent morbidity and mortality—especially as PCI become more commonplace. In this case, further sequelae of femoral PSA were prevented by the actions of an astute clinician. We reviewed the clinical features, diagnosis, and management of PSA in the primary care setting.

GLABRATA GOES ON: TREATMENT FAILURE IN VULVOVAGINAL CANDIDIASIS

Sophia Kerman¹; Kriti Prasad². ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Medicine, Boston Medical Center, Boston, MA. (Control ID #4064071)

CASE: A27-year-old woman with class III obesity (BMI 57) presents to clinic with vulvovaginal pruritus and malodorous discharge. 2 weeks prior she received a 7 day course of Bactrim for perianal abscess. Abscess resolved with exam showing vulvovaginal erythema and malodorous white discharge.

Empiric oral fluconazole was prescribed for a presumed candidiasis, but she had no improvement of symptoms. 3 days later she was instructed to take a second dose of fluconazole and symptoms resolved.

1 week later, patient returned with vaginal pruritus, erythema and discharge. Vaginal cultures grew Candida Glabrata. Topical Miconazole for 7 days was initiated with symptom resolution. Labs also showed HgA1c 12.5% and Metformin was started for new diabetes.

IMPACT/DISCUSSION: Vulvovaginal candidiasis (VVC) is a common disorder among women with ~75% reporting at least 1 lifetime episode. Typical symptoms include vulvar and/or vaginal pruritus, soreness or irritation, dyspareunia, dysuria, and vaginal discharge although none are specific for VVC. Physical exam may show vulvar erythema, edema, vaginal erythema, and thick, clumpy white discharge. While this patient’s discharge was malodorous, most have no odor. Official diagnosis requires presence of Candida in the setting of characteristic clinical findings. VVC is classified as either uncomplicated or complicated. Criteria for complicated VVC include 3+ confirmed infections within 12 months, severe disease symptoms, suspicion for non-albicans species or fluconazole resistance, or host abnormalities such as pregnancy, uncontrolled diabetes, or immunocompromise. This patient has uncontrolled diabetes and cultures grew non-albicans Candida species so is classified as complicated VVC. For treatment, a single dose of intravaginal or oral azole treatment, such as fluconazole, results in symptom relief and negative cultures in 80% - 90% of uncomplicated VVC. C albicans is the cause of 80% - 92% of VVC and the next most common pathogen is C glabrata. C glabrata does not respond to usual VVC therapy. Optimal treatment of non–albicans VVC remains unknown given low quality evidence. CDC recommends a 7-14 days of non-fluconazole azole with addition of intravaginal boric acid gelatin capsule if symptoms recur. In contrast, IDSA recommends either 14 days of boric acid capsule or intravaginal nystatin suppository, but recommends against use of any azoles. In VVC cases with lack of response to traditional flucazole therapy, as seen in this patient, should lead to consideration of C Glabrata or other species. However, in this patient, treatment failure may have been multifactorial with inappropriate both pharmacotherapy and lack of glucose control given undiagnosed diabetes.

CONCLUSION: Varying treatment regimens highlight the importance of obtaining cultures in patients with persistent or recurrent symptoms. In cases of azole treatment failure, ensure appropriate species of candida are targeted and immunocompromising factors are addressed.

HINDSIGHT IS HUMBLING: PREMATURE CLOSURE IN A CASE OF WORSENING ANEMIA ON ANTICOAGULATION AND ANTI-PLATELET THERAPY.

Kathryn Vessel¹; Clare Nosenchuck²; Joshua Levenson²; Sarah Jones³. ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Heart and Vascular Institute, UPMC, Pittsburgh, PA; ³General Internal Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4065081)

CASE: Our patient is a 76-year-old man with a history of mild macrocytic anemia (Hgb 12.7 g/dL, MCV 103.8 fl) with mild B12 deficiency identified four years earlier. In the intervening years, he was diagnosed with atrial fibrillation and initiated on apixaban for stroke prophylaxis. Clopidogrel was also initiated after placement of drug eluting stents (DES) for obstructive coronary artery disease (CAD). After four years with stable hemoglobin between 11-13 g/dL, his hemoglobin acutely dropped to 9.7 g/dL with an inappropriately low red cell distribution width (RDW) and normal iron studies. Colonoscopy was ordered given concern for gastrointestinal (GI) bleeding but deferred as clopidogrel discontinuation was contraindicated. No additional anemia evaluation was completed at that time.

Months later, he then presented with weight loss and fatigue. Physical exam was notable for normal vital signs and pallor. Laboratory testing was notable for Hgb 8.7 g/dL, Platelets 605 x 10^9/L, MCV 105.6 fl, an inappropriately low reticulocyte index, and no evidence of iron deficiency or hemolysis. Peripheral blood smear revealed frequent rouleaux formation, anemia, and lymphopenia. Further studies revealed M-spike on protein electrophoresis and elevations in the free kappa/lambda ratio and β2 microglobulin. He was referred to hematology for evaluation of suspected multiple myeloma.

IMPACT/DISCUSSION: This case illustrates the challenges of deciding when a stable problem merits additional evaluation. In this case, when the patient’s chronic anemia worsened, clinicians recognized the change but only pursued a partial evaluation of the anemia. Given the high prevalence of bleeding complications in patients on direct oral anti-coagulants and anti-platelet medications, slow GI bleeding was the presumed etiology. However, discordant findings of macrocytic anemia with normal iron studies and inappropriately low RDW were dismissed, which is an example of premature closure bias. Rather than expand the differential diagnosis to include an evaluation for hypoproliferative or hemolytic anemia, the patient’s diagnosis of suspected multiple myeloma was delayed.

CONCLUSION: Internists are skilled at developing differential diagnosis for acute problems. This case illustrates how clinical reasoning bias may delay diagnosis when a chronic problem needs to be re-identified as a new, acute problem. As such, new or worsened anemia on medications that increase propensity for bleeding should be evaluated urgently as hypoproliferative, hemolytic, and blood loss anemia – not exclusively as blood loss anemia.

HISTORY IS KING: A CASE OF SUPPLEMENT-INDUCED CUSHING SYNDROME

Nathan G. Rockey¹; Ben Drumright³; Katherine Ochoa². ¹Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²General Internal Medicine, Denver Health Medical Center, Denver, CO; ³Internal Medicine, Denver Health, Denver, CO. (Control ID #4058105)

CASE: Patient is a 50-year-old Hispanic woman with history of hypertension not on medications and hyperlipidemia on a statin who presented to clinic with facial swelling and progressive fatigue for 4 months. She denied any skin changes or sleep alteration. She had no leg swelling, orthopnea or paroxysmal nocturnal dyspnea. She had not noticed morning stiffness or myalgias. She had no known family history and did not smoke, use alcohol or other drugs. Her vitals were normal and her BMI was 35. On exam, her face was round, slightly out of proportion to her body. She had no striae on her abdomen. Heart and lung exam were normal. She had no JVD or lower extremity edema. Labs were notable for a morning cortisol that was undetectably low (<0.5 ug/dL). Her TSH, CBC, CMP, BNP were normal. Upon further discussion with the patient, we learned she was taking a daily supplement called Artri King for pain over the past 6 months. This supplement contains several undeclared ingredients including dexamethasone. The patient was advised to slowly taper this medication. On follow up more than one month after discontinuation, the patient was feeling significantly improved with resolving facial plethora and without clinical evidence of adrenal insufficiency.

IMPACT/DISCUSSION: Testing for Cushing syndrome should include 1 or 2 of the following, a) low dose dexamethasone suppression test, b) Late night salivary cortisol or c) 24-hour urinary free cortisol. Indications for testing include constellation of symptoms consistent with Cushing (proximal myopathy, easy bruising, facial plethora, abdominal striae), as well as signs of hypercortisolism such as osteoporosis at a young age. In our case, our clinical suspicion for Cushing syndrome was low as the patient had only one clinical sign and thus we deviated from typical workup. The result was serendipitous. Ordering a serum cortisol which was unexpectedly low prompted further historical investigation which uncovered the diagnosis of exogenous Cushing syndrome. Notably, a dexamethasone suppression test would have been normal in this patient. This case highlights supplement use as an essential component of gathered history when suspecting endocrinopathies. Multiple case reports exist of Artri-King induced Cushing Syndrome including causing hip fracture and subsequent adrenal insufficiency upon cessation. However, despite the FDA warning of Artri King, it is still being used by patients, particularly from Central America.

CONCLUSION: Exogenous Cushing syndrome via OTC supplements is an essential component of the history in a patient with suspected hypercortisolism.

IGA VASCULITIS: IT'S NOT JUST FOR KIDS

Emily E. Kahlandt. Internal Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI. (Control ID #4063663)

CASE:

A 67yo female with a history of alcohol use disorder, migraines and chronic pain presented to the ED with headaches and diffuse arthralgias. Her usual doses of ibuprofen and acetaminophen offered no relief. In a recent hospitalization, she was treated for a urinary tract infection with 2 doses of ceftriaxone and 3 days of nitrofurantoin. ED exam revealed palpable purpura on the bilateral lower extremities of which the patient was unaware. Labs including CMP, CBC, and PT/INR were normal so symptoms were attributed to a possible viral syndrome. Patient was discharged with advice to follow up with her dermatologist and PCP. One week later, Dermatology performed a punch biopsy of her lower extremities that revealed positive direct immunofluorescence (DIF) for IgA and C3, consistent with IgA vasculitis. Her symptoms resolved over the next month, and patient remains without complications.

IMPACT/DISCUSSION:

IgA vasculitis is typically self-limiting and 2-33 times more common in children with a mildly higher incidence in males. The most common symptom is purpuric rash, but arthritis and abdominal pain also occur. One study found that 96% of patients presented with purpuric rash and 61% with arthritis. Given a lower incidence in adults, skin biopsy is recommended to confirm diagnosis. Kidney injury is also seen on presentation; one paper reported renal involvement in 1/3 of adult patients. Thus, monitoring serum creatinine, UA and blood pressure for at least a year is warranted. Symptoms resolve spontaneously in the majority of cases, 89% according to one report. Some patients do experience relapse (32% in one study) usually with purpuric rash (88.7%). Disease pathogenesis is unclear but infections and medications are common preceding exposures. A South Korean pediatric study reported seasonal incidence: 31% of cases occurred in the spring, peak time for respiratory/enteral illness. The pathogens included influenza virus, norovirus, and rotavirus. Another pharmacologic database study found beta-lactams to be associated with high incidence of IgA vasculitis. Case reports reveal an association between solid-organ malignancy and IgA vasculitis; a 2012 review suggested malignancy evaluation for adults with no other explanation for presentation. In this case, we suspected that presentation was due to either UTI or antibiotics. The case heightened my awareness of IgA vasculitis as a cause of purpura in adults. It also reinforces the judicious use of antibiotics and importance of patient counseling on side effects.

CONCLUSION:

1. IgA vasculitis presents with nonthrombocytopenic palpable purpura, arthralgias and abdominal pain

2. It is usually self-limited with spontaneous resolution in most adult patients

3. While the etiology is unclear, a preceding illness or exposure to new medications, particularly beta-lactam antibiotics, can trigger IgA vasculitis

IMMUNOTHERAPY ALERT FOR INTERNISTS: A CASE OF CUTANEOUS TOXICITY IN A PATIENT ON PEMBROLIZUMAB

Natasha Mathur²; Parvinder Khurana¹. ¹Medicine, The George Washington University, Washington, DC; ²Internal Medicine, The George Washington University, Washington, DC. (Control ID #4062665)

CASE: Our patient is a 55-year-old female with stage 3C high-grade serous ovarian carcinoma diagnosed in May 2021. After failing six cycles of Carboplatin/Paclitaxel treatment, she was started on daily cyclophosphamide and infusions of Pembrolizumab every 3 weeks in December 2022.

Six months later, she presented to the General Medical clinic for a routine exam. A review of systems revealed a history of pruritis vulvae and spots on her thighs, particularly in areas that she had been scratching. Her last Pembrolizumab infusion was 10 days prior and she had not started any new medications or had any change in her body cleansers or detergents. On exam, there were hypopigmented macular, vesicular, and plaque like lesions on her vulva, and thighs. Lesions were of varying size with vulvar lesions being largest. Overall, the rash had the appearance of a lichenoid dermatitis.

On our list of differential diagnoses, Pembrolizumab toxicity was the most likely. On further discussion with her oncologist, she was started on topical clobetasol, and her Pembrolizumab was held for six weeks, with a plan for a skin biopsy if her rash did not improve. Fortunately, her rash improved and her Pembrolizumab treatment was resumed with continuation of topical steroids.

IMPACT/DISCUSSION: Pembrolizumab is a type of monoclonal antibody belonging to the class checkpoint inhibitors and subclass PD-1 inhibitors. Dermatologic adverse effects of Pembrolizumab are well known in the oncology community, occurring in up to 34% of patients, and typically at 9-20 weeks after treatment initiation. The most common manifestations include pruritis, maculopapular, and vitiligo-like lesions, with fewer than 3% of patients progressing to a grade 3 or 4 reaction. Immunotherapy has made cancer a chronic disease, and internists will often manage patients on these drugs. Thorough medication reconciliation to include intermittent infusions is essential. Awareness of the risk profile of these drugs can lead to early recognition and prompt treatment. In mild cases, temporary discontinuation of Pembrolizumab, and treatment with topical steroids may be adequate to salvage the anti-neoplastic regimen. Some of the cutaneous lesions associated with the drug such as lichen sclerosis and vitiligo are associated with Koebner's phenomenon. Therefore, eliciting a history of new lesions at sites of trauma may lead to an earlier diagnosis. Furthermore, though Pembrolizumab is known to cause cutaneous adverse events there are very few reports describing vulvar involvement. Biopsy is recommended before use of systemic steroids.

CONCLUSION: ● Cutaneous manifestations are common side effects of immune checkpoint inhibitors like Pembrolizumab, a drug used in the treatment of several malignancies including advanced ovarian cancer.

● Lichenoid eruptions and vitiligo are the most common cutaneous side effects of these agents.

● Early recognition can lead to prompt treatment which in some cases can minimize compromise of their anti-neoplastic regimen.

IMPORTANCE OF SCREENING FOR SECONDARY CAUSES OF OSTEOPOROSIS

Ashley Rangel. Internal Medicine, The University of Texas Health Science Center at San Antonio Joe R and Teresa Lozano Long School of Medicine, San Antonio, TX. (Control ID #4061577)

CASE: A 53 year old female with past medical history of seasonal allergies presented to clinic for evaluation and treatment of osteoporosis. Patient was initially diagnosed with osteoporosis at age 30 in South Africa based on BMD. She reports that she was on Fosamax for 20 years and self-discontinued at age 50. Osteoporosis confirmed at current age based on BMD. She reports normal calcium intake during childhood and adolescent years, without history of eating disorders. Denied history of smoking or alcohol use. Denied treatment with glucocorticoid or anticonvulsant medications. Denied history of nephrolithiasis, RA, COPD. Family history remarkable for osteoporosis in grandmother. Secondary workup remarkable for elevated iPTH (124) and elevated Ca (11.7). Other secondary workup unremarkable. Given elevated iPTH and elevated calcium, patient underwent sestamibi scan that was remarkable for right paratracheal parathyroid adenoma lower pole thyroid lobe. She subsequently underwent parathyroidectomy. Repeat labs 2 months after parathyroidectomy remarkable for improvement in iPTH (42) and Ca (9.7). Plan to repeat BMD in one year with expected improvement in bone density. No further treatment of osteoporosis indicated in this patient given that underlying cause was treated.

IMPACT/DISCUSSION: Osteoporosis is a disorder of bone that results in increased bone fragility. The primary cause of osteoporosis is the loss of the protective effect of estrogen on bone that leads to loss of bone mass. Secondary causes of osteoporosis can be due to certain medications or other underlying process that can result in excessive bone resorption affecting bone mass (Ganesan K, Jandu JS, Anastasopoulou C, et al. Secondary Osteoporosis). Screening for secondary causes of osteoporosis is important because treatment can differ depending on underlying cause. Screening for secondary causes of osteoporosis can be done for all patients but is indicated for premenopausal women and men aged less than 50 years old.

This case highlights the importance of evaluating secondary causes of osteoporosis as this patient’s workup was remarkable for primary hyperparathyroidism. Hyperparathyroidism increases the risk of osteoporosis due to the increased rate of bone turnover. The treatment of hyperparathyroidism usually results in the reversal of bone loss after 1 to 2 years (Ganesan K, Jandu JS, Anastasopoulou C, et al. Secondary Osteoporosis). The effective management of secondary osteoporosis is to treat the underlying cause.

CONCLUSION: Screening for secondary causes of osteoporosis should be routine for indicated patient populations. Increased awareness of screening for secondary causes of osteoporosis can lead to optimal management and improved bone health for patients.

INCIDENTAL PANCREATIC MASS IN AN ASYMPTOMATIC 65-YEAR-OLD MALE

Maimuna Marenah¹; Bernice Ruo²; Jessica Chen². ¹School of Medicine, University of California System, Oakland, CA; ²Medicine, University of California San Diego, La Jolla, CA. (Control ID #4064395)

CASE: 65-year-old male with past medical history of impaired fasting glucose and an extensive family history of high-grade cancers presented to clinic with an incidental pancreatic mass found on abdominal ultrasound for monitoring of a hepatic cyst. The patient was otherwise healthy and denied weight loss, nausea, or vomiting. Physical exam showed anicteric sclera, non-jaundiced skin, and no abdominal tenderness. The patient was referred to oncology. Pancreatic tumor markers (CA 19-9 and CEA) and amylase were within normal limits. Magnetic resonance cholangiopancreatography confirmed the presence of a 2 cm mass which was associated with mild pancreatic duct dilation. Cytopathology from the fine needle aspirate of the mass found atypical cells, fragments of stromal fibrosis, and mild inflammation suggestive of low-grade pancreatic adenocarcinoma. Given the high suspicion for pancreatic malignancy, the patient proceeded with diagnostic laparoscopy and distal pancreatectomy. Surgical specimen cytopathology showed lymphoplasmacytic infiltrate with fibrosis and obliterative phlebitis without evidence of carcinoma. Reactive changes in pancreatic ducts and acini were consistent with prior atypical cells on FNA pathology. IgG4 and IgG immunostains were applied, which yielded 300 plasma cells per hpf for both, which is compatible with IgG4-related sclerosing autoimmune pancreatitis.

IMPACT/DISCUSSION: Autoimmune pancreatitis (AIP), also called sclerosing pancreatitis or non-alcoholic destructive pancreatitis, is a systemic fibroinflammatory disorder characterized by elevated IgG4 levels in serum and infiltrating individual organs causing dysfunction. There are two types of autoimmune pancreatitis: Type 1 is associated with fibrosis and sclerosis in multiple organs, while damage in Type 2 is localized to the pancreas. Infiltration of IgG4+ plasma cells may extend to the liver, retroperitoneum, bile duct, and salivary glands and can mimic malignancies of other organs including the kidney. In contrast to pancreatic cancer, AIP is largely benign with mild clinical symptoms. Patients often present with obstructive jaundice, pancreatic mass and/or enlargement, and pancreatitis with mild abdominal pain. Treatment with glucocorticoids can lead to marked decreases in IgG4 levels in the blood and affected organs. While there is no single laboratory marker for pancreatic cancer, there are tools available for identifying AIP. The Mayo Clinic HI-SORt criteria for diagnosing provides a useful mnemonic. HI-SORt criteria are met in patients with histology demonstrating lymphoplasmacytic infiltrate or fibrosis; imaging evidence of pancreatic enlargement; serology evidence of hypergammaglobulinemia (IgG4 elevation), other organ involvement; or response to steroid therapy.

CONCLUSION: A patient presenting with a pancreatic mass with suspicious cytopathology may suggest a poor prognosis. We present an atypical presentation of autoimmune pancreatitis as the cause of pancreatic mass.

INTERDISCIPLINARY COLLABORATION TO ADDRESS ANTIPSYCHOTIC-INDUCED WEIGHT GAIN

Ari M. Fish¹; Shyam Sundaresh². ¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Department of Medicine, Mount Sinai Health System, New York, NY. (Control ID #4064924)

CASE: A 55-year-old woman with class 3 obesity, prediabetes, hypertension, hyperlipidemia, and complex PTSD came to clinic to request an antiobesity medication. Despite multiple lifestyle interventions, her weight plateaued between 235-240 lbs. Worsening trauma-related symptoms, including auditory hallucinations, increased her desire to cope by eating, and her psychiatrist recommended starting aripiprazole which she worried would adversely affect her weight. Her insurance did not cover any antiobesity medication. On exam, she was alert and oriented with normal mood and affect. Vitals were notable for BP: 124/85, HR: 70 Wt: 237 lbs, Ht: 5' 2", BMI: 43 kg/m². Relevant labs included: A1c 5.7, TC 218, LDL 143, HDL 61, TG 70. We initiated an email thread with her psychiatrist, and after a thorough discussion about the pros and cons of various low-cost antiobesity medications, collaboratively decided to prescribe metformin.

IMPACT/DISCUSSION: This is an important case for the general internist because patients like ours with metabolic syndrome and obesity are at risk for antipsychotic-induced weight gain (AIWG), even with antipsychotics like aripiprazole which are considered to be more weight-neutral. When starting antipsychotic treatment, roughly 80% of patients gain a clinically significant amount of weight, which can increase risk for developing diabetes and heart disease. Thus, clinicians should feel empowered to prescribe antiobesity medications to prevent or treat AIWG if within the patient’s health goals. Choice of pharmacotherapy to prevent AIWG should take into account patient symptomatology, drug safety profile, and cost. Evidence-based antiobesity medications include GLP1RA, phentermine/topiramate, and bupropion/naltrexone. GLP1RA for obesity are not covered by many insurances and are costly out-of-pocket. Though complex PTSD is not an explicit contraindication to phentermine/topiramate or bupropion/naltrexone, our collaboration with psychiatry made clear that these medications had the potential to worsen our patient’s psychiatric symptoms. Emerging guidelines support the use of metformin for the prevention and treatment of AIWG. Thus, the decision was made to trial metformin, on which patients lose an average of 5-7% weight, which is clinically significant and impactful for health.

Increasing national rates of both obesity and psychiatric illness make this case particularly timely. Given that antipsychotic medications often cause weight gain and antiobesity medications may exacerbate psychiatric symptoms, close collaboration between general internists and psychiatrists should be commonplace in order to promote optimal patient outcomes.

CONCLUSION: 1) Literature supports metformin to prevent and treat antipsychotic-induced weight gain

2) Antiobesity medications may impact psychiatric conditions, so close discussion with psychiatry is beneficial to prescribe safely.

IRONING OUT THE DETAILS OF ASYMPTOMATIC HEPATOMEGALY

Akiff Premjee¹; Cary Blum². ¹Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; ²Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4050924)

CASE: A 32 y/o F with a PMHx of Raynaud’s presented for an incidental finding of hepatomegaly on MRI done for low back pain (found to be sacroiliitis). A liver ultrasound showed a liver span of 18.5 cm (ULN 16 cm) with smooth contour and normal echogenicity and a 3.6 x 2.6 x 3.3 cm homogeneous hyperechoic lesion with surrounding vessels, consistent with a hemangioma.

The patient endorsed nausea but no jaundice, abdominal pain, diarrhea, fever, weight loss, or fatigue. There was no history of smoking, alcohol use, or other drug use. Her physical exam was benign. While the hemangioma was an adequate explanation for her liver size, the patient requested a workup to rule out other etiologies of hepatomegaly.

Initial diagnostic studies included LFTs, iron deficiency profile, alpha-1-antitrypsin level, CBC, BMP, and TSH. Results were all within normal limits. However, the patient’s transferrin saturation was 46% (ULN = 50%) and ferritin was 166 (ULN = 204). A fasting repeat sample two weeks later with a genetic analysis for hemochromatosis showed a transferrin saturation of 18%, ferritin of 59, and negative HFE gene analysis. Given these results, the most likely cause of her hepatomegaly was the hemangioma.

IMPACT/DISCUSSION: This case highlights the diagnostic workup of hepatomegaly, the low specificity of iron studies in the workup of iron overload, and the challenge of recognizing results that are “within normal limits” but abnormal for a given patient. In our patient’s case, a high-normal transferrin saturation in a menstruating person was unexpected. This triggered us to consider hemochromatosis as an explanation for hepatomegaly, even in the face of a more likely diagnosis (hemangioma). In this case, the initial high-normal ferritin was likely related to sacroiliitis, and high-normal transferrin saturation was possibly related to ingestion of an iron-containing meal.

Hepatomegaly is not an uncommon finding, with one study showing a liver span of >16 cm (considered hepatomegaly) present in 12% of patients. Though sex and body size should be considered, a general workup for asymptomatic hepatomegaly includes evaluating for cholestatic liver disease (PBC/PSC), storage disorders (hemochromatosis, Wilson, or alpha-1-antitrypsin deficiency), and infiltrative diseases (amyloidosis, sarcoidosis, hemangiomas, FNH, or malignant tumors).

CONCLUSION: - Diagnostic considerations in patients with asymptomatic hepatomegaly include cholestatic liver disease, storage disorders, and infiltrative diseases.

- Elevated or high-normal transferrin saturation in a patient with menses is abnormal and may trigger genetic testing for hemochromatosis; however, recognize that iron studies can be strongly influenced by inflammation and iron ingestion.

IS A PERCEIVED NON-COMPLIANT PATIENT REALLY NON-COMPLIANT?

Jessica Chen¹; Armelia Sani¹; Miriam Hakim¹; James Samson². ¹Internal Medicine, University of California San Diego, La Jolla, CA; ²University of California San Diego, San Diego, CA. (Control ID #4061641)

CASE: A 47-year-old Hispanic female with a history of intermittent refractory hypothyroidism since 2006 and anxiety presented to Primary Care Clinic for progressive facial and hand swelling for 6 weeks, with associated increasing fatigue, constipation, and dyspnea on exertion. The patient denied bloating, diarrhea, allergies, itching, wheezing, tongue swelling, or paroxysmal nocturnal dyspnea, taking new medications, supplements, iron, calcium, or biotin. She also denied gluten sensitivity or non-compliance with her thyroid medication regimen. She had been taking a dose of 125 mcg of levothyroxine around 2-3 hours before bedtime for more than one year.

The physical exam showed normal vital signs, mild diffuse facial, hand, finger, and foot swelling, with mildly diminished deep tendon reflexes at the knees. Labs showed normal CBC, pro-BNP, and CMP. TSH was found to be 304.0. Her TSH was normal 10 weeks prior to this presentation. Patient had a history of intermittent refractory hypothyroidism with very elevated TSH (86, 251, 61, 162) of unknown etiology for the past several years and had consistently denied non-compliance. Her TTG IgA Ab was normal. Further questioning revealed that for years the patient placed her thyroid medication bottle on her nightstand next to a hot and bright lamp. This storage problem was determined to be the cause of her treatment-refractory hypothyroidism. Once the patient received a new prescription of levothyroxine 125 mcg and stored it in a medicine cabinet, her TSH level normalized consistently.

IMPACT/DISCUSSION: Even though poor compliance is the most common reason for refractory hypothyroidism, clinicians should consider other causes if a patient denies non-compliance. An increased need for thyroid hormone dosage can be attributed to several factors. One is interference with absorption, which includes the timing of medication administration with food and the consumption of other medications/supplements. Others include GI malabsorption, interference in immunoassay, increase in turnover or excretion, and the integrity of the medicine.

Up to 5% of refractory hypothyroidism can be attributed to improper storage, as in this patient’s case. The integrity of thyroid medication can be affected by heat, humidity, and light. Many patients keep medications in the bedroom or kitchen. This patient’s thyroid medication was stored in a transparent vial, exposed to bright light and heat next to a large hot lamp at a nightstand for many hours a day. Recent guidelines recommend storing Levothyroxine at 20-25° C (68–77° F). Many textbooks or guidelines do not mention inappropriate storage as a cause for treatment failure.

CONCLUSION: A perceived non-compliant patient may not be non-compliant.

Proper medication storage should be part of the history for refractory hypothyroidism

IS IT DIARRHEA OR CONSTIPATION? NAVIGATING COMPLICATIONS IN PARKINSON’S DISEASE

Dillon A. McKinley, Emily M. Jones. General Internal Medicine, University of Colorado System, Denver, CO. (Control ID #4057688)

CASE: A 62-year-old male with a history of Parkinson’s Disease (PD), iron deficiency anemia (IDA), and gastric bypass surgery presented to clinic with acute on chronic left-sided abdominal pain, bloating, and watery diarrhea with episodic fecal incontinence. Over the course of several visits, the patient complained of GI symptoms as well as persistent fatigue thought to be related to his IDA. He underwent upper endoscopy and colonoscopy which did not identify a source of bleeding but did show changes consistent with chronic constipation. A few months later, his diarrhea worsened. GI PCR returned negative, and symptoms were attributed to IBS. He was provided a course of rifaximin, which had been helpful for a prior IBS flare. 8 weeks later, he returned with continued loose stools, worsening abdominal pain, bloating, and new shortness of breath. At that time, vitals were normal. Abdominal exam revealed distention and mild diffuse tenderness without rebound or masses. An abdominal X-ray revealed a 7.5cm rectal fecalith, establishing a diagnosis of fecal overflow incontinence secondary to PD-related autonomic dysfunction resulting in chronic constipation. The patient was given a glycerin suppository, started on senna and miralax, and was provided dietary and lifestyle education to prevent recurrence.

IMPACT/DISCUSSION: 90,000 adults are diagnosed with PD in the US annually; however, it is notoriously difficult to establish care with Neurology. Some studies have cited wait times of more than 35 business days following referral placement. This supply and demand mismatch for Neurology appointments may negatively impact patient outcomes, thus this case emphasizes the importance of understanding the multi-system consequences of PD as an ambulatory provider. Patients with PD experience many non-motor symptoms such as autonomic dysfunction, fatigue, anxiety, and depression – conditions commonly managed in primary care clinics. Given the growing population with PD, the limited availability of outpatient Neurology providers, and the significant wait time to establish care, it is critical that internists are empowered to identify and address non-motor manifestations of PD. Internist-driven early symptom intervention provides a path to improved quality of life and patient satisfaction as they navigate a complex, diffuse disease process.

CONCLUSION: * The incidence of Parkinson’s Disease is increasing while wait times to establish with Neurology lengthen.

* Parkinson’s Disease leads to complications familiar to and managed by internists, therefore non-motor symptom intervention will improve patient quality of life.

IT’S NOT CANCER, JUST A VARICOSE VEIN: A RARE CAUSE OF AXILLARY MASS

Srilakshmi Garikapati¹; Cary J. Blum². ¹Internal Medicine, Mount Sinai Health System, New York, NY; ²Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4031278)

CASE: We present the case of a 29-year-old female with no PMH who presents with a painless lump under her left armpit first noticed by the patient in the shower while washing the area. On exam, the patient was noted to have at least 2 axillary masses palpable only in the standing position with the left arm abducted and externally rotated. Due to an additional concern on exam for a possible breast mass, she underwent a mammogram and breast ultrasound, both of which were unrevealing. She then had an MRI without contrast of the shoulder which noted slight prominence of the basilic vein but was otherwise normal. These findings prompted further evaluation with Doppler ultrasound which revealed a basilic vein aneurysm with multiple outpouchings up to 2.5 cm in diameter, thus explaining the palpable findings. She was referred to vascular surgery and options for management were discussed including watchful waiting for any changes vs. surgical excision.

IMPACT/DISCUSSION: This case highlights the availability bias and confirmation bias that may impact the workup of an axillary mass. In this case, multiple modalities of breast imaging were used in pursuit of a breast pathology to explain the exam findings. However, the observation that her masses became more prominent with the patient’s arm elevated overhead suggest a diagnosis of venous aneurysm as opposed to more common entities such as lymphadenopathy or a neoplasm. Duplex ultrasonography can confirm the diagnosis and provides useful information regarding the anatomy and physiologic impact of the lesion. Basilic vein aneurysms in particular are a rare entity and are typically asymptomatic. However, it is important to consider this diagnosis in the differential for an axillary mass, as early recognition may prevent unnecessary testing and patient anxiety. Once diagnosed, management of a basilic vein aneurysm typically occurs in collaboration with a vascular surgeon, and may involve surgical excision or a more conservative approach with periodic monitoring.

CONCLUSION: a) Considering basilic vein aneurysms as a possible etiology of an axillary mass can lead to earlier diagnosis and prevention of invasive testing.

b) Performing a physical exam with special attention to positional changes can help distinguish venous aneurysms from other types of masses.

c) Doppler ultrasound is a readily available and minimally invasive modality with high sensitivity and specificity for venous aneurysm.

JOURNEY FROM ALCOHOL POLYNEUROPATHY TO A RARE DIAGNOSIS

Aditi Sharma¹; Michelle V. Conde^1,2. ¹Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ²Audie L Murphy Memorial Veterans' Hospital, San Antonio, TX. (Control ID #4064098)

CASE: A 41-year-old male with MDD and ETOH disorder presented to the primary care clinic with low back pain, bilateral knee pain, falls, and numbness and tingling in feet for 5 years. Family history was unknown. His diagnosis was alcohol polyneuropathy. He presented for follow-up several months later with persistent numbness and tingling in feet, repeated falls, and fecal and urinary incontinence.

He craved salt and had persistent symptoms of fatigue and poor appetite plus hyperpigmentation of oral mucosa and tongue. His BP was 120/70. Neurological exam was notable for lower extremity weakness with upper motor neuron (UMN) findings of increased tone, bilateral patellar hyperreflexia, and clonus (R>L). Na⁺ was 140 and K⁺ 3.8. HIV and syphillis screen were nonreactive. Brain MRI showed findings consistent with white matter lesions in cerebellum and corpus callosum and diffuse atrophy of the thoracic spinal cord at the T5 level. Because B12 and copper deficiency can result in combined myelopathy and neuropathy, these levels were also checked and were normal. An EMG was suggestive of a symmetric, demyelinating polyneuropathy involving the lower limbs. Primary adrenal insuffiency (AI) was confirmed by elevated ACTH levels and low baseline cortisol with no stimulation response. Plasma very long-chain fatty acids (VLCFAs) were markedly elevated; thus, genetic testing was obtained and found to be hemizygous for variant known to cause X-linked adrenoleukodystrophy (X-ALD). The patient was diagnosed with X-linked adrenomyeloneuropathy (X-AMN).

IMPACT/DISCUSSION: The patient’s initial symptoms were attributed to DJD and alcohol polyneuropathy. The initial physical examination did not include a systematic evaluation to elicit findings concerning for upper motor neuron lesions. There was a predominant focus on the patient’s mental health problems and less focus on his other health concerns, which is described in the literature as diagnostic overshadowing.

X-ALD is a peroxisomal disorder caused by genetic mutations in the ABCD 1 gene that results in accumulation of abnormal VLCFAs in the CNS, adrenal cortex, and testes. X-AMN is seen in patients with X-ALD and usually presents in the 3rd – 4th decade of life. Key clinical features often include pain in legs, urinary sphincter dysfunction and gradually progressive spastic paresis. Imaging findings may be confused with multiple sclerosis and other demyelinating diseases. Patients with ALD can also develop AI. While the prognosis is variable, often patients are unable to ambulate unassisted by the time they are 50 years of age. There is currently no disease modifying therapy for AMN. The patient is on medications for MDD and AI.

CONCLUSION: In summary, this case highlights the importance of: 1. recognizing diagnostic overshadowing in leading to diagnostic delay and 2. performing a structured neurological exam to avoid missing UMN findings. PCPs can also consider X-AMN as an etiology of myeloneuropathy plus adrenal insufficiency in younger adults.

KLINEFELTER SYNDROME, AN UNDERDIAGNOSED CAUSE OF MALE INFERTILITY

Julia Ferreira de Carvalho, Sharel Sadud, Deborah Edelman. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4044354)

CASE: A 42-year-old male with a past medical history of morbid obesity presented to our clinic for an infertility workup and chronic testicular pain. The patient reported a 4-year history of intermittent stabbing, severe right testicular pain. The couple had a prior pregnancy 13 years ago that resulted in miscarriage. The patient's wife reported she had previously undergone infertility workup which was unremarkable.

On physical exam, the patient was noted to have small, tender testicles bilaterally. Subsequently, the patient was referred to urology and underwent scrotal US, which revealed small bilateral testicles (1cc) with normal vascularity. Hormone testing revealed elevated FSH 27.5 mIU/mL (1.6-8mIU/mL) and LH 13.5mIU/mL (1.5-9.3mIU/mL) and decreased total and free testosterone, measuring 85 ng/dL (250-1100ng/dL) and 13.5pg/mL (35-155pg/mL), respectively. These findings raised concern for primary hypogonadism.

Further laboratory testing produced unremarkable results, including normal prolactin 8.8 ng/mL, alpha-fetoprotein 3.1 and beta-HCG <5 mIU/mL. Consequently, the patient underwent chromosomal analysis, which revealed a 47 XXY genotype, consistent with Klinefelter Syndrome. Patient was referred to endocrinology for further discussions about management.

IMPACT/DISCUSSION: Klinefelter syndrome, genotype 47, XXY, is the most common chromosomal abnormality in males, estimated to affect 1 in 650 men. 60% of males with KS go undiagnosed and the mean age of diagnosis is the mid-30s. Due to significant phenotypic variability and low suspicion in many PCPs for genetic diagnosis in adults, diagnosis is frequently made during an infertility workup. Additionally, prior studies have shown that PCPs play a crucial role in timely diagnosis and monitoring comorbid conditions associated with KS.

Males with KS typically exhibit testicular atrophy, reduced testosterone levels, and cognitive, motor, and behavioral symptoms. Of note, the presence of small testes and low serum testosterone with elevated FSH and LH levels is highly suspicious for KS. Patients with KS are at increased risk of cardiovascular, metabolic and bone-related health concerns. Infertility is a significant concern, as most patients are azoospermic. Testosterone replacement therapy may improve symptoms and long-term outcomes. As advocated by the European Academy of Andrology guidelines, emphasis should be placed on increasing the diagnosis of KS in general practice, allowing for timely interventions and enhancing quality of life.

CONCLUSION: KS is a common prevalent chronic disease.

Primary hypogonadism combined with small testes should raise suspicion for KS.

PCPs play a crucial role in diagnosis and monitoring of comorbid conditions in patients with KS.

LEUKOCYTOCLASTIC VASCULITIS (LCV) FOLLOWING INFLUENZA VIRUS VACCINATION

Olivia Steczko, Christine Li, Areeka Memon, Mridula Sree Naagendran, Madura Saravanan. Medicine, UConn Health, Farmington, CT. (Control ID #4064591)

CASE: An 83-year-old woman presented to the ED with a 6-day history of weakness, new-onset mild lower extremity edema, and worsening rash of lower extremities.

Medical history was significant for atrial fibrillation on apixaban, hypertension, hyperlipidemia, osteoporosis, postherpetic neuralgia on gabapentin, and hypothyroidism. A month prior to onset, she recovered from COVID-19. One week prior, she was vaccinated for influenza. One day prior to admission, she presented to urgent care and received cephalexin due to concern of cellulitis. On presentation she was found to have a bilateral erythematous palpable purpuric rash with crops of lesions in multiple stages of evolution. Lesions were as small as 1-2mm, predominantly clustered on distal extremities with coalescence into larger irregular patches most notably at the ankles. Isolated lesions reached up to the inner thighs. Physical exam was otherwise unremarkable. She was found to be hyponatremic and was admitted for sodium management.

CBC revealed normal white count and platelets. INR was normal. CMP revealed sodium 121, AST 69, ALT 117. ESR was 61. Blood cultures were sterile; urinalysis was unremarkable. Thoracic x-ray and CT revealed small pericardial and pleural effusions, right basal infiltrate, and two lung nodules. Skin lesion biopsy revealed perivascular inflammation with scattered karyorrhexic dermal neutrophils and mild capillary vessel edema. Immunofluorescence revealed superficial perivascular granular 2+ C3 deposition without IgG, IgA, or IgM.

She was diagnosed with LCV. During hospitalization, edema improved and pruritus rapidly self-resolved. The rash continued to evolve and resolved with no intervention within 4 weeks of discharge.

IMPACT/DISCUSSION: LCV commonly presents as a burning rash in dependent areas 1-3 weeks after a trigger. Etiologies include autoimmune disease, infection, drugs, and vaccination but LCV is commonly idiopathic. Mild cutaneous LCV has favorable prognosis and is self-limiting, requiring only supportive measures with rest, ice, elevation and management of underlying cause. Pathogenesis involves immune complex deposition, complement activation, neutrophilic karyorrhexis and fibrinoid necrosis on biopsy. Biopsy is most diagnostic when obtained within 24 hours of onset.

LCV in our patient was most likely precipitated by influenza vaccination. She had no history of autoimmune disease or recent medication changes, although she did recover from COVID-19 a month prior. Biopsy yield was likely reduced as it was performed a week after rash onset. Further outpatient workup is recommended for autoantibodies and hepatitis serologies. Recurrence is possible but LCV is not a contraindication to vaccination.

CONCLUSION: LCV should be considered on the differential when a patient develops a purpuric rash 1 or more weeks after a trigger such as autoimmune disease, illness, or vaccination. LCV is uncommon, prognosis is favorable, and is not a contraindication to vaccination.

METASTATIC CANCER MASQUERADING AS GASTRITIS

Aagamjit Singh¹; Inayat Gill²; Atulya A. Khosla¹; Nishant Aggarwal¹; Atulkumar Patel²; ¹Internal Medicine, Corewell Health Beaumont Hospital, Royal Oak, MI; ²Corewell Health Beaumont Hospital, Royal Oak, MI. (Control ID #4063854)

CASE: A 64-year-old female with a past medical history of well-controlled reflux presented for evaluation of weight loss and nausea. She also had a history of lobular breast cancer with diffuse metastases to bone which were stable for 10 years. She denied dysphagia, abdominal pain, or change in bowel habits. Physical examination was unremarkable. A recent CT of the chest/abdomen/pelvis failed to reveal any new lesions or abnormalities in the gastric wall. Consequently, an esophagogastroduodenoscopy (EGD) was scheduled, exhibiting esophagitis and mildly erythematous gastric mucosa. Intriguingly, no evident linitis plastica or lesions indicative of cancer were observed during the procedure. Antral biopsies revealed mucosal cells exhibiting signs of mild gastritis. Notably, within the lamina propria, small foci of large atypical cells were identified, which were confirmed to be secondary to breast adenocarcinoma on immunohistochemistry. A subsequent PET scan did not detect metastatic disease in the stomach, underscoring the challenges of relying solely on imaging modalities. The patient underwent chemotherapy, and a follow-up EGD conducted two years later revealed an absence of cancer cells in the gastric biopsy. Significantly, the patient experienced weight gain, and her symptoms abated, highlighting the efficacy of the therapeutic approach.

IMPACT/DISCUSSION: The discussion surrounding this case delves into the existing literature, emphasizing the gastrointestinal (GI) tract as an infrequent site of breast cancer metastasis. Patients may present with symptoms such as new-onset nausea, dysphagia, weight loss, or heartburn, often accompanied by radiological or endoscopic features indicative of cancer. A high index of suspicion is warranted, particularly in individuals with a prolonged history of breast cancer who develop symptoms over time, as exemplified by our case, where imaging initially proved inconclusive. In such instances, microscopic examination and immunohistochemistry on endoscopic specimens become imperative for establishing an accurate diagnosis. In conclusion, this case highlights the challenges associated with diagnosing metastatic cancer in the stomach, particularly when presenting alongside mild gastritis and inconclusive imaging results. A high index of suspicion along with an inter-disciplinary evaluation is important in the formulation of a diagnosis, ultimately guiding effective treatment strategies.

CONCLUSION: -Esophagogastroduodenoscopy (EGD) is crucial for assessing patients with reflux who present with red flag signs such as weight loss, aiming to identify potential primary esophageal or gastric malignancies, but also metastatic cancer to the gastrointestinal tract.

-Patients with a long-standing history of metastatic cancer require a multi-system diagnostic approach to identify metastases, incorporating endoscopy with biopsy when appropriate, rather than solely relying on imaging modalities.

MISLEADING HEPATITIS B SEROLOGY FOLLOWING INTRAVENOUS IMMUNOGLOBULIN (IVIG) INFUSIONS AND ITS IMPLICATIONS

Sunwoo Park, Paul O'Rourke. Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #4057323)

CASE: 71yo female patient with autoimmune necrotizing myositis (+HMGCR antibody) on IVIG infusions and methotrexate presents to clinic for an annual wellness visit. Review of routine health maintenance items and immunizations showed a positive hepatitis B core antibody (HBcAb) in May 2023. Hepatitis B serologies were sent by her Rheumatologist prior to initiation of Rituximab, which she had agreed to try given her ongoing poor functional status. HBsAg was negative and HBsAb was positive at the time, consistent with HBV immunity. Repeat serologies were sent the following month, which again revealed positive HBcAb and negative HBsAg. HBV quantitative PCR assay showed undetectable viral load. Given these results, her positive core antibody was thought to be secondary to the IVIG. However, her rheumatologist still recommended she receive treatment with Entecavir prior to Rituximab and continue treatment for at least 6 months after Rituximab has been stopped.

IMPACT/DISCUSSION: This vignette demonstrates a case of false positive HBcAb following IVIG infusions in a patient who was previously immunized against hepatitis B. Her serologies revealed positive HBcAb (IgG+IgM) and HBsAb in the absence of HBsAg, indicating resolved HBV infection or false positive HBcAb. Given this patient had no risk factors and signs or symptoms of infection, it is unlikely that she had asymptomatically acquired the infection. This was also confirmed with HBV DNA PCR. Physicians should consider the possibility of passive acquisition of HBcAb from the IVIG therapy as immunoglobulin products may contain antibodies and proteins and consequently cloud serology results. Literature search found several cases of unexpected results following IVIG administration.

It is important to remember the reason why the serologies were sent; she was considering treatment with Rituximab which has a risk of reactivating latent hepatitis B. All patients are thus screened serologically before treatment. This patient did not initiate Rituximab due to lack of insurance coverage, but she would have required antiviral therapy prior to and during treatment with Rituximab.

Abnormal serology results can thus delay the treatment of primary disease and often cause unnecessary investigations and treatment. Therefore, careful and thoughtful review of serology results, current medications, clinical signs and consideration of unusual causes of false positive results are crucial.

CONCLUSION: - Clinicians should check for hepatitis serologies before initiating treatment with Rituximab given its risk of reactivation of latent hepatitis B.

- Clinicians should thoroughly discuss the serology results with patients and the implications on their health.

- When faced with unexpected results, clinicians should consider the possibility of a false positive result and consider the unique health or risk factors that may contribute to possible test results.

MISSED OPPORTUNITY FOR ANAL CANCER SCREENING IN PEOPLE LIVING WITH HIV

Christina M. Pugliese¹; Peggy B. Leung². ¹Internal Medicine, Weill Cornell Medicine, New York, NY; ²Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY. (Control ID #4043454)

CASE: A 66 y/o woman with HIV on ART presented to her PCP for routine care. Review of systems was notable for occasional bleeding from external hemorrhoids. She otherwise felt well and had no acute complaints. Exam of the lungs, heart, abdomen and extremities was unremarkable. Labs showed an undetectable HIV viral load and CD4 count of 201.

Six months later, she presented to the ED with anal pain. Exam showed a 3 cm tender anal mass with serosanguinous drainage. She was discharged home with antibiotics and referred to Dermatology. Biopsy later revealed aSCC and she was referred to Colorectal Surgery. High resolution anoscopy (HRA) and CT confirmed local disease. She was treated successfully with chemoradiation.

IMPACT/DISCUSSION: Despite availability of a preventative HPV vaccine, aSCC incidence has been rising over several decades. PLWH have a 19-fold higher risk of aSCC compared to the general population, with the highest rates in older patients, MSM and those with lower CD4 counts.

Currently, no national guidelines recommend screening for anal dysplasia or cancer due in part to the previous lack of data supporting treatment of precursor high-grade squamous intraepithelial lesions (HSILs) for prevention of aSCC. However, the 2022 ANal Cancer/HSIL Outcomes Research (ANCHOR) study showed that treating HSILs in PLWH over age 35 reduces aSCC rates by 57% compared to active monitoring. The patient in this case would have fit the inclusion criteria for this study and should have been offered HSIL screening with anal Pap test for secondary prevention of aSCC.

Research shows that patient awareness of aSCC risk is low, even in high risk groups. Earlier detection of aSCC is associated with lower mortality, yet diagnosis is often delayed due to nonspecific symptoms that are often mistaken for hemorrhoids. PLWH should be asked about common signs of anal cancer (ie, anal bleeding, pain or mass). Digital anorectal exam (DARE) is an accessible test involving visualization and palpation of anal masses. Cohort studies of PLWH suggest that DARE promotes earlier cancer diagnosis in this population and should be offered annually to asymptomatic patients and whenever symptoms develop. This patient’s symptoms of anal bleeding were suspicious for anal cancer. DARE performed at the initial visit may have detected the mass, allowing for earlier referral for HRA-guided biopsy and treatment.

CONCLUSION: PLWH have a substantially higher risk of aSCC compared to the general population. Screening and treatment of precancerous HSILs decrease the incidence of aSCC in PLWH ≥35 years. Delayed diagnosis of aSCC is common due to nonspecific symptoms and is associated with a poorer prognosis. This case highlights opportunities for secondary (ie, HSIL screening by anal Pap) and tertiary (ie, patient education and DARE) prevention of aSCC in this high-risk population.

MORE THAN ACHES AND PAINS: A RARE CASE OF STATIN-INDUCED AUTOIMMUNE MYOSITIS

Kim Ngan Vu¹; Ambili Ramachandran¹; Emily S. Wang¹; Rami Pacha². ¹Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ²Internal medicine, South Texas Veterans Health Care System, San Antonio, TX. (Control ID #4057921)

CASE: A 71-year-old female with hypertension, hyperlipidemia, and type 2 diabetes mellitus presented to her PCP with a 2-month history of diffuse body aches and progressive muscle weakness. She had difficulty raising her arms and legs. Her medications were atorvastatin 80 mg, benazepril 5 mg, and metformin 1000 mg. She denied prior viral illnesses, diplopia, or rashes. Physical exam was notable for 4/5 muscle strength in proximal bilateral upper and lower extremities and absence of Gottron’s papules, heliotrope rash, digital ulcers, or synovitis. Labs showed CK 13,546, AST/ALT 204/283, ANA 1:40 with nuclear and speckled pattern, negative RF and CCP, normal ESR and CRP, and normal creatinine. She had been on atorvastatin for 6 years and was advised to stop taking it, but her symptoms persisted. A month later, Rheumatology started her on prednisone 30 mg daily (½ mg/kg). The next month, labs showed positive anti-HMGCR Ab of 75, elevated aldolase of 44, CK 6397, and negative antisynthetase antibodies. She continued prednisone 30 mg for 6 months with improvement in muscle weakness, then began prednisone taper. CK, aldolase, and liver enzymes normalized over months with resolution of muscles weakness.

IMPACT/DISCUSSION: Statins are one of the most widely prescribed drugs. They are associated with side effect of myalgias. Typically, muscle symptoms occur weeks to months after starting a statin and resolve after drug discontinuation. Patients who have been on long-term statin therapy may develop a different disease known as statin-induced autoimmune myositis (SIAM). This condition is rare (prevalence about 1/100,000) and features myalgias plus proximal muscle weakness, markedly elevated CK, and positive anti-HMGCR antibody. The proposed mechanism is that statins upregulate HMGCR, and overexpression of this enzyme stimulates HMGCR antibodies which leads to the autoimmune disease. It is important to differentiate SIAM from statin-induced myalgias since SIAM requires immunosuppressive therapy in addition to stopping the culprit medication. Other testing such as MRI of thigh muscle, EMG, and muscle biopsy were not done in this patient due to her response to steroids and out of cost consideration. Patients who do not respond to steroid monotherapy can be treated with methotrexate, IVIG, azathioprine, or tacrolimus. Severe cases of SIAM demonstrating distal muscles weakness, bulbar weakness, or pulmonary disease due to weak diaphragm muscles merit these additional immunosuppressive treatments.

CONCLUSION: SIAM is a rare adverse process due to statin therapy that presents with proximal muscle weakness and myalgias. Unlike statin-induced myalgias, SIAM persists despite discontinuation of the statin and exhibits a positive anti-HMGCR antibody. Resolution of muscle symptoms can be achieved with high-dose steroids or immunosuppressive medications.

MVP– BEING THE MOST VALUABLE PHYSICIAN FOR MITRAL VALVE PROLAPSE PATIENTS

Joo-Young Lee¹; Jennifer P. Weintraub². ¹Internal Medicine, 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 #4065032)

CASE: 55 year old female with a history of mitral valve prolapse (MVP) and premature ventricular contractions (PVCs) presents after VFib arrest. She was watching a performance when she was found pulseless. ROSC was achieved after CPR and two shocks. No chest pain, palpitations, or dizziness before arrest. No history of arrest or syncope in the past. She sees a cardiologist for yearly echos, all of which were unchanged in the recent past. Her brother has MVP. She denies family history of sudden cardiac death (SCD). She was admitted to the CCU. Physical exam was notable for holosystolic murmur. TEE confirmed severe mitral regurgitation. Right-heart catheterization showed clean coronary arteries. A PET-cardiac MRI showed bileaflet MVP and late gadolinium enhancement and inflammation of the papillary muscle. No mitral annular disjunction (MAD: mitral valve leaflet inserts into atrial wall further than its normal insertion site). She had her mitral and tricuspid valve surgically repaired with no complications. An implantable cardioverter-defibrillator (ICD) was placed. She was discharged in a stable condition.

IMPACT/DISCUSSION: Though MVP is common and usually asymptomatic, recent literature shows there may be findings that increase SCD risk, suggesting a new term: arrhythmic mitral valve prolapse (AMVP). Sriram et al studied cardiac arrest outside of the hospital and outlined AMVP risk factors as: bileaflet MVP, female sex, and frequent PVCs on electrocardiography (ECG). This patient had all three. Basso et al studying MVP and SCD brought evidence that late gadolinium enhancement in papillary muscles on cardiac MRI is seen in MVP with complex ventricular arrhythmias, overlapping with histopathological features seen in SCD patients and seen in our patient as well.

Significant debate exists among experts on MVP risk-stratification. Basso et al suggests that MAD on echocardiography is a red flag for AVMP and should trigger us to consider PET-cardiac MRI or SCD prevention. Essayagh et al supported this association and also included repolarization abnormalities and family history of MVP as risk factors for SCD in MVP. MAD was not seen in our patient, though she had a family history of MVP. While there is a lack of consensus in the literature about which patients should undergo Holter monitoring, we suggest that recognizing common risk factors can help the general internist decide when to order additional monitoring, cardiac imaging, or referrals to cardiology or CT surgery. With the recency bias of this case, there may be clinical utility in considering ICD for secondary prevention of life-threatening arrhythmias in patients who have the classic findings of AMVP and a positive family history of MVP.

CONCLUSION: AVMP risk factors include bileaflet MVP, female sex, and frequent PVCs on ECG. MAD on echocardiography should raise a red flag for further monitoring.

Consider Holter monitoring or ICD for secondary prevention of SCD in those with classic AMVP findings and family history of MVP.

MYOCARDIAL INFARCTION IN THE SETTING OF PHENTERMINE USE AND MYOCARDIAL BRIDGING

Austin Saugstad, Carmold Murray, Malak Tashin, Chelsea Azevedo. Internal Medicine, Creighton University, Phoenix, AZ. (Control ID #4063590)

CASE: A 31 year old female with hypothyroidism and GERD presented with intermittent chest pain for 3 months. Pain is substernal, radiating to the right shoulder, lasts for multiple days and occurs at least once a week. Home medications include levothyroxine, pantoprazole, and was recently started on phentermine 4 months ago for weight loss. The patient denied any chest pain episodes prior to phentermine initiation. The patient denies any personal or familial history of cardiac disease and denies any tobacco or substance use. In the ED, the patient was hemodynamically stable and initial troponin negative. Subsequent troponin was elevated and peaked at 0.363. EKG was normal sinus rhythm with ST depressions in II, III, and aVF and inverted T waves in III and aVF. Chest x-ray and chest CTA were negative for acute disease. Additional lab work included a microcytic anemia. The patient was admitted for NSTEMI, given aspirin, atorvastatin, metoprolol succinate, and started on a heparin infusion. Subsequent left heart catheterization revealed intramyocardial bridging of the mid left anterior descending (LAD) artery; all other vessels were patent. An echocardiogram was completed with an ejection fraction of 54-74%, without regional wall abnormalities, and RVSP 30mmHg. ASCVD risk score was calculated at 0.7%. The patient was discharged on metoprolol succinate and oral iron tablets. The patient was counseled on the stimulatory properties of phentermine and was recommended to discontinue the medication.

IMPACT/DISCUSSION: Herein, we present a case of myocardial infarction in the setting of recent phentermine initiation with pre-existing LAD intramyocardial bridging. FDA approved for short term treatment of obesity, phentermine is an amphetamine analog that potently stimulates norepinephrine release and limits reuptake, thus inducing appetite suppression. Contraindications to phentermine to use include coronary artery disease, arrhythmia, heart failure, uncontrolled hypertension, hyperthyroidism, and substance abuse. Ischemic events, palpitations, primary pulmonary hypertension, and valvular disease are known adverse reactions of phentermine use. Multiple case reports have hypothesized potent coronary sensitivity to the noradrenergic stimulatory properties of phentermine, thus inducing coronary vasospasm (^1,2,3). Uniquely, our patient possessed an abnormal LAD with myocardial bridging, an independent risk factor for coronary vasospasm. Additionally, our patient’s premedication EKG revealed Q waves and ST depressions in multiple leads that may have warranted further work-up prior to initiation of phentermine.

CONCLUSION: Phentermine is a highly potent noradrenergic agent commonly prescribed for the treatment of weight loss. Adverse cardiac reactions are known complications following drug initiation, thus requiring a thorough cardiac evaluation prior to administration. Patients should be counseled on the risks of phentermine prior to use and may need further cardiac screening to assess overall risk.

NECROTIZING MYOSITIS- A RARE CONDITION FROM A COMMON AGENT

Kylie Anthony, Mary Solis, Katherine Sorrentino. Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4063954)

CASE: A 67-year-old woman with T2DM and HTN presented to clinic with six weeks of myalgias. Her symptoms progressed from her legs to her shoulders, limiting her ability to climb stairs or lift her arms. She denied numbness, rashes, rheumatologic conditions or recent medication changes. She was previously on simvastatin for several years and switched to atorvastatin two years prior. Exam showed proximal muscle weakness without other neurologic deficits. Labs were notable for TSH 1.31, CK 6,832, Cr 0.70, AST 378, ALT 287, with normal ESR and CRP. She was recommended to hold her statin and hydrate. Repeat labs four days later showed mild improvement (CK 6,002, AST 256, ALT 258).

Three weeks later, she reported continued decline with difficulty getting out of bed. Repeat CK was 12,674. She received an urgent rheumatology appointment and was direct admitted for progressive myositis. MRI of the femur demonstrated feathery edema of the musculature. CT chest, abdomen, and pelvis showed no malignancy. She improved with IV solumedrol and received two doses of IVIG while inpatient. RF was mildly positive (9.6), but extended myositis panel was negative. HMG-Co-R IgG was positive at >200. Biopsy of the vastus medius muscle returned with few necrotic fibers and mild variation in fiber sizes without primary inflammation, confirming necrotizing autoimmune myopathy. She later transitioned from monthly IVIG to mycophenolate mofetil with gradual improvement in functional status.

IMPACT/DISCUSSION: Statins are one of the most common medications prescribed in primary care. Up to twenty percent of patients report myalgia as a side effect, but few develop myositis. Necrotizing myositis should be considered in patients with rapidly progressive myopathy, usually worse in the upper extremities, and highly elevated CK levels. Our clinical suspicion increased when our patient's symptoms progressed despite holding the statin. Confirmatory muscle biopsy shows myofiber necrosis with minimal inflammatory infiltrates.

Autoimmune necrotizing myopathy is a group of conditions identified in 2004. A subset, HMG-Co-R antibody positive myositis, is strongly associated with statins, though not all patients have had prior exposure. Full remission requires both statin discontinuation and immunotherapy. There is no standard treatment, but patients commonly receive steroids and IVIG, with plans for long-term immunotherapy to prevent relapse. Rapid diagnosis is key, as prolonged inflammation causes fatty infiltration of muscles and poor strength recovery.

CONCLUSION: Primary care providers prescribe a significant number of statins and must be familiar with potential side effects.

Necrotizing myositis is a rare condition that can be associated with positive HMG-Co-R antibody and statin exposure.

Patients with clinically suspected disease require both statin discontinuation and immunotherapy.

NOTABLE SMARTWATCH NOTIFICATIONS: A CASE OF WIDE COMPLEX TACHYCARDIA

Nicole Guynn, David Annakie, Alexandra Eckert. internal medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4063948)

CASE: A 64 year old male with a bicuspid aortic valve, status post aortic valve replacement (AVR) with redo bioprosthetic AVR (7/2015), presented to his PCP with 1 month of palpitations associated with blurry vision, dyspnea on exertion, and presyncope. Vital signs and exam were unremarkable and the clinic EKG showed NSR with 1st degree AV block (AVB). The patient shared some EKG recordings from his smartwatch which revealed a wide complex tachycardia with HR of 150. The rhythm strip from his smartwatch was forwarded to a cardiologist and the patient was directed to the ED for further work up. On admission, he was found to be in sinus rhythm, with heart rate in the 70s, and a physical exam notable for a 2/6 systolic murmur. EKG showed NSR with 1st degree AVB. Labs showed K of 3.7mEq/L, BNP 117pg/ml and troponin of 13 that trended downwards to 11ng/mL. He was admitted to the floor on telemetry; he required transfer to the ICU after he developed monomorphic ventricular tachycardia with runs up to 19 beats long. He underwent left heart catheterization that showed nonobstructive coronary artery disease and a cardiac MRI without infiltrative disease but with concern for myocarditis. A single chamber defibrillator was placed and the patient was discharged on steroid taper and metoprolol with plans to follow up as an outpatient.

IMPACT/DISCUSSION: This is a potentially lethal case of symptomatic palpitations presenting to a primary care office. It highlights the importance of a thorough history, the value of interdisciplinary care, and the utility of a smart watch in the detection of potentially lethal arrhythmias beyond atrial fibrillation. Many patients have smart devices but most PCPs do not query them to gather additional information. The Apple watch irregular pulse detection algorithm was found to have a positive predictive value of 0.84 for identification of atrial fibrillation (AF). In a recent study evaluating arrhythmias other than AF detected in the Apple watch irregular pulse algorithm, any arrhythmia (excluding SVT <30 beats and pauses <3 seconds) was detected in 119 out of 297 participants (40.1%). These arrhythmias included atrial and ventricular ectopy as well as heart block. This case highlights an opportunity to increase options for ambulatory noninvasive screening and management of common symptoms such as palpitations and sudden cardiac arrhythmias, including ventricular arrhythmias, and to better define at-risk populations.

CONCLUSION: Palpitations account for 16% of visits to generalist physicians and are the second leading cause of visits to cardiologists. Presyncope or loss of consciousness should raise concern for arrhythmias, such as ventricular tachycardia, or structural heart disease. Smart watches have significant potential in the early detection and management of arrhythmias in high risk patients.

NOT EVERY RATTLE IS REACTIVE: UNRAVELING AN UNCOMMON CAUSE OF RESPIRATORY DISTRESS

Allison J. Hare^1,2; Kathyrn F. Bitner¹; Sarah E. Post¹. ¹Internal Medicine, Atrius Health Inc, Boston, MA; ²Department of Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4059096)

CASE: HPI: Patient is a 25-year-old woman who presented for evaluation of respiratory symptoms. 6 weeks prior, she had been hospitalized for COVID-19-associated respiratory failure requiring intubation for 8 days. She subsequently had persistent dyspnea and chest tightness, reporting that she felt like she was “breathing through a straw”. She had been treated with several courses of oral and inhaled corticosteroids as well as albuterol, which she was continuing to use every 4 hours with minimal relief.

Pertinent positives and negatives: Endorsed cough with scant bloody sputum. Denied palpitations, fever, recent travel, or new exposures.

Social history: Worked as a security guard. Denied using tobacco, alcohol, or other substances.

Past medical history: Class 3 obesity, type 2 diabetes. No history of asthma.

Family history: Mother had sickle cell trait, father had type 2 diabetes.

Medications: Albuterol, fluticasone, dulaglutide, metformin.

Pertinent physical exam findings: BP 110/80, HR 116, SpO2 93%, afebrile. In significant respiratory distress and wheezing loudly enough to be heard outside the exam room with the door closed. Accessory muscle use noted through palpation (unable to see due to body habitus). Diffuse wheezing heard on auscultation.

Diagnostic studies: CMP and CBC unremarkable. ESR 44 mm/hr and CRP 13.9 mg/L. D-dimer 227 ng/mL. TSH 1.42 mIU/L. EKG with sinus tachycardia. CT chest with bibasilar bandlike subsegmental atelectasis and few small, scattered ground-glass opacifications. PFTs with FEV1 0.89 (28% predicted) and FEV1/FVC 25%. Inspiratory and expiratory portions of the flow-volume loop were flattened.

Interventions: Upon receipt of PFT results, the referring provider advised the patient to seek emergency care. Fiberoptic nasolaryngoscopy showed significant subglottic stenosis. She received intravenous dexamethasone and underwent bronchoscopy with balloon dilation. She subsequently experienced significant symptomatic relief.

IMPACT/DISCUSSION: This case highlights the potential for severe respiratory complications following intubation and underscores the need for heightened vigilance and ongoing monitoring in patients recovering from respiratory failure.

Timely recognition and management of an unstable airway is critical in outpatient settings. Patients should be advised to seek emergency care if airway obstruction is suspected before completing PFTs, which may take weeks to coordinate.

In patients with obesity, creative physical exam techniques, such as palpation of accessory muscles of respiration, can aid in identifying signs of respiratory distress.

CONCLUSION: In patients with unexplained dyspnea refractory to bronchodilator therapy, consider a diagnosis of subglottic stenosis, particularly in those with a history of intubation.

NOT ONLY THE KING'S EVIL: A CASE OF SCROFULA FROM LATENT TB REACTIVATION IN THE U.S.

Rebecca Unterborn¹; Laura Macke². ¹Internal Medicine, University of Colorado, Denver, CO; ²General Internal Medicine, University of Colorado, Denver, CO. (Control ID #4025078)

CASE: A 50-year-old female with no significant past medical history presented with left-sided tender cervical lymphadenopathy for 3 weeks, without any accompanying constitutional symptoms. She did not have any recent illnesses or dental issues. She took no medications. She had no relevant family history. Social history was significant for immigrating to the US from Ethiopia 17 years ago. Physical exam was notable for two 2cm firm and tender nodules along the left neck. Ultrasound showed two thyroid nodules, which met criteria for biopsy, and several enlarged lymph nodes measuring up to 21x16x13mm. In the setting of a thyroid nodule, there was concern for thyroid malignancy with lymphatic spread. She underwent fine needle aspiration (FNA) and core biopsy of a submandibular lymph node and pathology demonstrated necrotizing granulomas. She ultimately underwent excisional lymph node biopsy with bacterial and acid-fast bacilli (AFB) cultures. AFB culture was positive for Mycobacterium tuberculosis (TB) and pathology confirmed necrotizing granulomatous lymphadenitis without evidence of lymphoma or malignancy, therefore diagnosing tuberculous lymphangitis. Chest X-ray was negative, interferon gamma release assay (IGRA) was positive. She was initiated on treatment with rifampin, ethambutol, isoniazid, pyrimethamine, and pyridoxine for treatment of reactivation of latent TB.

IMPACT/DISCUSSION: This is a case of tuberculous lymphangitis that was initially thought to be malignancy. There are approximately 0.015 cases per 100,000 persons of tuberculous lymphangitis, or scrofula, in the US. This rarity creates a diagnostic challenge for primary care providers. The cornerstone of TB lymphangitis diagnosis is AFB culture. Although, excisional biopsy has the highest sensitivity for successful isolation of TB, FNA has been shown to have similar AFB positivity. If this patient had an AFB culture sent on the FNA, this could have expedited diagnosis. Additionally, this patient had a positive IGRA with a negative chest X-ray, which supports the likelihood that her lymphadenopathy was reactivation of previously latent TB. IGRA and the tuberculin skin test are the two recommended screening tests for latent TB in the US by the USPSTF. Screening should be performed based on risk factors which include: emigration from an endemic country, people experiencing homelessness or living in correctional facilities, persons living with HIV, immunosuppressed individuals, and healthcare workers.

CONCLUSION: This case emphasizes the importance of ensuring scrofula is on the differential for lymphadenopathy and of screening for latent tuberculosis infection in the primary care setting to prevent future tuberculosis activation.

OPPORTUNISTIC SCEDOSPORIUM INFECTION IN A PATIENT WITH CYSTIC FIBROSIS POST-LUNG TRANSPLANT

Marlena McClellan, Brian T. Montague. Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4062435)

CASE: A 29-year-old woman with a past medical history of cystic fibrosis status post bilateral lung transplant in October of 2022 presented to infectious disease clinic for management of a disseminated scedosporium infection in the setting of immunosuppression. Prior to her transplant, the patient had several episodes of life-threatening hemoptysis, she had developed chronic lung disease and pulmonary hypertension, and her native lungs were colonized by scedosporium. Post-transplant, she received voriconazole for antifungal prophylaxis. Her post-transplant course was complicated by disseminated scedosporium infection including: skin and soft tissue infection at her clamshell incision, osteomyelitis in her sternum, and infection of her lungs and mediastinum. She consistently had voriconazole trough levels under the therapeutic window, indicating that she is a rapid metabolizer of voriconazole and prompting a switch to posaconazole for antifungal treatment. Her infection continued to progress, so compassionate use was requested for the experimental drug Olorofim, a novel antifungal in the orotomide class which targets azole-resistant fungal infections. She has been on Olorofim and posaconazole since December of 2022, with gradual improvement of her surgical site.

IMPACT/DISCUSSION: The case of this 29-year-old woman with cystic fibrosis illustrates the difficult balance between protecting transplant patients from organ rejection versus leaving them susceptible to infection. CF patients can benefit greatly from lung transplants, with a median survival of 9.9 years post-transplant (1). CF patients are at increased risk for having airways that are colonized by multidrug-resistant organisms, placing them at high risk for infection following lung transplant. A retrospective cohort study of CF patients found 60% of the patients treated with voriconazole were at a sub-therapeutic trough level (2). In this patient’s case, the current FDA approved antifungals were not sufficient to prevent or treat her scedosporium infection, and there are few options left for patients that fall into this gap. Access to Olorofim is a challenge due to lack of FDA approval and limited supplies available for compassionate use. If this patient had developed her scedosporium infection after June of 2023, she would not have been able to benefit from this drug, as the Olorofim management action plan has suspended enrollment of new patients.

Works Cited:

1) Bos, Saskiaa; et al. Survival in adult lung transplantation: where are we in 2020?. Current Opinion in Organ Transplantation 25(3):p 268-273, June 2020

2) M Di Paolo; et al. A retrospective ‘real-world’ cohort study of azole therapeutic drug monitoring and evolution of antifungal resistance in cystic fibrosis, JAC-Antimicrobial Resistance, Volume 3, Issue 1, March 2021, dlab026

CONCLUSION: Patients with CF are at increased risk of resistant fungal infections

There is limited access to novel antifungal medications for patients with highly-resistant infections

ORDINARY OR OMINOUS?: NSCLC PRESENTING WITH BELCHING AND HICCUPS

Natalie Meeder, Caitlin Peirce. General Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #4063944)

CASE: An 84 yo woman with Alzheimer’s disease, HTN, hypothyroidism, and 10 pack year smoking history presented to clinic with 7 months of hiccups and belching. She had persistent hiccups, constant belching, decreased appetite, 10 lb. weight loss, post-prandial epigastric pain, and nausea. She denied emesis, dysphagia, dyspnea, cough, carbonated beverage use, gum chewing, stool changes, or night sweats. Physical exam was unremarkable. She was started on a PPI and referred for EGD and speech/swallow evaluation. EGD was negative for mass or esophagitis. Belching persisted with PPI. Speech/swallow team found possible vocal cord paralysis, which was confirmed by ENT evaluation. CT chest and neck showed aggressive mass in the left paravertebral region involving the superior laryngeal nerve and an elevated left hemidiaphragm suggestive of malignant phrenic nerve invasion. Biopsy and staging confirmed T4N3M0, stage IIIC NSCLC. She underwent chemoradiation followed by immunotherapy. She continued to have belching and hiccups along with poor appetite, falls, PE, and brain metastases. She transitioned to hospice care and passed away at home about 1 year after diagnosis.

IMPACT/DISCUSSION: Prolonged hiccups are rare and are considered intractable when present for more than 1 month. Common causes include CNS disturbance, vagus or phrenic nerve irritation, GI disturbance, medications, or psychogenic. A systemic review showed that 1-9% of patients with advanced cancer had persistent or intractable hiccups. Belching is a common complaint in the outpatient setting. Common causes are GI related, air swallowing, intraluminal production, or decreased gas absorption due to obstruction. Involvement of an interdisciplinary team including speech pathology ultimately led to the diagnosis of unilateral vocal cord paralysis. Vocal cord paralysis typically presents with dysphonia, dyspnea, or dysphagia. Belching is not a common presenting symptom, but recurrent laryngeal nerve lesions have been implicated in central control of swallowing. It is important to consider an intrathoracic mass as the cause for intractable hiccups and unilateral vocal cord paralysis as early detection can expedite treatment. This case highlights how nonspecific symptoms can be the presenting symptom of systemic disease.

CONCLUSION: While hiccups are often benign, evaluation for malignancy should be considered for intractable cases. Evaluation of intractable belching includes treatment of GERD, careful consideration of risk factors for systemic illness, and thorough dysphagia evaluation. In patients with new symptoms of dysphonia, dysphagia, or dyspnea, unilateral vocal cord paralysis should be considered with intrathoracic malignancy as a common cause.

OVERTREATMENT OF BACTERIURIA IN AN ELDERLY WOMAN

Caroline B. Ledet¹; Mohamed Elhadi¹; Will M. Schouten². ¹Internal Medicine Residency Program, Mayo Clinic Minnesota, Rochester, MN; ²Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4057430)

CASE: An 85-year-old female presented to primary care with symptoms of vaginal pruritis, dysuria, urinary urgency, and malodorous urine. Urinalysis was negative for leukocyte esterase and nitrites. Urine microscopy showed 4-10 WBC/hpf. Urine culture grew > 100,000 cfu/mL of Enterobacter cloacae complex. Sensistivities showed resistance to nitrofurantoin, cefazolin, and penicillin. A 7-day course of oral ciprofloxacin was prescribed for acute bacterial cystitis. Trimethoprim-sulfamethoxazole was considered but avoided given the patient’s CKD and concern for hyperkalemia.

Eight days later, she presented to the emergency department with 2 days of sudden-onset left proximal anterior thigh pain and weakness without inciting trauma. She could not bear weight on her left leg and had significant pain and weakness with left hip flexion. MRI of the of the left hip showed advanced tendinopathy and low-grade partial-thickness tear of the iliopsoas insertion. Fluoroquinolone (FQ)-associated tendinopathy was diagnosed.

IMPACT/DISCUSSION: In the presence of typical symptoms, a diagnosis of urinary tract infection (UTI) is supported by findings of pyuria on urine microscopy (>10 WBC/hpf) and bacterial growth on urine culture (>10⁵ cfu/mL). Given the prevalence of asymptomatic bacteriuria (ASB) in elderly adults, bacterial growth on urine culture alone is not specific for bacterial cystitis in this population. In this case, the patient had a positive urine culture but no pyuria. Given the high sensitivity of pyuria for diagnosing UTI, its absence made UTI highly unlikely. The positive urine culture without pyuria was suggestive of bacterial colonization, and alternative explanations for the patient’s symptoms should have been explored.

Diagnostic stewardship can minimize the harms of antimicrobial therapy. Ideally, urine should not be cultured in the absence of pyuria. In clinical practice, urinalysis and urine culture are often sent in tandem. Clinicians may feel pressure to prescribe antibiotics once a positive urine culture returns, even if the urinalysis is not suggestive of infection. Recent quality improvement initiatives have demonstrated reduction in antibiotic use in patients with ASB through decreased ordering of inappropriate urine cultures. A diagnostic testing cascade for dysuria whereby urine culture is only performed if pyuria is confirmed could reduce exposure to inappropriate antibiotic therapy.

FQ-associated tendinopathy classically involves the Achilles. However, cases involving the iliopsoas tendon have been reported. Prescribers should consider alternatives to FQ, especially in patients at increased risk of tendinopathy, including the elderly, and those taking glucocorticoids or with CKD.

CONCLUSION: Thoughtful interpretation of diagnostic testing, maintaining a broad differential diagnosis, and practicing principles of diagnostic stewardship can prevent unnecessary antibiotic therapy and unfortunate complications in older adults who present with acute lower urinary tract symptoms.

PAINLESS ORAL ULCERS-A BROAD DIFFERENTIAL

Anna K. Shah¹; Jane Abernethy². ¹Department of Medicine, Johns Hopkins University, Baltimore, MD; ²General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4064700)

CASE: A 66-year-old woman with a history of discoid lupus erythematous presented to her primary care clinic for multiple, painless lesions on the bilateral lateral and frontal aspects of the tongue. They appeared shallow, erythematous, ulcerated, and non-bleeding. Besides vaginal discharge, she denied all other complaints. While she had previously been diagnosed with multiple cutaneous lesions from lupus, she had never had oral ulcers before. Inflammatory workup was sent, revealing ESR 58, CRP 3.43. Her ulcers were presumed to be a manifestation of a lupus flare, and she was referred to rheumatology.

She returned two months later with non-healing oral ulcers. A sexual history revealed that she had recently engaged in unprotected oral sex with multiple new sexual partners. Additional lab tests were sent, resulting in an anti-dsDNA autoantibody titer of 1:20 and rapid plasma reagin (RPR) of 1:256. A diagnosis of secondary syphilis was made. Due to an anaphylactic penicillin allergy, she was treated with a prolonged course of oral doxycycline twice a day. After 3 days of doxycycline, her oral lesions resolved. Syphilis titers decreased to 1:32 four weeks after the initiation of treatment.

IMPACT/DISCUSSION: Oral ulcers are a common manifestation of secondary syphilis, which can also present as condyloma lata and split papules in the oral cavity.1 While the differential diagnosis for oral ulcers generally is broad, ulcers that are painless can be explained by a narrower differential -- syphilis, lupus erythematosus, traumatic ulceration from neuropathy, or carcinoma. 2,3 Distinguishing between painless ulcers caused by lupus erythematosus and syphilis can be challenging as they carry a similar clinical appearance, but a thorough history and workup such as anti-dsDNA, serum complement fractions, RPR, and biopsy can provide critical information to finalize a diagnosis.

Sexual health is an infrequent topic in visits with patients over 65, with one sample revealing that only 17% of patients in this age group had discussed sex with their clinicians in the past 2 years.4 Data from the US Center for Disease Control and Prevention indicate that the prevalence of syphilis among those aged 65 years or older has increased from 0.3 cases per 100,000 people in 2010 to 1.5 cases per 100,000 in 2021, with other sexually transmitted infections following a similar rise.5 As older adults become more at risk for sexually transmitted infections, obtaining a thorough sexual history should be a routine step in the workup of new complaints.

CONCLUSION: - Painless oral ulcers can be caused by syphilis, lupus erythematosus, traumatic ulceration from neuropathy, or squamous cell carcinoma.

- Sexually transmitted infections, including syphilis, are increasing in prevalence in patients older than 65 and must be addressed by obtaining a thorough sexual history.

- While prior medical history is key to contextualizing a patient’s symptoms, other causes must be considered.

PANCYTOPENIA WITH SEVERE HYPOPLASTIC MARROW IN A CASE OF HASHIMOTO'S DISEASE

Sayaka Aoyama, Sao Yoshinaga, Masanao Fujii, Jun Ito, Shotaro Hagiwara. Internal Medicine, Mito Kyodo Byoin, Mito, Ibaraki, Japan. (Control ID #4058436)

CASE: A 51-year-old man without a medical or family history arrived at the hospital for an evaluation of his hoarseness, fatigue, and bilateral hand edema. He does not consume alcohol regularly. Laboratory findings revealed hemoglobin of 9.6 g/dL with a mean corpuscular volume of 99.3 fL, a white blood cell count of 1900/μL, a red blood cell count of 294 x 104/L, and a platelet count of 148 x 109/L. Thyroid-stimulating hormone levels on arrival were 128.77 μIU/L (normal range: 0.35-4.94 μIU/L), free thyroxine was <0.40 ng/dL (normal range: 0.70-1.48 ng/dL), creatinine was 1.32 mg/dL (normal range: 0.6-1.2 mg/dL) , and creatine kinase was 3477 IU/L (normal range: 60-270 IU/L). Iron and ferritin levels were 71 μg/dL and 900.4 ng/mL, respectively. Antithyroglobulin antibodies and antithyroid peroxidase antibodies were elevated at 1230 IU/mL and 390 IU/mL, respectively. The soluble interleukin-2 receptor, vitamin B12, and folate levels were within normal ranges. Lactate dehydrogenase and total bilirubin were normal and inconsistent with hemolysis. Bone marrow biopsy revealed severe hypoplastic marrow with decreasing erythroblasts and megakaryocytes. Endoscopy did not reveal gastritis or cancer. Levothyroxine was initiated based on the laboratory data, resulting in the improvement of symptoms and pancytopenia with treatment.

IMPACT/DISCUSSION: Pancytopenia, a rare condition characterized by a simultaneous reduction in red blood cells, white blood cells, and platelets, is an unusual and scarcely documented complication of Hashimoto's disease. Limited case reports describe the co-occurrence of Hashimoto's disease and pancytopenia.

Furthermore, the risk of lymphoma associated with Hashimoto’s disease complicates the hematological landscape. The literature reports the association of anemia with hypothyroidism. Normocytic normochromic anemia with normocellular marrow is the most common. Iron deficiency anemia and vitamin B12 deficiency are also reported. However, this case deviates from the norm with hypoplastic marrow, along with normal iron, vitamin B12, and folate levels.

In addition, most cases are female. This report is the first adult male case of Hashimoto's disease with pancytopenia. It contributes valuable insights into the hematological manifestations of Hashimoto's disease, emphasizing the need for clinicians to consider the complications beyond the typical thyroid-related symptoms.

CONCLUSION: In conclusion, this case adds a unique dimension to the existing knowledge of hypothyroidism-related hematological complications. While hypothyroidism is commonly associated with anemia, typically of normocytic origin and occasionally microcytic or macrocytic etiology, the manifestation of pancytopenia in this context is a distinctive and rare occurrence.

PARADOXICAL PLAQUES: GUTTATE PSORIASIS DUE TO TUMOR NECROSIS FACTOR INHIBITOR THERAPY

Ivan Berezowski¹; Attiya H. Randolph¹; Karl Saardi²; Nadine Mbuyi¹; Jillian S. Catalanotti¹. ¹Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; ²Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4026536)

CASE: A 44-year-old woman with history of retinal vasculitis and chronic recurrent multifocal osteomyelitis treated for 7 years with adalimumab presented with widespread intensely pruritic rash. The rash was initially localized to her trunk and upper extremities and improved with fading and reduction of pruritus after topical triamcinolone and 8 days of prednisone prescribed by a dermatologist. Upon completing prednisone, the rash worsened and spread to back and lower extremities. Physical exam revealed an erythematous rash of innumerable edematous, confluent papules, crusting diffusely and covering 70-80% of body surface area, sparing joints and abdominal injection sites. She was referred to dermatology. She underwent punch biopsy and was prescribed triamcinolone ointment and a 3-week prednisone taper. Biopsy revealed acanthosis, parakeratosis and focal loss of the granular cell layer with eosinophils suggesting psoriasiform drug eruption. PAS staining for dermatophytes was negative. At a rheumatology visit 1 month later, rash was nearly resolved, requiring continued maintenance topical steroids. Adalimumab was stopped; ixekizumab was begun.

IMPACT/DISCUSSION: Tumor necrosis factor inhibitors (TNFi) are used to treat various moderate-to-severe inflammatory conditions, including psoriasis. Paradoxically, TNFis can induce de novo or worsening psoriasis in 0.6% to 5.3% of patients. This may present as plaque psoriasis (15.8%–50%), palmoplantar pustular psoriasis (33.3%–45%), psoriasiform (19.9%), guttate (7%–15%), generalized pustular psoriasis (5.3%–12%), or inverse psoriasis (1.7%–4%). One study found mean age of onset is 48 years, female predominance and mean TNFi treatment duration of 17 months prior to developing new or worsening psoriasis. For adalimumab, mean treatment duration prior to developing psoriasis was 1 year, ranging up to 8 years. Although some patients sufficiently controlled psoriasis while continuing TNFi therapy, discontinuing TNFi led to higher rates of complete response.

In those with mild induced psoriasis and controlled underlying disease, a “treat through” approach is preferred using traditional psoriasis therapies while continuing TNFi. In those with mild TNFi-induced psoriasis and uncontrolled underlying disease, or with moderate-to-severe induced psoriasis and controlled underlying disease, TNFi should be withdrawn temporarily or changed to an alternative TNFi agent or other class of biologic agent tailored to underlying disease.

Our patient developed guttate psoriasis after 7 years of adalimumab and responded appropriately to prolonged oral and topical steroids. Given moderate-to-severe induced psoriasis requiring ongoing topical steroids and poorly controlled rheumatologic disease, she was transitioned to ixekizumab, an interleukin-17 inhibitor.

CONCLUSION: Induction of psoriasis is a known complication of TNFi therapy. A multidisciplinary approach to diagnosis and management should include assessing severity of psoriasis and status of underlying disease.

PARANEOPLASTIC MANIFESTATION OF NASOPHARYNGEAL CARCINOMA

Murali K. Duggirala. Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4060130)

CASE: Patient is a 38-year-old man with no significant past health history, has developed recurrent nosebleeds approximately 1-1/2 year ago. He does not smoke cigarettes, or use alcohol. Rhinoscopy revealed a mass in the nasopharynx, a PET/CT scan confirmed an enhancing, metabolically active mass. Biopsy of the mass showed nonkeratinizing nasopharyngeal carcinoma. He was referred to our acaemic center for further treatments.

Laboratory evaluation showed a hemoglobin of 13.1 (13.2-16.6 gm/dL), WBC count 4.1 (3.4-9.6 10⁹/L), platelet count 331 (135-317 10⁹/L). Serum electrolytes, calcium, BUN, creatinine were normal. ESR was elevated at 44 (2-12 mm/hr). Urinalysis showed a protein of 291 mg/dL, with predicted 24 hour urinary protein of 3,518 mg. Protein/osmolality ratio was also high at 3.99 (< 0.42). There were no red cells, white cells or casts seen on urinalysis. A 24 hour urinary protein confirmed proteinuria of 2940 mg/dL. Serum protein electrophoresis did not show any monoclonal protein. ANA, extractable nuclear antibodies, ANCA antibodies, hepatitis B, C serologies were all negative. Thrombospondin Type1 Domain-Containing 7A Antibody test (THSD7A) and Phospholipase A2 Receptor Indirect Immunofluorescence Assay (PLA2R) were negative. A kidney biopsy showed membranous glomerular nephropathy, PLA2R negative. Patient was diagnosed with membranous nephropathy as a paraneoplastic syndrome secondary to the nasopharyngeal carcinoma. He was started on gemcitabine, cisplatin induction chemotherapy with a close follow-up of kidney function.

IMPACT/DISCUSSION: Our patient is a 38-year-old with no significant past health history and was diagnosed with pharyngeal carcinoma. He had no known kidney disease or kidney dysfunction but was incidentally noted to have large amount of urinary protein without active urinary sediment. It was thought the reason for the proteinuria could include a primary membranous nephropathy or secondary membranous nephropathy from the underlying solid tumor. Negative THSD7A antibody and PLA2R assay did not support the diagnosis of a primary membranous nephropathy. Kidney biopsy confirmed a membranous nephropathy PLA2R negative. He was diagnosed with paraneoplastic membranous nephropathy secondary to nasopharyngeal carcinoma.

CONCLUSION: Paraneoplastic syndrome implies the clinical manifestations are not directly related to tumor but are the result of tumor cell products or its antigens. Paraneoplastic membranous nephropathy (MN) can be seen in patients with solid tumors such as lung, breast, gastrointestinal tract, or bladder cancer. A positive antibody response to PLA2R thrombospondin or type 1 domain-containing 7A (THSD7A) support the diagnosis of primary or idiopathic MN. Both of these antibodies were negative in our patient suggesting that the glomerulonephropathy is secondary to paraneoplastic syndrome from is known nasopharyngeal carcinoma. While rare, paraneoplastic membranous nephropathy can be associated with nasopharyngeal carcinoma.

PERSISTENT SHIGELLOSIS IN STAGE IV RECTAL CANCER PATIENT

Pritika Parmar, Sara Scherrer. Division of Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4064367)

CASE: We report a 76-year-old man with Stage IV rectal adenocarcinoma presenting with severe diarrhea, weight loss, rectal bleeding and discomfort. On 4/15/23 he reported rectal pain and diffuse weakness. He was afebrile, nontoxic, with no abdominal tenderness or distension. He reported >6 liquid stools daily for the past 6 months. He endorsed recent travel to Mexico. GI PCR was positive for shigella/enteroinvasive E. coli (EIEC). Stool culture sent to the state lab grew Shigella boydii. He was treated with Azithromycin (3 days), with symptom improvement. On 5/31, he returned to the ED with worsening bloody diarrhea, discharged with oxycodone. Imaging confirmed rectal cancer diagnosis, and he was started on FOLFOX chemotherapy on 6/9. His diarrhea persisted, and GI PCR retesting on 7/6 was positive for shigella/EIEC not recoverable on culture. He was not given antibiotics but referred to infectious disease. A third GI PCR collected on 8/23 had positive shigella/EIEC, unable to be cultured. He was given a 3-day trial of Ciprofloxacin. At this time, the microbiology lab found the plate from his 4/17 sample and performed sensitivity testing. The strain was resistant to Ampicillin and Bactrim but sensitive to CRO and Ciprofloxacin. The patient had improvement on the short course of ciprofloxacin, but symptoms returned a few days later. He was given an extended ciprofloxacin course (14 days) and symptoms improved. Subsequent GI PCR on 9/28 was negative for Shigella.

IMPACT/DISCUSSION: Our patient likely experienced persistent carriage of Shigella due to his immunocompromised state. Infection likely resulted from travel to Mexico or other food/water exposure. Shigella boydii is the rarest pathogen causing shigellosis, responsible for 1% of global infections.^1-6 Persistent infection is attributed to the O-antigen, a bacterial surface protein.^6-8 Immunocompromised patients are at-risk for severe infection.^1,9-10 However, chronic shigellosis is extremely uncommon. It has been associated with immunosuppression due to acquired immunodeficiency syndrome (AIDS).¹¹ Our patient tested negative for HIV but had other risk factors for immunosuppression including chemotherapy. Given the clinical sequelae, our patient likely experienced an ongoing infection that was not adequately treated with antibiotic management. Treatment strategies should encourage an extended course of antibiotics with confirmation of Shigellosis particularly in immunocompromised patients. While there are currently no approved vaccines for S. boydii, early attempts at vaccinations show promise for patients at risk of chronic or severe infection.^12-13

CONCLUSION: Chronic shigellosis is a rare but treatable cause of severe diarrhea in immunocompromised patients.

Early treatment with extended course ciprofloxacin or reducing immunosuppression may prevent persistent shigellosis.

PETH AND ITS IMPACT ON MANAGEMENT OF ALCOHOL-RELATED DISEASE

John Debella¹; Leia Wedlund¹; Peggy B. Leung². ¹Internal Medicine, Weill Cornell Medicine, New York, NY; ²Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY. (Control ID #4063093)

CASE: A 56 yo M with PMH of HTN and AUD (s/p prior hospitalization for pancreatitis & alcoholic hepatitis) presented to clinic for HTN management. Given his PMH, he was screened for current alcohol use. He reported drinking ~1 drink per night, 4 nights weekly, and insisted he drinks “socially” to unwind from work stress. He was precontemplative and declined further counseling or medication-assisted therapy. A plan was made to discuss further at next visit.

5 weeks later, the pt returned to clinic diffusely jaundiced, reporting new dark urine and transient abdominal pain. Notably, he reported abstaining from alcohol entirely for two weeks prior to this presentation. Suspicion for alcoholic hepatitis was initially low given his reported abstinence. T bili collected during the visit resulted at 38, and he was sent to the hospital for further evaluation. Workup ultimately ruled out infectious, autoimmune, and obstructive causes, and he was diagnosed with a recurrence of alcoholic hepatitis. MDF score was 93.7, nearly 3x higher than the cutoff of 32 for severe alcoholic hepatitis. A PEth drawn on admission resulted at 826 ng/mL.

IMPACT/DISCUSSION: The term “alcoholic hepatitis” is used to describe the acute onset of symptoms due to alcoholic steatohepatitis. Despite this pt’s concerning PMH, the provider had initially anchored on an alternate process, particularly since he had reported abstinence from alcohol for 2 weeks prior to his 2nd presentation to clinic. In reality, alcoholic hepatitis often presents several weeks following a period of complete abstinence, as pts often stop drinking after onset of initial symptoms (in this case, abdominal pain).

This case illustrates the difficult task of accurately assessing alcohol intake when relying on patient-reported data. The PEth, or phosphatidylethanol, is a biomarker used to estimate average EtOH intake over 4 weeks. A PEth of > 200 ng/mL is used as a cut off for very heavy drinking, consistent with intake of ~4.3 drinks daily. Despite reporting intake of only 4 drinks/week at his initial visit, the degree of elevation of this pt’s PEth (826 ng/mL) equates to ~5-7 drinks daily over the prior 4 weeks. A PEth measured during the initial visit would have provided evidence that the pt is underestimating his intake, therefore facilitating more time spent counseling and more frequent follow up, potentially improving his odds of cutting back. This ultimately could have slowed or even prevented his relapse of alcoholic hepatitis, and demonstrates a role for PEth in outpatient management of alcohol-related disease.

CONCLUSION: Alcoholic hepatitis typically presents following weeks of complete abstinence from alcohol. PEth is a helpful tool for high-risk pts or cases in which an accurate assessment of alcohol intake is difficult to obtain.

PRESCRIPTION OF DOXYCYCLINE POST-EXPOSURE PROPHYLAXIS (DOXY-PEP) FOR THE PREVENTION OF BACTERIAL STI’S FOR PATIENTS WHO DO NOT MEET CLINICAL TRIAL INCLUSION CRITERIA

Colleen McGourty¹; Zakir Safdar¹; Emma D. Bainbridge². ¹General Internal Medicine, University of California San Francisco, San Francisco, CA; ²Infectious Diseases, University of California San Francisco, San Francisco, CA. (Control ID #4050005)

CASE: Mr. D is 29-year-old heterosexual cisgender male with history of primary syphilis and urethral gonorrhea (2022) on Truvada for HIV pre-exposure prophylaxis (PrEP). He presented for routine STI screening. In the last 3 months, he has had insertive oral, vaginal, and anal sex with 9 new cisgender female partners and does not use condoms. He exchanges money for sex. He does not meet inclusion criteria for the recent major doxy-PEP trials. However, through shared decision-making and consultation with public health guidelines he is determined to be high risk for bacterial STIs so is prescribed doxy-PEP.

IMPACT/DISCUSSION: Recent randomized control trials demonstrated the benefit of doxy-PEP (doxycycline taken after unprotected sexual encounters) in preventing gonorrhea, chlamydia, and syphilis in high-risk patients. The Doxy-PEP trial evaluated its use in cisgender men who have sex with men (MSM) and transgender women (TGW) on HIV PrEP or living with HIV with a history of at least one bacterial STI in the past year. Doxy-PEP was 65% effective at preventing gonorrhea, chlamydia, and syphilis with efficacy in the pharynx, urethra, and rectum. However, a separate trial which evaluated doxy-PEP in cisgender women on PrEP found no clinical benefit. There are no published trials of doxy-PEP in heterosexual cisgender males.

Guidelines such as those from San Francisco County recommend offering doxy-PEP to all patients who meet inclusion criteria of the DoxyPEP trial, and to consider it for MSM and TGW who are at high risk regardless of recent STI diagnoses. Others like the California Department of Public Health recommend more liberal criteria including high risk heterosexual cisgender men, transgender men, and cisgender women on a case-by-case basis despite lack of efficacy data.

Most guidelines recommend 1) Prescription of 200mg doxycycline taken up to 72 hours after condomless sex as often as daily, and 2) Screening for HIV, syphilis, and gonorrhea/chlamydia at all exposed sites every 3 months.

Bacterial resistance is a risk of widespread doxy-PEP use. Doxy-PEP may increase existing tetracycline resistance in gonorrhea, but the relevance of this is unclear as doxycycline is never used to treat gonorrhea. Resistance seems less likely to develop for chlamydia and syphilis as there are no prior reports of tetracycline resistance despite routine use of doxycycline for their treatment. Research is ongoing regarding the impact of doxy-PEP on the gut microbiome and skin flora. Other concerns exist about doxycycline misuse (e.g., self-treatment for genitourinary symptoms) so it is important to limit refills.

CONCLUSION: Doxy-PEP is a safe, effective STI prevention tool that PCPs can feasibly offer.

Providers should perform STI screening every 3 months and limit doxycycline refills to reduce improper antibiotic use.

Doxy-PEP may be offered to patients who have not met trial inclusion criteria but have high-risk sexual practices or recent STIs based on shared decision making.

PROMPT EARLY DIAGNOSIS: A CASE REPORT OF PLEOMORPHIC ADENOMA OF SUBMANDIBULAR GLAND PRESENTING AS PAINLESS NECK MASS.

Farnaz Sadr, Nidhiben Patel, Natalia Plotskaya. Capital Health, Trenton, NJ. (Control ID #4063614)

CASE: A 34-year-old male with no significant past medical history presented with a growing right submandibular mass. The mass had gradually increased in size over a couple of months. Patient denied any fever, systemic symptoms or local pain over the affected area. Physical examination revealed smooth, mobile, round, solid mass 3 cm in diameter in the right submandibular area. No lymphadenopathy was present. Initially patient was referred to see a dentist who excluded any dental abnormality. Soft tissue ultrasound (US) of the neck revealed a hypoechoic mass corresponding to the palpable concern measuring 3.5 cm x 2.7 cm x 3.2 cm. The mass was found to be in the subcutaneous region with no other anatomic landmarks to determine whether this was within or adjacent to any of the glandular structures. There was blood flow internally to the mass. An ultrasound was not able to differentiate between intraglandular mass and large adenopathy. Patient underwent ultrasound-guided core needle biopsy with fine needle aspiration (FNA). Cytology was consistent with pleomorphic adenoma (PA). Computed tomography (CT) of neck demonstrated 3.6 cm hypervascular, enhancing lesion in the right submandibular space anterior to the right of submandibular gland. Patient was referred to head and neck surgeon and underwent right submandibular mass excision. Pathology confirmed the diagnosis of pleomorphic adenoma. Patient was recommended yearly surveillance.

IMPACT/DISCUSSION: PA is the most prevalent neoplasm among salivary gland tumors. It has diverse cellular patterns and predominantly affects the parotid gland (55%). However, it can also occur in the submandibular (5%) and minor salivary glands with the palate being the most frequent site amongst these glands. PA typically exhibits a slow progression and lack of noticeable symptoms, frequently manifesting as swelling of the salivary glands without cervical lymphadenopathy and neurologic symptoms. Diagnostic tools, including imaging modalities like CT, along with US and FNA play crucial role in confirming the diagnosis and guiding treatment decisions.

CONCLUSION: PA is characterized by its mixed appearance and benign nature.It often appears as an asymptomatic, slow-growing mass, typically discovered by the patients or during routine physical examinations. Although PA is generally benign, it varied histopathologic presentation requires differentiation from other salivary gland tumors, such as adenoid cystic carcinoma, myoepithelioma, mucoepidermoid carcinoma, and basal cell adenoma. The optimal approach for treating pleomorphic adenoma of the submandibular gland is resection, encompassing both the tumor and the affected gland, with the marginal mandibular nerve injury being the most common complication. A delayed diagnosis and treatment of pleomorphic adenoma elevates the risk of malignant transformation. So early diagnosis and appropriate management are crucial for favorable outcomes.

RETURNING TO THE GREAT IMITATOR

Harrison Tran¹; Shirley J. Chan³; Kristie Hsu². ¹School of Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ²Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ³Internal Medicine, Santa Clara Valley Medical Center, San Jose, CA. (Control ID #4062178)

CASE: An otherwise healthy 58-year-old man, out of care for 18 years, presented to urgent care for 5 days of episodic lightheadedness. He described episodes of his vision going “blackout” without prodromal symptoms and had associated dyspnea. His symptoms initially were triggered by exertion but progressed to 3-5 times per day at rest. He denied chest pain, headache, hearing loss, or other vision changes. His exam was unremarkable; there were no skin or mucosal lesions, and he was neurologically intact. An ECG showed right-bundle branch block and prolonged PR interval.

Further history revealed that he had sex with men, most recently 10 months ago. He first developed multiple tender ulcers on his penis and then had a sore throat with night sweats that resolved 5 months ago.

Non-treponemal (RPR) blood testing returned with a titer of 1:128. CBC and BMP were within normal limits. Emergency LP revealed positive non-treponemal test (VDRL) diagnostic of neurosyphilis for which he received 14 days of IV Penicillin G (PenG) followed by 1 dose of IM PenG. His symptoms temporarily improved but he was then found to have high-grade AV heart block on ZioPatch and required a pacemaker for resolution. After 3 months, he had an expected 4-fold RPR titer decrease to 1:32. A cardiac MRI most recently demonstrated active cardiac inflammation pending further work-up.

IMPACT/DISCUSSION: After determining a patient is experiencing pre-syncope, not vertigo, history and physical should help prioritize common causes: cardiogenic, hypovolemic, neurogenic (vasovagal), or iatrogenic. For this patient, PR prolongation was an early indicator for cardiogenic cause corroborated by later ZioPatch.

A history of pre-syncope with constitutional symptoms should evoke a broader differential including systemic sexually transmitted infections. Neurosyphilis in early stages can present as meningitis, whereas late neurosyphilis classically presents as general paresis and tabes dorsalis. Vertigo can be present in otosyphilis or ocular syphilis but pre-syncope is not a classic presentation. Interestingly, studies have demonstrated cardiac involvement beyond the classic aortitis of tertiary syphilis such as evidence of gummas in the conducting system of the heart leading to complete heart block.

Notably, 30% of patients who are infected with syphilis will have CSF abnormalities without neurological symptoms. Whether syphilis was the source of this patient’s heart block or a factor exacerbating an underlying condition such as amyloidosis remains unclear. Nonetheless, this presentation underscores the importance of uncovering exposures, particularly sexual history, to assist diagnosis and treatment of pre-syncope.

CONCLUSION: Pre-syncope has a broad differential with an established framework for work-up. A thorough sexual history should be incorporated into this framework as evidenced by a unique case of syphilis in a patient with progressive heart block requiring a pacemaker.

REVOLVING DOORS ALLOW FOR EVOLVING SYMPTOMS: CAREFUL WORKUP OF NIGHT SWEATS IN A PRIMARY CARE CLINIC

Mallory Bryant¹; Christopher P. Terndrup². ¹Internal Medicine, Vanderbilt University Medical Center, Nashville, TN; ²General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN. (Control ID #4064858)

CASE: A 33 year old male with no known chronic medical conditions presents to primary care clinic with three weeks of significant night sweats. He was seen intermittently over the last three years for pleuritic chest pain attributed to costochondritis or acute viral illness. He has similar pain at this time exacerbated by long conversation or exertion. He has nonspecific symptoms including headache, cough, abdominal pain, nausea, fatigue, chills, and low-grade fevers. He estimates a 20 pound weight loss over the last several weeks. He has small children at home who had a viral upper respiratory infection at symptom onset three weeks ago. His family history is notable for an uncle with possible colon cancer but no known autoimmune disease. His initial physical exam was benign, notably without lymphadenopathy, focal abdominal tenderness, or rash.

Initial lab workup revealed AST 80 and ALT 144, Positive ANA (1:1280), SSA (Ro), and SSB (La). CRP was elevated. CK was 231 (aldolase negative). HIV and hepatitis serologies were negative. PFTs showed a mild restrictive deficit. TTE was normal. CT chest revealed pleural based opacities and no suspicious lymph nodes. He was referred to Rheumatology. Since he did not meet full criteria for an autoimmune disease, close follow-up was arranged, and empiric treatment was deferred. He returned to primary care clinic three months later with painful cervical lymph nodes. Repeat CT scan demonstrated new diffuse lymphadenopathy most consistent with a lymphoproliferative process.

IMPACT/DISCUSSION: When the patient first presented, the three buckets for this constellation of symptoms were discussed: autoimmune, malignancy, and infection. Many providers utilize this framework as pathologies within each category can mimic one another, especially in early stages. After the initial workup, our suspicion was highest for a smoldering autoimmune condition even after rheumatology concurred that he did not meet criteria. This was largely due to his waxing and waning pleurisy and positive antibodies. It was tempting, especially when he was symptomatic, to proceed with an empiric steroid course. However, this could have lowered the yield of diagnostic testing he is currently undergoing for likely lymphoproliferative disease. An underlying autoimmune disease is entirely possible, though it has not fully presented itself at this time.

CONCLUSION: - Objective data should be taken as part of a story and valued in constellation with, and not superior to, subjective evaluation.

- Consider each diagnosis on a differential thoroughly as treatment of one likely pathology could be detrimental to another.

- The primary care setting allows time for undiagnosed diseases to evolve, adding pieces to the puzzle that can help assure proper diagnosis and treatment.

ROUX-EN-WHY THE LOW PHOSPHATE? A CASE OF IV IRON-INDUCED HYPOPHOSPHATEMIA IN A PATIENT WITH MULTIPLE COMPETING ALTERNATIVE ETIOLOGIES

Emily Gore, Cary J. Blum. Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4054256)

CASE: A 32-year-old male with hypertension, obesity, Roux-en-Y gastric bypass (RYGB) 1 year prior with >200-pound weight loss, vitamin D deficiency complicated by secondary hyperparathyroidism (HPT), and iron deficiency anemia presented to clinic reporting poor appetite and ongoing weight loss. History was notable for receiving IV ferric carboxymaltose (FCM) several weeks prior. Labs showed low phosphate (1.8 mg/dL). Despite the presence of multiple risk factors, the clinical history was most suggestive of FCM-induced hypophosphatemia. After two weeks of oral phosphate repletion, labs showed normal phosphate, normal parathyroid hormone (PTH), and appropriately low urinary phosphate excretion.

IMPACT/DISCUSSION: Hypophosphatemia can arise via several mechanisms: (1) intracellular shifting, (2) decreased intestinal absorption, and (3) increased urinary excretion, which is often mediated by proximal tubular dysfunction and/or excessive PTH and fibroblast growth factor 23 (FGF23) activity. FGF23 promotes renal phosphate wasting and inhibits calcitriol synthesis, further potentiating hypophosphatemia.

Via an unknown mechanism, certain formulations of IV iron result in acute increases in circulating FGF23 levels. This phenomenon is seen in 47% of patients treated with FCM and less commonly with other formulations. Workup of FCM-induced hypophosphatemia typically shows increased urinary phosphate excretion, mildly reduced 25-(OH) vitamin D, markedly reduced calcitriol, and elevated PTH. In our patient, the normalization of phosphate level, PTH, and renal phosphate excretion several weeks after FCM administration was most consistent with FCM-induced hypophosphatemia.

Risk factors for hypophosphatemia in our patient include severe iron deficiency treated with FCM, normal renal function, HPT, vitamin D deficiency, and prior RYGB with chronically poor oral intake. Though FCM-induced hypophosphatemia is typically self-limited to 2-3 weeks, as in our patient, it may persist for 6 months in 5% of cases and can cause fatigue, bone pain, weakness, and osteomalacia. Patients presenting with symptoms and high-risk asymptomatic patients (i.e., post-RYGB) should be screened to determine the need for repletion and/or alternative iron formulations. All patients with phosphate <2.0 mg/dL should be repleted. Distinguishing between etiologies of hypophosphatemia using techniques like urinary fractional excretion of phosphate may have implications for management.

CONCLUSION: Hypophosphatemia is a common but under-recognized complication of IV iron infusions. Measuring urinary phosphate excretion can help distinguish between renal and extra-renal etiologies of hypophosphatemia. Monitoring serum phosphate after FCM infusion should be considered in patients at high risk of hypophosphatemia, such as those with a history of RYGB.

SARCOID MASQUERADING AS OCCULT MALIGNANCY

Dylan Bergstedt²; KC Moore²; Konner Feldhus²; Ashley McKenzie¹; Kelsey Klingel²; Samay Dalal². ¹Internal Medecine, Saint Joseph Hospital, Denver, CO; ²Internal Medicine Residency, National Jewish Health Saint Joseph Hospital, Denver, CO. (Control ID #4055030)

CASE: A 58-year-old female with a past medical history of smoking and hypertension presented to her primary care provider complaining of 40-lb weight loss over the last 9 months. This raised concern for possible malignancy, so workup was initiated. A CT scan of her chest showed diffuse interstitial nodular infiltrate in the bilateral lower lobes along with mediastinal and hilar adenopathy. Multidisciplinary Chest Conference discussed the patient and recommended a PET scan which showed the following: pleural masses; numerous hypermetabolic lymph nodes in the posterior right lower lung lobe; heterogeneous consolidation with nodular septal thickening; bilateral pleural effusions; hypermetabolic right supraclavicular, porta hepatis, abdominal retroperitoneal and bilateral inguinal femoral lymph nodes; probable liver metastases; and a right adrenal mass. Upon further discussion with pulmonology, the patient endorsed an intermittent, non-productive cough and associated chest discomfort for the last 3 years. A lymph node biopsy showed non-necrotizing granulomatous lymphadenitis; subsequent right middle lobe CT-guided biopsy showed non-caseating granulomatous inflammation. Broad infectious workup was negative indicating sarcoid was the most likely diagnosis.The patient was started on high dose steroids. A repeat CT scan showed significant improvement of her sarcoid.

IMPACT/DISCUSSION: Sarcoid is a granulomatous disease that often affects multiple organ systems. Accumulation of granulomas, later leading to fibrosis, is the cause of most clinical manifestations, which can vary widely based on organ involvement. Cough and dyspnea are common presenting symptoms of sarcoid. Extrapulmonary symptoms involving a variety of organ systems are present in around 50% of cases. Lung and thoracic lymph node involvement is seen in 90-95% of sarcoid cases. 18F-FDG-PET does not differentiate sarcoid from malignancy or infection and will likely be positive in any of these pathologies. PET scans may have a role for biopsy planning and as an evaluation tool for disease activity and medication response. Sarcoid remains a diagnosis of exclusion. A comprehensive history and physical, chest radiographs, CBC, serum chemistries, and EKG can be useful in narrowing the differential. The diagnosis of sarcoid often requires biopsy with histopathological detection of non-caseating granulomas with negative infectious workup. Given this patient’s weight loss and multisystem involvement on PET, malignancy was initially suspected. Biopsy with broad infectious testing were critical in determining the correct diagnosis of this patient.

CONCLUSION: Sarcoid can have variable imaging findings, some of which may be initially mistaken for infection or malignancy. A comprhensive history and physical along with suggestive imaging are important for the diagnosis of sarcoid, but biopsy with histopathological detection of non-caseating granulomas is often required.

SPINAL CORD TUMOR OR NEUROMYELITIS OPTICA? THE CASE OF A RARE SPINAL MASS-LIKE PRESENTATION AS DIAGNOSTIC MIMIC OF NEUROMYELITIS OPTICA

Luisa Tsang. Internal Medicine, Alameda Health System, Oakland, CA. (Control ID #4054166)

CASE: A 77-year-old woman with baseline complete left eye vision loss due to retinal detachment presented with subacute progressive bilateral lower extremity weakness. At the time, MRI spine showed T3-T8 intraparenchymal lesion, that was initially concerning for astrocytoma versus ependymoma. T5-8 laminectomies were performed for tumor resection. Pathology showed rare, atypical cells and was not diagnostic of neoplasm. Two years later, she developed subacute right eye blurry vision associated with pain and loss of color vision. Neurologic examination was notable for pyramidal weakness, diminished vibration and temperature sensation in the legs, and hyperreflexia. Neuroimaging was notable for optic nerve enhancement. CSF profile was bland and negative for oligoclonal bands. Serum workup revealed aquaporin-4 antibody (AQP4 IgG). Based on the patient's presentation with optic neuritis and positive AQP4 IgG, she was diagnosed with seropositive neuromyelitis optica spectrum disorder (NMO). In retrospect, her prior myelopathy was most consistent with longitudinally extensive transverse myelitis, rather than a spinal cord tumor. Treatment was initiated with IV steroids and plasmapheresis followed by prolonged prednisone taper, though unfortunately she did not improve. Her condition has since been stable on rituximab.

IMPACT/DISCUSSION: Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disease of the central nervous system. NMOSD encompasses multiple clinical entities that are still incompletely understood. Seropositive NMOSD (NMO) is characterized by typical attacks and isolation of the aquaporin-4 antibody (AQP4 IgG) in serum. The AQP4 IgG primarily destroys astrocytes by targeting the AQP4 water channel, with secondary demyelination and neuronal loss. Typical clinical features include optic neuritis and transverse myelitis; other typical, but less common, attacks include area postrema syndrome, acute brainstem syndrome, acute narcolepsy, and acute brain syndrome. NMOSD can be a challenging diagnosis with significant clinical and radiographic overlap with other diseases including multiple sclerosis and, more rarely, mass-like presentations. We present the case of a patient ultimately diagnosed with NMO who initially presented with what appeared to be a spinal cord tumor.

CONCLUSION: This case illustrates a rare spinal mass-like presentation as a potential diagnostic mimic of NMO, which led to delayed diagnosis and treatment. AQP4 antibody can aid in diagnostically challenging cases to distinguish from multiple sclerosis and other central nervous system autoimmune or neoplastic processes. Recognition of NMO is critical to timely and appropriate therapy and management to prevent further disability accrual.

SPONTANEOUS EMPYEMA MANIFESTING AS SUBACUTE BACK PAIN

Peter Leonard. Internal Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH. (Control ID #4063921)

CASE: A 53-year-old male with hypertension presented with subacute back pain persisting for two and a half weeks. Despite prior treatments, including muscle relaxants and a steroid taper, his right back pain persisted. There were no alleviating factors. Aggravating factors included movement and deep inspiration. He denied any history of recent infection or trauma. On presentation, he was afebrile and mildly tachycardic. CBC showed WBC 9.8, hemoglobin 9.3, and platelets 716.

A d-dimer was obtained (elevated to 2,626); CT pulmonary embolism (CTPE) revealed new fluid collections in the right pleura and pre-vertebral posterior mediastinum at T8-T9. MRI confirmed a multiloculated right inferior pleural empyema with left ventral paraspinal abscess at T9-T10.

Interventional radiology was consulted for aspiration of the empyema. Pleural fluid studies showed WBC 11,696 (68% neutrophils, 32% mononuclear cells), pH 7.36, protein 5.1, and LDH 1,164. Gram stain revealed Gram-positive cocci with culture growing Staphylococcus aureus. The patient was successfully managed with a chest tube and IV antibiotics.

IMPACT/DISCUSSION: In the primary care setting, the most common complaint is back pain. While not all cases are critical, there is a need for vigilance and an understanding of red flag symptoms of back pain that warrant further exploration. These symptoms, including urinary retention, loss of bowel/bladder control, fevers, night sweats, pleuritic nature of pain, or unexplained weight loss, serve as indicators of an acute cause for pain, demanding prompt work-up. These encompass neurological issues (spinal cord compression, cauda equina syndrome), infectious causes (epidural abscess), and malignancies. A broad differential approach is crucial, and ongoing reassessment is necessary for recognizing atypical presentations, as seen in a patient seeking treatment for the third time with symptoms evolving beyond the musculoskeletal system.

Classically, empyema manifests with fever, chills, cough, and chest discomfort. Diagnosis involves imaging (chest x-ray, CT, ultrasound), with CT revealing the split pleura sign, indicating visceral and parietal pleural thickening. Treatment for parapneumonic effusion and empyema varies by stage. In Stage 1, pleural fluid analysis may show low/normal WBC, LDH <1000, and no bacteria, potentially resolving with antibiotics alone or drainage if symptomatic. Stage 2 (fibropurulent) features high WBC, LDH >1000, and may require antibiotics and drainage. Stage 3, marked by a thickened pleural covering restricting lung movement, is managed with antibiotics, drainage, and possibly VATS.

CONCLUSION: Empyema can present subacutely with nonspecific symptoms and exam findings like malaise, pleuritic pain, dyspnea, tachycardia, and low-grade temperature. The absence of a history of recent pneumonia, trauma, or substance use does not preclude the development of empyema.

STARTING FROM SCRATCH: AUTOIMMUNE HEPATITIS PRESENTING WITH DIFFUSE PRURITUS

Adam Rosenstein, Eric Woods. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4063147)

CASE: A 41-year-old woman presented to her primary care physician complaining of two weeks of progressive pruritus that began in her hands and feet and then became generalized and persistent. She had no history of dermatologic disease, allergies, malignancy, chronic renal disease, or liver disease. She had no recent sick contacts and no change in medications, hygienic products, or environmental exposures. She denied malaise, nausea, change in urine output, or weight changes. Physical exam was only significant for superficial excoriations without evidence of cutaneous abnormalities.

Laboratory testing revealed ALT 478, AST 292, alkaline phosphatase 669, total bilirubin 1.4. Total bile acids (55), anti-smooth muscle autoantibodies (27), and IgG (2,045) were elevated. There was immunity to HAV and HBV without HCV antibodies. ANA, AMA, and anti-LKM antibodies were negative. Right upper quadrant ultrasound was consistent with hepatic steatosis. Subsequent liver biopsy showed portal tracts with mild inflammation, damaged bile ducts, and lobules with spotty necrosis. The patient was started on corticosteroids, with improvement in LFT abnormalities and pruritus. A diagnosis of type I autoimmune hepatitis (AIH) was made and the patient was eventually transitioned to azathioprine for maintenance of remission.

IMPACT/DISCUSSION: Patients with generalized pruritus but no primary cutaneous lesions should be evaluated for a systemic cause of their symptoms. This patient’s pruritus resembled the characteristic itch of liver disease: starting in the palms and soles before becoming generalized, often worsening in the evenings. Pruritus can lead to a marked decrease in quality of life and is a common symptom of liver disease, with prevalence estimates from 25% in AIH to 70% in primary biliary cholangitis. Itching can frequently be the first manifestation of cholestasis, even before the onset of jaundice. While the etiology of cholestatic pruritus is not fully understood, it is likely caused by accumulation of pruritogens such as bile salts, steroid hormones, endogenous opioids, histamine, and serotonin. Identifying pruritus associated with cholestatic liver disease can help general internists facilitate efficient diagnoses and treatment.

Therapeutic interventions should focus on adequate treatment of the underlying hepatobiliary disease, as this may result in improvement of pruritus. Additionally, removing the pruritogens from the enterohepatic cycle by non-absorbable, anion exchange resins such as cholestyramine is considered first-line. Rifampicin, opiate antagonists, and the serotonin reuptake inhibitor sertraline are alternatives. For patients with intrahepatic cholestasis of pregnancy, treatment with ursodeoxycholic acid improves both pruritus and liver function.

CONCLUSION: Liver diseases, including those not classically considered cholestatic, like AIH, may present with generalized pruritus. Improvement in cholestatic pruritus can be accomplished by treating the underlying liver disease.

SUBJECTIVE FEVER AND CHILLS AFTER A SAFARI TRIP IN SOUTH AFRICA

Beemnet Amdemicael¹; Carmel Malvar¹; Christina Schultz²; Bernice Ruo². ¹School of Medicine, University of California San Diego, La Jolla, CA; ²Medicine, University of California San Diego, La Jolla, CA. (Control ID #4063821)

CASE: 64 year-old male presented to clinic with a 5-day history of fatigue, headache, fevers, chills, body aches, and joint pain. He had returned from a South African safari 4 days ago and noticed the first episode of severe fever and chills 5 days ago. He was seen the day prior at urgent care. Labs including blood counts, basic metabolic panel, respiratory virus panel, and serologies for Trypanosoma cruzi, malaria, and dengue were sent. He was started on cephalexin for possible leg cellulitis. He also described one day of soreness in the right calf and groin. He had taken malaria prophylaxis and denied chest pain, cough, nausea, vomiting, vision changes, pruritis, confusion, hematuria, or dysuria. He denied sick contacts and was up-to-date with COVID vaccines. He had completed multiple negative COVID antigen tests. On physical exam, he was afebrile, had a mildly tender 1 cm right inguinal lymph node, a tender right calf without palpable cords or edema, and a small, scabbed lesion on right lower leg without redness or tenderness.

A lower extremity venous duplex ultrasound showed no evidence of deep vein thrombosis. The next day, dengue serologies were IgG positive and IgM negative. Blood count was notable for leukopenia. One week later, the patient reported resolution of symptoms.

IMPACT/DISCUSSION: There has been a recent rise in the incidence of dengue in the United States¹. Though this traveler returned from South Africa, which is classified as “no evidence of dengue risk ”², a thorough work up including a clinical history that includes onset and duration of symptoms, exposures to insects, animals, sick persons, food and water is essential³. Physical exam should include assessment of skin lesions, rashes, lymphadenopathy, and neurologic exam. Malaria, dengue, typhoid, and chikungunya are the most common causes of fever and chills in returning travelers and should be evaluated serologically^4,5.

.

Many cases of dengue are asymptomatic with <5 % developing severe disease. Symptomatic dengue typically presents with fever, headache, joint /muscle pain, rash, and mild epistaxis lasting 2-7 days^3,4. Rarely, it progresses to a fatal thrombocytopenic hemorrhagic fever.

Symptomatic patients should be treated with supportive care, hydration, and pain management, avoiding NSAIDs due to their anticoagulative properties in a potentially thrombocytopenic setting ³.

CONCLUSION: -Symptomatic dengue typically presents with fever, headache and joint/muscle pain.

-Though it is important to consider geographic risk factors, serologic evaluations for dengue should not be excluded simply because certain areas are not considered endemic for dengue virus.

SUPPRESSED BUT NOT ADDRESSED

Melissa Margolis¹; Betty Kolod¹; Divya Shah². ¹Medicine, Mount Sinai Health System, New York, NY; ²Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #4060108)

CASE: A 35-year-old cisgender, gay man with no past medical history presented to clinic with an enlarging upper arm rash after recently moving from Colombia. A year ago, he noticed atraumatic, asymptomatic “bruises” that had enlarged over the past few months. Physical exam revealed violaceous patches on his upper arms and a right thigh. The patient declined HIV testing, awaiting recent test results. He returned 3 months later with right jaw swelling after being diagnosed with HIV at an outside clinic and had not started HIV treatment. He did not have fever, night sweats, dysphagia, shortness of breath, or dental issues. On exam he had tender right submandibular swelling extending to the maxillary region and multiple violaceous plaques on his upper extremities, chest, and tip of the nose. Two weeks later, he was admitted for worsening swelling. CT facial bones showed numerous enlarged submandibular, jugular, and posterior cervical lymph nodes and soft tissue swelling from the right mandible to the orbit. A submandibular core needle biopsy was positive for HHV-8, CD31, and ERG, diagnostic for Kaposi sarcoma (KS). Notably, he had a serum HHV-8 PCR of 77k copies/mL, a CD4 count of 97 cells/mm³, and a viral load of 31 copies/mL. He started bictegravir-emtricitabine-tenofovir alafenamide and now follows with ID and Oncology for KS treatment.

IMPACT/DISCUSSION: This patient’s cutaneous lesions and submandibular swelling in the setting of a new HIV diagnosis represent a case of AIDS-defining KS, confirmed by biopsy. KS can involve any site; however, it commonly presents with dermatologic findings. While cutaneous manifestations of KS can be identified by a trained clinician, they may be missed due to the decreased incidence of KS in the era of accessible and effective antiretroviral therapy for HIV. Further, for patients with atypical cutaneous manifestations and systemic symptoms, diagnosis of KS requires a high index of suspicion and confirmation by biopsy.

This patient had an unusual presentation of HIV-related KS. Paradoxically, he presented with an opportunistic infection and low CD4 count but an undetectable viral load before the start of ART. HIV controllers are defined as having plasma HIV-1 RNA loads below 2,000 copies/mL without ART after 12 months of infection. There are two types of controllers: typical controllers who have a CD4 count >450 cells/mm³ and discord controllers who have a CD4 count <450 cells/mm³. HIV controllers are exceedingly rare, comprising <1% of people living with HIV. Limited research exists about the degree of immunosuppression in HIV controllers and the incidence of AIDS-defining conditions like KS.

CONCLUSION: -Consider Kaposi sarcoma in individuals presenting with rash and unilateral lymphadenopathy.

-HIV controllers should be evaluated for opportunistic infections, like KS, upon HIV diagnosis and throughout the disease course.

SYPHILIS DISGUISED AS GIANT CELL ARTERITIS: A UNIQUE CASE PRESENTATION

Shreena Kamlesh Gandhi¹; Payton A. Markley²; Samvid Kotia³; Thomas Moore¹; Maya Estephan¹. ¹Internal Medicine, The University of Kansas School of Medicine Wichita, Wichita, KS; ²Medical Student, The University of Kansas School of Medicine-Wichita, Wichita, KS; ³Diagnostic Radiology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India. (Control ID #4063886)

CASE: This is the case of a 79-year-old Spanish-speaking Hispanic female immigrant with a medical history of hypertension and dyslipidemia who presented to the clinic with complaints of persistent unilateral temporal headaches over the past six months. Due to the language barrier, her daughter served as the translator during medical visits. She reported visual field deficits, blurry vision, morning stiffness, body aches, and generalized malaise. She denied motor or sensory deficits, amaurosis fugax, jaw claudication, scalp tenderness, fevers, recent travel, or exposure to infectious contacts. She refused to provide a sexual history. The physical exam was unremarkable. She had elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values. She was suspected to have giant cell arteritis (GCA) and started on high-dose steroids, with a referral for a temporal artery biopsy.

Her temporal artery biopsy yielded a negative result, yet she was continued on a tapering steroid regimen due to a strong clinical suspicion. At this point, the daughter disclosed a distant recollection of a potential history of sexual abuse in the patient, prompting tests for sexually transmitted infections. Her Rapid Plasma Reagin (RPR) showed a significant elevation, indicating an underlying untreated syphilis. A confirmatory lumbar puncture diagnosed neurosyphilis. Treatment with IV penicillin resulted in a rapid resolution of her symptoms.

IMPACT/DISCUSSION: Syphilis, often referred to as the great mimicker, had its earliest documented diagnosis in 1495 and continues to stump physicians to this day. In light of more awareness, regular testing, and proven therapy, the more recognizable forms of syphilis have become less prevalent. We are now encountering more cases of atypical secondary or tertiary syphilis, which can pose a diagnostic challenge.

Patient with neurosyphilis or ocular syphilis often get misdiagnosed with rheumatological diseases due to overlap of symptoms such as myalgias. Similar to our case, clinical indicators like the patient's ethnicity, a negative temporal artery biopsy, and an inadequate response to standard treatment should prompt consideration of alternative diagnoses.

The patient's sexual history is pivotal. Broaching this subject delicately is crucial to prevent the patient from feeling judged or discriminated against, as fear of embarrassment may lead them to avoid testing, treatment, and follow-up care. In our scenario, language proved to be a barrier, hindering the establishment of a safe space for discussing the patient’s sexual trauma. This emphasizes the importance of translation services in fostering effective communication.

CONCLUSION: Uncommon syphilis types like neurosyphilis and ocular syphilis are rising.

Their vague symptoms often lead to misdiagnosis as rheumatologic conditions. Watch for patients showing atypical responses to treatment.

Use translation services for better communication and a strong doctor-patient bond in cases where language barriers exist.

THE AIR WE BREATHE: AN UNUSUAL CASE OF ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS

Arianna Vessal¹; Tamanna Sahni¹; Luis Ruiz². ¹Mid-Atlantic States Residency Program, Kaiser Permanente, Oakland, CA; ²Pulmonary Medicine, Mid-Atlantic Permanente Medical Group, Gaithersburg, MD. (Control ID #4043518)

CASE: 73YO female with a history of controlled type 2 diabetes, hypothyroidism, and remote history of breast cancer status post mastectomy presents to urgent care for 3 months of cough with dark sputum without any other associated symptoms. Symptoms began after working in her garden days after the 2023 Canadian wildfires. She was previously seen by her PCP a month prior and completed a course of amoxicillin and azithromycin.

CT chest showed a mass-like consolidation of the right middle and lower lung lobes. Lab tests including but not limited to Aspergillus antigen and antibody, hypersensitivity pneumonitis precipitins, HIV, and IGRA were negative. Total IgE was 185 IU/mL mildly elevated, and eosinophil count was significantly elevated.

During bronchoscopy, mucoid endobronchial plugs in RML and RLL segments were seen with otherwise normal airways and mucosa. Bronchoalveolar lavage was done in the occluded segments. Brushings and biopsies were obtained from the affected segments. Fungal cultures isolated A. fumigatus confirming the diagnosis. The patient was treated with 4 months of itraconazole with resolution of symptoms and of consolidation on CT without underlying lesions of the lung. PFTs showed normal function.

IMPACT/DISCUSSION: Aspergillus is known for its several opportunistic infections; from allergic to invasive pulmonary disease.¹ We regularly inhale conidia of this ubiquitous fungus, however disease is almost exclusively seen in immunocompromised patients with predisposing conditions i.e. asthma or cystic fibrosis.¹ A filamentous fungi, it thrives in soil and decomposing vegetation independent of a host,² and when disease is left untreated, Aspergillosis can cause several coinciding manifestations.^2,3 This case reviewed a patient without classic risk factors that presented with a constellation of symptoms suspicious for Aspergillosis, uncommon imaging findings, and did not meet the major criteria for diagnosis. Final diagnosis was obtained when bronchoscopy isolated A. fumigatus.

ABPA without asthma or CF is rare.^4,5 Although this patient that did not have predisposing conditions nor meet the obligatory criteria⁶ of IgE against Aspergillus or total IgE (>1000IU/mL) but did have elevated total eosinophils, this opportunistic infection was successfully isolated and treated with an appropriate regimen and patient improvement.

CONCLUSION: A high index of suspicion must be had in patients with suspicious symptoms without classic risk factors. Wildfire smoke contains viable aerosolized microbes, spores, and conidia that can travel hundreds of miles and is associated with increased hospitalizations due to fungal infections.^7-10 This patient also presented with radiographic findings that are not included in any known pattern of pulmonary aspergillosis- aspergilloma nor invasive disease. A retrospective study also described 11 patients with aspergillosis and similar radiographic findings in immunocompetent patients,¹¹ suggesting an otherwise undefined pattern of Aspergillosis.

THE DYSPNEA DILEMMA: BASE RATE FALLACY IN EXERTIONAL SHORTNESS OF BREATH AND HEART FAILURE WITH PRESERVED EJECTION FRACTION (HFPEF)

Ankitha Radakrishnan^2,1; Shyam Sundaresh^2,1. ¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Department of Medicine, Mount Sinai Health System, New York, NY. (Control ID #4054030)

CASE: A >80 year-old woman with hypertension, obesity, and atrial fibrillation was seen in clinic. The patient reported months of worsening exertional dyspnea and lower extremity edema. Examination was notable for JVP 2cm above the sternal angle at 90°, faint bibasilar crackles, and 1+ edema to bilateral shins. Vitals and labs were normal. An echocardiogram demonstrated EF=58% and E/e’ 17. A pharmacologic myocardial perfusion stress test was obtained and showed mild-moderate apical ischemia. The patient was started on aspirin, atorvastatin, and metoprolol, and referred to cardiology. Empagliflozin was prescribed, resulting in marked improvement.

IMPACT/DISCUSSION: This is an important case for the general internist because the diagnosis of HFpEF is challenging, as the signs and symptoms of heart failure are often nonspecific. The H2FPEF score is a composite score considers clinical variables, including obesity, atrial fibrillation, age >60 years, treatment with ≥2 antihypertensive medications, and two echocardiographic parameters: early mitral inflow velocity/mitral annular early diastolic velocity >9 and pulmonary artery systolic pressure >35mmHg. Weighting is applied to create the composite score ranging from 0 to 9, with scores ≥6 indicating a high likelihood of HFpEF. In this case, the patient’s symptoms and physical exam findings were very suggestive of heart failure. Integrating echocardiographic findings, the patient’s calculated H2FPEF score was ≥6, indicating an 89.3% probability of HFpEF. Ischemic work-up, interpreted as a false positive, likely could have been deferred, at least until after a trial of HFpEF management.

This case serves as a poignant example of the base rate fallacy, wherein there is a tendency to underemphasize the underlying probability of an event in favor of individuating information. In this case, the possibility of obstructive coronary disease may have overshadowed the more likely possibility of HFpEF, missing an opportunity for a therapeutic medication trial and resulting in unnecessary testing. While it is true that women, older adults, and patients with obesity and diabetes may present with “atypical” symptoms of ischemic disease, and clinical decision-making should have a higher suspicion for anginal equivalents in these populations, this should not be at the expense of other diagnoses. Patients with obstructive CAD can present primarily with dyspnea on exertion, but this represents a minority of presentations of cases, with chest pain still being the most likely manifestation. In this case of dyspnea on exertion in an older female patient, the differential diagnosis should have prioritized HFpEF over obstructive CAD.

CONCLUSION: 1. Utilizing measures like the H2FPEF score enhances diagnostic precision in HFpEF assessment

2. Recognizing the cognitive bias of base rate fallacy is crucial for improving the diagnostic accuracy of chronic dyspnea on exertion because obstructive coronary disease is often not the correct diagnosis

THE FIRST SYMPTOM OF RENAL DISEASE: A HEADACHE

Rebecca Fisher²; Douglas Farrell¹; Allison Samuel²; Nicholas B. Safian³. ¹Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY; ²Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ³Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4062970)

CASE: A 22-year-old male with no significant past medical history presented with weeks of worsening headache without neurological changes. Initial Emergency Department presentation was notable for blood pressure of 180/120, unremarkable physical examination, and unremarkable CT head and CTA head and neck. The patient was referred to primary care for hypertension management. Due to his young age and healthy status, a secondary hypertension workup was pursued, which revealed elevated creatinine and nephrotic-range proteinuria. He was urgently returned to clinic, revealing confirmed creatinine elevation, low serum albumin, and microscopic hematuria. Labs were concerning for glomerulonephritis, and he was referred to the Emergency Department for an urgent kidney biopsy.

IMPACT/DISCUSSION: Kidney disease is the most common cause of secondary hypertension,[1] of which includes glomerulonephritis. This case highlights the importance of glomerulonephritis in the evaluation of hypertension as it tends to be overlooked in the evaluation of secondary hypertension. Glomerulonephritis is treatable, but if caught too late it may progress to ESKD and dialysis dependence. Testing, including serum creatinine and urinalysis, is readily accessible to most clinical sites with minimal economic costs. This patient was diagnosed with IgA nephropathy after evaluation for secondary hypertension, which is the most common cause of glomerulonephritis.[2] IgA nephropathy presents with gross hematuria in 40-50% of cases, microscopic hematuria in 30-40%. Less than 10% of patients with IgA nephropathy present with either rapidly progressive glomerulonephritis or nephrotic syndrome.[3] The patient was started on all three of the therapeutic modalities shown to reduce his disease progression: tight blood pressure control, reduction in proteinuria with angiotensin receptor blockers and SGLT-2 inhibitors, and immunosuppression with systemic glucocorticoids.[4]

[1] Taler SJ. Secondary causes of hypertension. Prim Care. 2008;35(3):489-vi. doi:10.1016/j.pop.2008.06.001

[2] Wyatt RJ, Julian BA. IgA nephropathy. N Engl J Med. 2013;368(25):2402-2414. doi:10.1056/NEJMra1206793

[3] Galla JH. IgA nephropathy. Kidney Int. 1995;47(2):377-387. doi:10.1038/ki.1995.50

[4] Lv J, Wong MG, Hladunewich MA, et al. Effect of Oral Methylprednisolone on Decline in Kidney Function or Kidney Failure in Patients With IgA Nephropathy: The TESTING Randomized Clinical Trial. JAMA. 2022;327(19):1888-1898. doi:10.1001/jama.2022.5368

CONCLUSION: One should always consider glomerulonephritis as the etiology of secondary hypertension. This case highlights the importance of continuity of care and the crucial role primary care and ED physicians play in diagnosing critical illnesses.

THE GREAT PRETENDER STRIKES AGAIN: INITIAL MISDIAGNOSIS OF AN ATYPICAL COURSE OF SYPHILIS

Maria Novitskaya¹; Sagar Chapagain¹; Elizabeth Olson¹; Daniel Thomas¹; Paul O'Rourke². ¹Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD; ²Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #4063580)

CASE: A 56 year old woman with history of hypertension and idiopathic urticaria presents with worsening right eye vision impairment for 4 days. She notes a blurry circle in the center of her vision on the right side without pain or redness and denies left eye deficits. She started having a diffuse erythematous nonpruritic maculopapular rash 5 months ago that seemed to spread across her trunk, upper and lower extremities, and face, but not palms or soles. Her PCP referred her to an allergist who performed allergy testing, revealing cat, dander, and grass allergies, and diagnosed her with spontaneous idiopathic urticaria. She was treated with daily cetirizine and a trial of steroids which partially cleared up the rash, only to have it return. She has since trialed 4 steroid packs with lack of relief. Review of systems was notable for sore throat for the past 5 months. She lives with her long-term boyfriend and has an open relationship. She has had one other male partner in the last 6 months and 3 male partners in the last year, endorsing both vaginal and oral sex. Her long-term male partner has had sex with multiple female partners in the last 6 months. She endorses negative STI testing one year ago. She cannot recall any genital or oral ulcers in the past 12 months. Upon presentation, she was diagnosed with neuroretinitis by an ophthalmologist and tested positive for syphilis with a reactive RPR of 1:32, and T pallidum antibody was positive. She tested negative for gonorrhea and chlamydia in the urine, but positive for chlamydia DNA NAT on pharyngeal and rectal swabs. MRI brain and orbits was negative. She was treated with penicillin G every 4 hours for 10 days for syphilis, prednisone 40mg for a 14-day course then taper for ocular syphilis, and doxycycline 100mg twice daily for 7 days for chlamydia.

IMPACT/DISCUSSION: This ocular syphilis case underscores the importance of avoiding anchoring and obtaining a thorough social, including sexual, history for a new rash. It also highlights the importance of keeping syphilis in the differential diagnosis, given the increasing rates of syphilis across the country. Furthermore, it shows the importance of testing for STIs at the sites of sexual contact, including the oropharynx and anus, as this patient tested negative for chlamydia in the urine but positive in the oropharynx and anus. Her sore throat could have been from syphilis or chlamydia pharyngitis.

CONCLUSION: Appreciate the importance of a thorough social and sexual history, and avoid anchoring in the diagnosis of maculopapular rash.

Test for STIs at all sites of sexual contact including oropharynx and anus if applicable

THE IMPORTANCE OF THE PHYSICAL EXAM: A CASE OF ACROMEGALY PRESENTING AS CHEST PAIN

Martha Dillon¹; Ben Thomas¹; David Wozny¹; Rachel A. Zielinski¹; Kavita Advani^1,2. ¹Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; ²Trinity Health, Livonia, MI. (Control ID #4064844)

CASE: We present a 55-year-old male who was diagnosed with acromegaly secondary to a growth hormone (GH) secreting pituitary adenoma after presenting with chest pain based on unique physical exam findings. Past medical history was significant for previous tobacco use. The patient was referred to primary care after multiple emergency room visits over a year and a half for left sided chest pain. The pain occurred nearly every day, on exertion and rest. There were no exaggerating or relieving factors, no radiation and no associated symptoms. During his multiple evaluations, the patient had multiple EKGs which showed normal sinus rhythm with no PR interval or QTc prolongation, or ST segment changes. Chest X-rays showed no acute cardiopulmonary process. Troponin was checked on initial ED visit, and was undetectable. An outpatient exercise stress test revealed no ischemia. Physical exam was significant for large doughy feeling hands and signs of hyperhidrosis. Based on the physical exam findings and musculoskeletal chest pain, insulin-like growth factor 1 (IGF-1) was checked to rule out acromegaly. The results came back elevated at 359 ng/mL and 385 ng/mL on repeat (normal range 68 to 247 ng/mL). Follow up 2-hour glucose tolerance test did not suppress growth hormone levels, confirming the diagnosis. An MRI was obtained and revealed hypo-enhancing 1.0 x 0.4 cm nodule representing microadenoma in left aspect of pituitary gland. Patient was started on a trial of cabergoline 0.5 mg twice weekly for acromegaly secondary to a growth hormone secreting pituitary adenoma.

IMPACT/DISCUSSION: This case highlights the importance of the physical exam when evaluating the patient. Enlargement of facial features, hand and feet are predominant features of acromegaly. Additionally, patients can develop cardiovascular disease, headache, vision loss, uncontrolled diabetes and arthropathies. Acromegaly is diagnosed by elevated serum IGF-1 concentrations, which has a constant level through out the day unlike GH. As the symptoms are non-specific in the early stages and the prevalence of the disease is so low, there is on average a five year diagnostic delay. Our patient’s presenting symptom was recurrent chest pain. The underlying cause was undiagnosed until it was paired with a detailed physical exam finding of large doughy hands. It is important to always perform an extensive and detailed physical exam when meeting patients for the first time. This allows for physicians to gain valuable knowledge, shorten diagnostic delay, and prevent the high mortality in uncontrolled disease.

CONCLUSION: This case highlights the important role that physical exam plays during the diagnostic process. Acromegaly is a rare condition that initial presents with nonspecific symptoms but several key and specific physical exam findings. Without detecting these physical findings, the common diagnostic delay leaves the patient vulnerable to the high mortality associated with untreated disease.

THE SOUNDS OF STENOSIS: AUDIBLE WHEEZING LEADING TO A DIAGNOSIS OF GERD/LPR-INDUCED TRACHEAL CONSTRICTION

Corinne R. Corbett¹; Jennifer L. Cluett¹; Adnan Majid²; Judy Nee². ¹Medicine, Beth Israel Deaconess Medical Center General Medicine Division, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4055382)

CASE: A 38-year-old female with a PMH of mild intermittent asthma and GERD controlled with intermittent famotidine presented for urgent care with dyspnea on exertion. People around her reported hearing her breathing; she also felt winded particularly when climbing stairs. On exam she had coarse lung sounds and 97% oxygen saturation on room air. A peak flow reading was 250 L/min (normal for age/height is 340 L/min). Inhaled fluticasone/salmeterol was prescribed for a presumed diagnosis of worsened asthma. After a month, she returned to clinic with progressive symptoms including difficulty swallowing solid foods and postprandial regurgitation. The inhaler had not helped. On exam she had audible stridor but no diffuse wheezing. A CT of her neck and chest showed circumferential irregular thickening of the subglottic region/superior trachea measuring 6mm with <50% narrowing of the tracheal lumen. A bronchoscopy showed an 8mm subglottic stenosis 11mm distal to the vocal cords which was dilated to 13mm. Biopsy showed fragments of airway mucosa with fibrosis and acute and chronic inflammation. Other testing included a normal CBC and negative RF, ANA, and ANCA. A second bronchoscopy was done one month later with additional dilation and cryospray. Esophageal manometry with pH impedance showed ineffective motility and a DeMeester score, which categorizes GERD severity, was 17.5 (normal <14.7). PFTs were normal. After the second bronchoscopy, she was started on omeprazole 40mg daily with improvement in symptoms. In summary, her diagnosis is complex subglottic stenosis secondary to chronic airway inflammation from GERD.

IMPACT/DISCUSSION: Dyspnea is often framed as a cardiovascular versus respiratory problem yet it is known that GERD can exacerbate underlying asthma, thereby leading to cough, dyspnea, and wheezing. In a young patient with mild intermittent asthma the suspicion for underlying bronchospasm was reasonable. However, concern appropriately shifted from asthma when she reported dysphagia. Bronchoscopy with subglottic stenosis invokes a larger differential: trauma, inflammatory causes such as vasculitis, sarcoid, or rheumatoid arthritis, infection or malignancy. Evaluation for these has been negative, leaving her with a diagnosis of chronic inflammation secondary to GERD. Tracheal stenosis from GERD is an uncommon manifestation of a common condition and should remain on the differential for respiratory complaints.

CONCLUSION: GERD is a common condition (20% prevalence) encountered in internal medicine and understanding the range of symptoms is important to all general internists. Considering tracheal stenosis and other pulmonary manifestations of GERD expands our differential diagnosis and current concepts regarding potential complications of this condition.

THE SWEET SPOT: A CASE OF TREATMENT INDUCED NEUROPATHY OF DIABETES

Shirin Nour. General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4054054)

CASE: A 47-year-old female, with a medical history of longstanding type 2 diabetes and neuropathy, presented for evaluation of worsening pain in her extremities and dizziness. Patient had an established diagnosis of diabetic neuropathy but reported an increase in the level of her discomfort. She described new burning pain in her thighs and hands. She also had dizziness upon standing from seated position. She had restarted her medication regimen of metformin, glipizide, insulin degludec, and semaglutide three months prior to presentation. Physical examination was notable for absent ankle reflexes and decreased sensation to pinprick, light touch, and vibration in the toes bilaterally.Her labs were significant for a glycated hemoglobin (HbA1C) of 6.7. HbA1C four months prior was 13.8. Thyroid stimulating hormone, vitamin B12, and copper were within normal limits. A small IgA kappa was noted on monoclonal gammopathy study.

An electromyography (EMG) showed advanced length-dependent axonal sensorimotor peripheral neuropathy with more active denervation than would typically be expected for a chronic neuropathy. Autonomic reflex testing showed evidence of distal postganglionic sympathetic sudomotor, severe cardiovagal, and moderate to severe cardiovascular adrenergic impairment.On tilt table testing, blood pressure decreased from (150/90) to (128/78) after 10 minutes. Thermoregulatory sweat testing showed widespread anhidrosis except for patches on the right arm, forehead, and thighs. Findings were consistent with treatment induced neuropathy of diabetes with autonomic neuropathic component. Patient's pain was treated by uptitrating her dose of gabapentin. She was counseled on measures to manage symptoms of orthostatic hypotension including the use of abdominal binder and increasing fluid and sodium intake.

IMPACT/DISCUSSION: Treatment induced neuropathy of diabetes (TIND) is an underdiagnosed painful sensory and autonomic neuropathy. The number of reported cases in literature remains small.TIND is characterized by the onset of either neuropathic pain or autonomic dysfunction within 8 weeks of a decrease in average glucose values. It is associated with a decrease in HbA1C of 2 points or more over a 3-month period. The risk of TIND and intensity of pain is increased when the A1c is reduced by more points.

TIND is more common in individuals who have type 1 diabetes, but can occur in both type 1 and type 2 diabetes.TIND has been documented in patients treated with insulin, oral hypoglycemic medications, or diet. It is important to recognize the risk factors for TIND and the potential consequences of aggressive glucose control.

CONCLUSION: Treatment induced neuropathy of diabetes is an underrecognized iatrogenic neuropathy that is associated with rapid decrease in HbA1C in patients with longstanding hyperglycemia.It results in painful neuropathy in addition to autonomic dysfunction which can significantly impact patients.

THE SYNCHRONIZED DISARRAY OF DIAGNOSING PRIMARY CILIARY DYSKINESIA

Peyton M. Boyd¹; Meghan Althoff^1,2; Sunita Sharma^1,2. ¹Internal Medicine (Pulmonology), University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²Internal Medicine (Critcal Care), University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4058125)

CASE: A 26-year-old female, a non-smoker with a history of rhinosinusitis, pneumonia, otitis media, and asthma, presented with concerns of a “breathy” cough. She reported wheezing, dyspnea, and small-volume hemoptysis. She took albuterol for asthma; however, this did not provide symptom relief. Her surgical history is pertinent for sinus surgery and tympanostomy tube placement. Prior sinus cultures have grown pseudomonas and S. aureus.

Given no symptom improvement with albuterol, the patient’s asthma diagnosis was verified with pulmonary function tests. Her tests revealed an obstructive lung process, with an FEV1/FVC ratio of less than 70%. However, there was no response to bronchodilators, which is expected in asthmatic patients. This prompted other possible diagnoses, including bronchiectasis, COPD, and cystic fibrosis. Within the patient context, bronchiectasis is a probable cause, requiring imaging that shows dilated bronchi for diagnosis.

Our patient's CT imaging was consistent with bronchiectasis. Her imaging findings, symptoms, and history of recurrent sinus and ear infections raise a concern of primary ciliary dyskinesia (PCD), a genetic condition characterized by absent or immotile cilia. To screen for PCD, the patient received a nasal nitric oxide (NO) test, which measures the amount of NO, a molecule believed to regulate ciliary motility. Low levels of nasal nitric oxide are expected in PCD, which was reflected in our patient’s results. For symptom management, the patient was advised to use a physiotherapy vest to control mucous production and stop using inhaled corticosteroids. Since initiating this plan, she has not had any recurrent episodes of pneumonia.

IMPACT/DISCUSSION: PCD is a rare, inherited disease in which genetic variants have been associated with ciliary dysmotility, dyskinesia, or aplasia. Given the similar presentation, PCD is often misdiagnosed as asthma. Unlike asthma, which is a chronic inflammatory disease of the airway characterized by reversible airflow obstruction, PCD often results in fixed airflow obstruction. Our patient did not have reversible airflow obstruction, which prompted the need to look for an alternative diagnosis. Her history of recurrent sinus and ear infections raised the possibility of PCD, which was supported with nasal nitric oxide. PCD should be considered in patients who do not respond to conventional asthma therapies, those who have irreversible airflow limitations, and those with a history consistent with recurrent sinus or respiratory infections.

CONCLUSION: Asthma must be diagnosed with PFTs if available. An obstructive air pattern along with reversibility of airflow obstruction with a bronchodilator is necessary for diagnosis.

Many respiratory diseases mimic asthma symptoms. Additional investigation is warranted in individuals who do not respond to traditional asthma therapies.

Combined histories of recurrent pneumonia, otitis media, and or sinusitis should raise concern for primary ciliary dyskinesia.

THROUGH THE DARIéN FOREST TO THE CONCRETE JUNGLE

Joseph Abraham, Deborah Edelman. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4060165)

CASE: A 33-year-old female 'KV' presented to our internal medicine resident-run clinic to establish care. Using a translator, she reported being well with minimal medical history (pituitary adenoma, mild anxiety, and ovarian cyst). She reported progressive astigmatism and mild pityriasis capitis; the latter was distressing, fearing looking "unhygienic." Given her non-English proficiency, we inquired about her path to the US. KV described working as a family medicine physician in Venezuela until 3 months ago. Fleeing violence, she and her husband took their young son on foot through Central America to the United States (US). Through the Darién Forest and up through Mexico, she witnessed violence and direct verbal assault. Upon arrival in the US, they were bussed to NYC to a shelter; there, the twice-daily meals were "very poor." After 2 months, the shelter evicted them. KV tearfully wondered where she would sleep. Employment attempts failed, save one offer at a nightclub, which she declined due to safety concerns.

As an asylum seeker, we established KV’s immunity to Measles, Mumps, and Rubella. She had no evidence of STIs, hepatitis, or exposure to Tuberculosis or Chagas disease. Her only notable lab was absolute eosinophilia 1032 cells/uL without Strongyloidiasis. Our resident clinic set up in-house appointments with optometry, dentistry (for caries), and OBGYN. KV was linked to our care management team for food insecurity and housing. We recommended close follow-up with primary care as well as our mental health counselors for her unique psychosocial experience and challenges.

IMPACT/DISCUSSION: Over 3% of 2023 asylum seekers arriving in our city, many traversing the perilous Darién Forest, sought treatment at our health system. Traveling through the Darién Forest Gap is a choice of desperation. Conditions are notoriously dangerous for travelers, with corpses lining the wayside. Migrants are exposed to harsh terrain and climates, numerous tropical diseases, aggressive human trafficking, and not uncommonly verbal, physical, and sexual assault. Our documented cases include tuberculosis, strongyloidiasis, and HIV, with 100% reporting extortion.

CDC offers general guidance on anemia, STIs, hepatitis, and HIV for refugees, but specific guidelines for this new immigration influx are lacking. KV’s case exposes these gaps and emphasizes that immigration challenges persist beyond the border. Primary care providers, often the sole point of contact in this new setting, play a crucial role in coordinating psychosocial determinants of health and leveraging the expertise of various disciplines necessary for the care of these patients.

CONCLUSION: - Initial encounters with a new patient, especially when English is not their primary language, should prompt investigation into possible refugee status.

- To safely transition to life in the US, refugees, especially those navigated through perilous areas, need screening for medical, psychological, and social concerns.

TICK-TALK: HOW TO SPOT ROCKY MOUNTAIN SPOTTED FEVER

Hassan Beesley¹; Mayce Mansour^1,2. ¹Internal Medicine, Mount Sinai Health System, New York, NY; ²Internal Medicine, Icahn School of Medicine at Mount Sinai, Brooklyn, NY. (Control ID #4055088)

CASE: A 61-year-old woman with no significant past medical history presents with five days of fever, chills, new-onset rash, and nausea. She returns from a four-day trip to Virginia five days prior. Exam is significant for a pruritic, maculopapular erythematous rash over the left arm, chest, and face, sparing the palms and the inside of the mouth. The patient takes no medications. Initial laboratory studies show a white blood cell count of 3400/uL, aspartate transaminase of 401, and an alanine transaminase of 341. The patient is empirically started on Doxycycline 100mg BID. A broad infectious workup is performed and testing for Borrelia, Lyme, Hepatitis A, B and C, CMV, Bartonella, EBV, HIV, and TB is unremarkable. However, the patient has an elevated RMSF IgM and negative RMSF IgG. All symptoms have resolved by the time of follow-up phone call one week later.

IMPACT/DISCUSSION: The patient’s fever, nausea, and new-onset diffuse, maculopapular rash with elevated transaminases and positive RMSF IgG are consistent with RMSF.

RMSF is a tick-borne illness occurring throughout the United States, although five states (Arkansas, Missouri, North Carolina, Tennessee, and Virginia) account for over 50% of all cases. Early symptoms are often non-specific. Most patients with RMSF develop a maculopapular rash within the 3^rd-to-5^th day of illness, which may become petechial over time. However, many patients may present with non-specific symptoms prior to developing a rash and a high clinical suspicion should be maintained especially when a travel history is suggestive.

The differential diagnosis for a febrile patient with maculopapular rash includes viral infections such as measles, infectious mononucleosis, viral hepatitis, and primary HIV; bacterial infections such as secondary syphilis, ehrlichiosis, and streptococcal infection; and non-infectious etiologies such as vasculitis, adult-onset Still’s disease, and drug-reactions.

Antibiotic therapy should be initiated empirically as soon as the diagnosis is suspected. A delay in treatment has been associated with three times the mortality of patients treated within the first five days of symptoms. First-line treatment is with doxycycline for a minimum 5-to-7-day course, but generally continued until at least 72 hours after defervescence.

CONCLUSION: A broad differential and workup are appropriate in the febrile patient with maculopapular rash, with both infectious and non-infectious considerations.

RMSF classically presents fever, headache, and rash but patients may present without the entire triad and should be suspected in patients with travel history to high-risk states.

Empiric treatment for RMSF should be initiated when the diagnosis is clinically suspected, as delays in care are associated with increased mortality.

TO FIND A WAY: UTILITY OF CLINICAL CALCULATORS IN DECREASING TIMELY DIAGNOSIS OF GOUT IN AN UNDERSERVED POPULATION.

Alyson B. Meyer, Deborah Edelman. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4059983)

CASE: We present a case of SS, a 34-year-old male with a history of sleep apnea, BMI >40, who is a patient at our residency clinic located at a Federally Qualified Health Center (FQHC) in Manhattan.

SS was in his usual state of health until ~ one week ago when he acutely developed right-sided first metatarsal (MTP) swelling, warmth, tenderness to palpation, and inability to ambulate. The night before, he ingested red meat and consumed 42 (3/day) sweetened iced teas over the prior 2 weeks. Within 48 hours of initial symptoms, he presented to the emergency room where he was given naproxen, and no further workup was done. Within a week of discharge, SS presented to our clinic with 8/10 pain and the need to ambulate with assistance. His right 1^st MTP was tender and erythematous. His serum uric acid level was 7.9 mg/dL and x-ray revealed erosive changes around the first MTP head. Acute Gout Diagnosis Rule Score (AGDRS) of 9.5 and ACR/EULAR Gout Classification Score of 10. He was treated for gout with colchicine and had resolution of symptoms within 1 week.

IMPACT/DISCUSSION: Gout, known as monosodium urate (MSU) crystal deposition disease is defined as serum urate concentrations greater than 6.8 mg/dL. Clinically, it requires MSU crystal formation and subsequent deposition in tissues with acute and or/chronic inflammation. Initial gout flares are typically monoarticular, often affecting the first MTP joint. Symptoms include severe pain, erythema, warmth, and swelling of the affected joint. Gold standard diagnosis for an initial gout flare uses arthrocentesis and synovial fluid evaluation with MSU crystal identification on microscopy. While arthrocentesis is the most accurate, diagnostic calculators can aid in earlier identification and treatment of the disease.

In determining clinical guidelines in 2017, the American College of Physicians (ACP) found that clinical algorithms had >80% sensitivity and specificity in diagnosing gout. The AGDRS specifically includes a uricemia cutoff, gender, and cardiovascular disease. A score >8 on this tool corresponds with an >80% prevalence of gout. The ACR/EULAR Gout Classification Criteria requires entry criteria of > one classic episode before requiring at least seven classification criteria based on frequency, characteristics, urate levels, and x-ray findings. Once scored, patients are then risk stratified for gout vs. non-gout arthritis and need for joint fluid analysis to finalize the diagnosis (sensitivity 92%, specificity 89%).

In our FQHC, systematic barriers to subspecialist healthcare include (timely) access, cost of care, health literacy, and language hurdles. Clinical calculators may benefit patients with these barriers by decreasing treatment delays and preventing the progression of the disease.

CONCLUSION: -The gold Standard for diagnosis of gout is arthrocentesis.

-Clinical diagnostic calculators can aid in clinical reasoning, establish a gout diagnosis, and decrease the need for arthrocentesis in specific populations.

TOO YOUNG FOR HYPERTENSION

Neda Amirmokhtari¹; Sarah Han¹; 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 #4062789)

CASE: A 23-year-old female with no past medical history presented to the ED with headache, blurred vision, and orthopnea, and was subsequently found to be in hypertensive emergency. Her blood pressure (BP) was 230/150 requiring a labetalol infusion and creatinine was elevated to 2.2. Her physical exam was remarkable for trace lower extremity edema and mild basilar crackles with inspiration. Her BP had been elevated at ~180/90 at a PCP visit previously, but her elevated BP was contributed to anxiety at the visit. During her hospital stay, a workup for secondary causes of hypertension (HTN) included a renal ultrasound with vascular duplex, urine analysis (UA) with microscopy, renin/aldosterone ratio, and TSH. The UA was significant for >300 mg/dl protein and RBC >25 hpf. Renal ultrasound was suggestive of chronic medical renal disease with increased renal cortical echogenicity. The remaining results were unremarkable. Nephrology was consulted and recommended a renal biopsy which showed active advanced stage crescentic IgA nephropathy. Treatment included solumedrol 500 mg x3 days and her BP was controlled with anti-hypertensives from three different classes: beta blocker, calcium channel blocker, and angiotensin receptor blocker. Further work-up regarding her shortness of breath and blurry vision found that she had hypertensive retinopathy and left ventricular hypertrophy (LVH) with concentric remodeling.

IMPACT/DISCUSSION: It is important to recognize clues when secondary causes of hypertension may be more likely. Such examples are uncontrolled BPs (>140/90) despite use of three anti-hypertensives from unique classes including a diuretic, HTN with electrolyte abnormalities or in individuals age < 30 years old without risk factors, and severe HTN with findings of end organ damage. Typical work-up includes UA, TSH, chemistry, renin/aldosterone ratio, and renal ultrasound to rule out more common etiologies such as endocrine disorders, primary kidney disease and primary aldosteronism. Further evaluation is tailored to a patient’s age, risk factors, and presentation. In this case, the patient qualified for work-up of secondary HTN given her age and presentation. Her UA results of >300 mg/dl protein and RBC >25 hpf raised concern for potential nephropathy, prompting a renal biopsy and resulted in the contributing diagnosis.

Uncontrolled HTN should prompt evaluation for potential end-organ damage and in this case revealed LVH and hypertensive retinopathy. Her late diagnosis of HTN led to end organ damage and potential lifelong co-morbidities, highlighting the importance of early recognition of uncontrolled HTN and secondary HTN.

CONCLUSION: This case demonstrates the importance of promptly recognizing uncontrolled HTN and causes of secondary HTN. This patient’s HTN was under-appreciated due to her history of anxiety and age, leading to delayed diagnosis and potential lifelong co-morbidities including CKD, retinopathy and LVH.

TREATING PMR IN A PATIENT WITH STEROID-INDUCED MANIA: A GIANT CELL CONUNDRUM

Kemeberly Charles¹; Cary Blum². ¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4063873)

CASE: A 52-year-old M with a PMHx of HTN, DM, prostate cancer and bipolar disorder presented to his PCP with subacute progressive widespread pain and stiffness, and acute bitemporal headache with nausea and L eye blurry vision. Labs demonstrated CRP of 19.4 and ESR of 26, leading to a working diagnosis of polymyalgia rheumatica (PMR) complicated by giant cell arteritis (GCA). Notably, he had a history of steroid-induced mania, including a recent episode triggered by an intraarticular steroid injection. Given his high risk for complications and suspicion for GCA, he was admitted for treatment with high dose steroids, with improvement of his symptoms (including headache). He underwent a temporal artery biopsy (TAB) which did not show active arteritis. While hospitalized, the pt was started on valproate for bipolar disorder, and discharged on a medium-dose steroid taper for a presumptive diagnosis of PMR without GCA. However, three weeks into his taper, he was readmitted with mania, headache, diplopia and an elevated CRP. MRI at that time showed mural thickening and enhancement of the bilateral temporal arteries, suggestive of GCA. Due to the presence of steroid complications and relapse of GCA,the patient is being initiated on tocilizumab as a steroid sparing agent.

IMPACT/DISCUSSION: The diagnosis of PMR requires the presence of axial joint pain/stiffness and elevation in inflammatory markers in a patient over 50 years old. The sensitivity of CRP is ~99% whereas ESR is only 92%-94%, thus creating the possibility of discordant results, as seen in our patient. PMR is normally treated outpatient with steroids. In this case, the patient was admitted for initiation of steroids given both his high risk for steroid induced complications (including mania and severe hyperglycemia), as well as high suspicion for GCA (given monocular vision changes and new onset headache). While glucocorticoids are the mainstay of treatment in both PMR and GCA, tocilizumab has shown efficacy in RCTs as a steroid sparing agent. This case also illustrates the important point that while TAB remains the standard of care for the diagnosis of GCA, sensitivity is only 77%. Other useful diagnostic modalities in GCA include MR angiography and Doppler ultrasound, the latter of which can serve as a diagnostic surrogate for TAB but is not widely available.

CONCLUSION: Hospitalization is indicated for treatment of PMR for patients who have symptoms suggestive of GCA as well as history of serious adverse effects to steroids. While elevated ESR has been classically associated with PMR, it can be normal in a small fraction of cases. Patients with symptoms consistent with GCA and negative TAB should be treated empirically for GCA in the absence of an alternative diagnosis.

UNILATERAL AXILLARY SWELLING IN UNTREATED HIV: INFECTION OR NEOPLASM?

Hana Kusumoto¹; Lindsey E. Fish². ¹Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²Department of General Internal Medicine, Denver Health and Hospital and University of Colorado, Denver, CO. (Control ID #4063224)

CASE: A 41-year-old male without any medical follow up for 6 years presented to an urgent care facility with new swelling in his right armpit for 1 week with concern of an abscess. In the past 2 days the swelling had grown much larger in size. There was no associated redness or pain at the site. He denied fever and infectious symptoms. He denied swelling at other locations including groin or neck. ROS negative for weight loss, night sweats, cough, dyspnea, and hemoptysis.

PMHx: HIV, diagnosed 8 years ago, has been off of anti-retroviral therapy (ARVT) for 6 years

SHx: Denies smoking and illicit drug use. Drinks alcohol.

FHx: Non-contributory.

Medications: None.

Physical Exam: Vitals normal. Axillary swelling – 4x5cm well circumscribed firm mass. No erythema or TTP. No additional masses found in cervical, axillary or inguinal regions. Rest of exam normal.

Diagnostic Studies: Bedside POCUS without fluid collection in axilla. BMP normal. CBC shows WBC 3.6.

Clinical Course: CD4 count 76 and HIV viral load <216,000 confirmed active HIV infection and patient was referred for infectious disease follow up and started on ARVT. CT Abdomen pelvis 3 days later showed an ill-defined, mass like area, scattered thoracic and abdominal lymph nodes, and mild splenomegaly. An IR guided biopsy of the axillary lesion was conducted, and preliminary pathology came back showing B-cell lymphoma. Patient was directly admitted for PET/CT and chemotherapy initiation.

IMPACT/DISCUSSION: This case illustrates how an axillary mass, in an otherwise asymptomatic patient with untreated HIV, can represent many critical etiologies such as infectious and neoplastic conditions or the natural lymphoid hyperplasia of progressive HIV. Making a broad differential diagnosis is critical in the evaluation of masses in untreated HIV patients. Infectious causes include abscess, folliculitis, disseminated mycobacterial, fungal, and viral infections. Important neoplastic conditions to consider include lymphoma, Castleman disease, and Kaposi sarcoma. Affected lymph nodes, CD4 lymphocyte count, pulmonary symptoms, and central nervous system involvement may be helpful laboratory and clinical features to narrow diagnosis. Our patient had no constitutional symptoms (night sweats, weight loss, etc.) and presented only for unilateral axillary swelling, emphasizing that clinicians must be vigilant for even subtle presentations of HIV-related lymphoma and that the diagnosis for any suspected HIV-related lymphoma requires tissue biopsy.

CONCLUSION: - In outpatient settings with common presentations, clinicians must be vigilant for subtle presentations of HIV-related diseases.

- Clinicians must have a broad differential diagnosis in the evaluation of masses in untreated HIV patients.

- Diagnosis for any suspected HIV-related lymphoma requires a tissue biopsy.

UNVEILING THE PUZZLE: A CASE OF INCREASED BRUISING, EPISTAXIS, AND FATIGUE LEADING TO THE DIAGNOSIS OF IMMUNE THROMBOCYTOPENIA (ITP) IN A PRIMARY CARE SETTING

Omar Yaghi, Caroline Bockus. Medicine, The George Washington University, Washington, DC. (Control ID #4065205)

CASE: 66-year-old man with past medical history of hypertension and hypothyroidism presented to the primary care clinic with 3 months of fatigue, epistaxis, and easy bruising that worsened after a flu-like illness 2 weeks ago. He was up to date with cancer screenings and did not have a family history of bleeding disorders. On physical examination, he had petechiae and purpura over the abdomen, legs, and shoulders.

Complete Blood Count (CBC) showed a platelet count of 25 x109/l. He was advised to go to the emergency room where his platelets dropped to 20 x109/l and no CT evidence of lymphadenopathy or splenomegaly was found. He was admitted to the inpatient service, received 2 doses of Intravenous Immunoglobulin (IVIG) and 2 doses of dexamethasone increasing his platelets to 66 x109/l. He left against medical advice after 2 days to feed his cat and was prescribed 2 more days of oral dexamethasone. On close follow-up, the platelet counts and symptoms continued to improve.

Hematology follow up is pending.

IMPACT/DISCUSSION: Thrombocytopenia can present with fatigue, easy bruising, and mucocutaneous bleeding. Primary care physicians should obtain a thorough history, complete physical examination, and order initial laboratory investigations, including a complete blood count (CBC) and a peripheral blood smear to determine the cause of thrombocytopenia, stratify bleeding risk, and decide the treatment.

ITP is an acquired autoimmune condition where autoantibodies attack platelet surface antigens GP IIb/IIIa. ITP is characterized by a platelet count <100 x109/l. It can be idiopathic or secondary to an inciting event like an infection, CLL, or an autoimmune disorder.2 The absence of a gold standard test and the low sensitivity of antiplatelet antibody testing makes ITP a diagnosis of exclusion; assessing medications and family history to rule out other etiologies is crucial for diagnosing ITP.

Prednisone at 0.1 mg/kg for 2 weeks or dexamethasone 40 mg for 4 days is the first line treatment for symptomatic patients with platelets <30 x109/l and response to treatment is defined by platelet counts >50 x109/l. Adding IVIG is preserved for patients with a high risk of bleeding. Asymptomatic patients with platelet counts >20 x109/l and no risk factors do not need to be admitted for observation but must be seen by a hematologist within 72 hours.

CONCLUSION: 1. History, physical examination, and investigations to rule out secondary causes of thrombocytopenia are pivotal in achieving timely diagnoses and initiating treatments, particularly in cases of ITP.

2. Incorporating patient input and social factors into decision-making, guided by treatment guidelines, improves outcomes and enhances compliance.

WHEN FACIAL NUMBNESS BECOMES FATAL IN A YOUNG MALE

Jessica Chen¹; Armelia Sani¹; Miriam Hakim¹; James Samson². ¹Internal Medicine, University of California San Diego, La Jolla, CA; ²University of California San Diego, San Diego, CA. (Control ID #4061655)

CASE: A 25-year-old male with a remote history of migraine presented to the urgent care for new-onset right facial numbness, persistent right retro-orbital headache, and diffuse sinus pressure that started after a COVID-19 infection seven weeks prior. He smoked electronic cigarettes. The physical exam showed right maxillary nerve numbness and diffuse sinus tenderness. ESR was normal. He was treated with fluticasone nasal spray and pseudoephedrine without improvement. A head CT was obtained by his primary care physician one month after onset of facial numbness and two and half months after onset of the severe sinus headache, showing extensive sinus opacification and bone erosion. Subsequent maxillofacial MRI showed an infiltrative, trans-spatial sinonasal mass centered within the superior meatus and ethmoid air cell chains with frank intracranial disease extension, and invasion of the frontal dura extending over the roof of the orbits. Biopsy of the nasal mass revealed alveolar rhabdomyosarcoma. Unfortunately, the patient succumbed to advanced cancer two years after diagnosis.

IMPACT/DISCUSSION: This case illustrates the importance of recognizing facial numbness as a potential red flag for severe and serious sinus diseases. The vast differential diagnoses of facial numbness can be divided into categories. These etiologies include infection (soft tissue or sinus infection, abscess), tumor (cancer, non-inflammatory lesion), autoimmune (giant cell arteritis, vasculitis), neurologic (Bell’s palsy, post-herpetic neuralgia, trigeminal neuralgia, multiple sclerosis, Guillain-Barre Syndrome, stroke, cervicogenic nerve impingement), trauma (facial, surgical, dental), and joint disorders (temporomandibular joint syndrome). This patient had a COVID-19 infection preceding his sinus pain and headache, but it was not the cause of his persistent facial numbness. It was likely that the sinus inflammation from this patient’s COVID-19 infection unveiled sinus symptoms related to his rhabdomyosarcoma. Conversely, his preceding COVID-19 infection delayed the investigation of a malignant cause of his persistent sinus pressure and facial numbness. This case also presents a rare case of adult-onset sinus alveolar rhabdomyosarcoma (RMS) as a cause of facial numbness. RMS is a high-grade soft tissue sarcoma of skeletal myoblast-like cells, usually affecting children. Soft tissue sarcomas account for 1% of cancer in adults, and rarely affect the orbits, nasal cavity, or paranasal sinuses.

CONCLUSION: Even though sinusitis may cause facial numbness, it is not commonly seen.

New facial numbness associated with sinus symptoms warrants a comprehensive evaluation and prompt follow up.

WHEN SEEING PEOPLE ISN’T PSYCHOSIS

Sara Towne¹; Nisha Chadha²; Jenny J. Lin¹. ¹General Internal Medcine, Mount Sinai Health System, New York, NY; ²Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4064757)

CASE: An 88-year-old woman with cirrhosis, chronic kidney disease, diabetes mellitus, osteoporosis, hypertension, insomnia, and macular degeneration presented to her PCP with visual hallucinations. She described recurrent nocturnal visions of a man who demanded money from her to prevent her from losing her vision. At the time, she was taking hydroxyzine and occasional mirtazapine at night for insomnia. Her hydroxyzine was discontinued, and her hallucinations briefly improved. At her next appointment, she described recurrent hallucinations of people trying to kill her. Her levocetirizine was discontinued, and she was started on buspirone for anxiety about her poor sleep and hallucinations. Her hallucinations persisted for months, and she was referred to sleep medicine to investigate an underlying sleep disorder. She was also restarted on her sleep aids, in case poor sleep was contributing to her hallucinations. Eventually, she was brought to the ER at an outside hospital for severe visual hallucinations, where she was diagnosed with Charles Bonnet Syndrome (CBS) in the setting of her macular degeneration.

IMPACT/DISCUSSION: CBS is a syndrome of visual hallucinations that occurs most commonly in older patients with significant vision loss. While the mechanism is unknown, it is theorized that reduced sensory input to the visual cortex of the brain due to ocular pathology, commonly at the level of the retina or optic nerve, leads to the generation or retrieval of past images by the brain as a compensatory mechanism. This phenomenon is similar to phantom limb. The primary risk factor for CBS is vision loss, and typical etiologies include macular degeneration, glaucoma, diabetic retinopathy, retinal vascular occlusions, cataracts, and stroke.

The hallucinations of CBS can be simple or complex. Simple hallucinations refer to lines, flashes of light, or shapes, while complex hallucinations can include people, animals, or other discrete images. Some patients experience the same symptom repeatedly, and others experience new hallucinations each time. Episodes can vary in length from seconds to hours, and triggers include poor lighting, fatigue, and stress. Symptoms can be distressing, and patients may under-report their symptoms due to fears of being stigmatized. What is distinctive about these hallucinations is that patients are typically aware that their hallucinations aren’t real.

In some cases, treatment of the underlying visual disorder resolves the hallucinations. Patients can also be taught simple coping mechanisms, including: rapid eye movements, blinking, and increasing visual stimuli (eg. turning on the lights). Symptoms often improve within 1-2 years. There is limited data on the role of antipsychotics for patients with persistent hallucinations.

CONCLUSION: There are many etiologies of visual hallucinations. In patients with a known history of severe visual compromise, CBS must be considered.

A diagnosis of CBS may help alleviate the anxiety that can occur with these hallucinations.

Clinical Vignette - Geriatrics and Palliative Care

"GIST WITH C-KIT MUTATION: CLINICAL ODYSSEY AND TARGETED TREATMENT"

Basak Basbayraktar^1,2; Letisha Mirembe³; Tanzina Afroze⁴; Mai Hamaad⁵. ¹Internal Medicine, TTUHSC, Amarillo, TX; ²Internal Medicine, Texas Tech University System, Lubbock, TX; ³Medicine, Texas Tech University System, Lubbock, TX; ⁴Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX; ⁵Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX. (Control ID #4015111)

CASE: A 65-year-old male with a history of hypertension presented with a two-month history of progressive abdominal pain, early satiety, bloating, and a noticeable weight loss of approximately 20 to 25 pounds. The discomfort was primarily localized in the left upper quadrant. Notably, he denied vomiting, hematemesis, or melena, and had no prior history of peptic ulcer disease, endoscopy, or colonoscopy. The patient also reported increased shortness of breath, reduced energy levels, and generalized weakness. Diagnostic investigations included a chest x-ray revealing mild bibasilar atelectasis. CT abdominal imaging unveiled a substantial 20 cm in diameter upper to mid abdominal mass featuring a low-density cystic area. This mass was positioned between the pancreas and the stomach, exerting a significant mass effect, notably, the mass's exophytic origin from the greater curvature of the stomach strongly suggested a GIST. The extension of this mass into the porta hepatis, causing displacement of the duodenal loop collections of loculated fluid was evident in the left subphrenic and epigastric regions surrounding the mass and the mass's compression of the portal vein led to the development of mesenteric venous collaterals. Histopathological examination of the mass through endoscopic ultrasound-guided fine-needle aspiration confirmed the diagnosis of GIST. Immunohistochemistry revealed positivity for c-kit, validating the presence of a c-kit mutation.

IMPACT/DISCUSSION: Gastrointestinal stromal tumors (GISTs) are rare entities, constituting less than 1% of all gastrointestinal tumors, with an estimated annual incidence of 10-20 cases per million individuals. While GISTs can manifest at any age, the median age of diagnosis hovers around 60 years. Frequently characterized by mutations in the c-kit proto-oncogene, GISTs present unique diagnostic and therapeutic challenges. The characteristic size of the tumor and its exophytic origin from the stomach's greater curvature align with the classical features of GIST. Given the potential for complications such as rupture and hemorrhage, timely diagnosis and intervention are paramount. The cornerstone of GIST management involves surgical resection of the tumor. In cases of unresectable or metastatic disease, tyrosine kinase inhibitors such as imatinib play a pivotal role in therapy. Molecular analysis, specifically for c-kit and PDGFRA mutations, guides treatment decisions.

CONCLUSION: It is important to recognize the clinical presentation of GIST and emphasize the critical role of early diagnosis in optimizing patient outcomes. While GISTs are indeed rare, they should remain on the diagnostic radar when patients present with abdominal symptoms and imaging findings suggestive of this condition. The prevalence and therapeutic progress in GISTs underscores the need for continued research and clinical awareness in the realm of oncology.

A CRUCIAL MISSED STEP: PROPERLY CONSENTING A HEALTH CARE PROXY PRIOR TO A MEDICAL PROCEDURE

Grace Kenley, Cassidy Low, Thalia Bowie, Alyssa Moore, Marcus Ruopp, Sarah King. Geriatrics and Extended Care, VA Boston Healthcare System Brockton Division, Brockton, MA. (Control ID #4064653)

CASE: An 81-year-old male with Alzheimer’s dementia was admitted to a skilled nursing facility (SNF) for generalized weakness. Prior to admission, he was living alone and receiving occasional assistance with activities of daily living and concerns regard incontinence, falls, and poor living conditions. During the SNF admission, the patient demonstrated poor insight into his health status while continually refusing rehab services; thus, concerns were raised about his capacity to make informed health related decisions and remain safe at home. Eventually, the patient was deemed to lack capacity and his health care proxy (HCP) was activated. Several months after HCP activation, the patient was seen by ophthalmology and scheduled for cataract surgery. Prior to surgery, a direct care clinician working with the patient identified that the activated HCP was not consented for the cataract surgery. Instead, it was documented that the patient himself was consented. The procedure was postponed until proper consents were obtained.

IMPACT/DISCUSSION: Obtaining informed consent is a crucial step prior to any medical procedure to ensure the care provided reflects the goals, preferences, and values of the patient. Consent must be obtained from an individual who maintains capacity to make decisions related to their healthcare. This raises concern about vulnerable patient populations receiving potentially unnecessary or inappropriate procedures, such as those presenting to appointments without family or other trusted individuals present that may act as an advocate. In response to this concern, a quality improvement initiative was instituted. Over the course of a 4 month period at a VA Medical Center, 55 encounters of patient with activated proxies where consent was obtained were reviewed. This review showed that 35 encounters had opportunities to improve the consent/documentation process. As a result, a stakeholder-driven prototype has since been proposed that will focus on collecting additional data and developing a multipronged approach to improve consents, including an educational curriculum and electronic medical record flag to increase knowledge and awareness.

CONCLUSION: This case illustrates a gap in knowledge related to properly consenting an activated health care proxy. Often during short interactions, a patient may present on a surface level as having the ability to make informed health care decisions, but with more formal assessment are deemed to lack capacity. Formal education and system modifications regarding informed consent for individuals who lack capacity is crucial to ensure patient-centered care.

ACUTE LOWER EXTREMITY WEAKNESS AFTER A FALL: A CASE REPORT OF AN OLDER MALE PRESENTING WITH INABILITY TO AMBULATE AFTER A RELATIVELY MINOR FALL IN HIS HOME.

Mathias E. Kant. Medicine, Penn State College of Medicine, Hershey, PA. (Control ID #4016251)

CASE: The patient is a 71-year-old, previously ambulatory, male with a history of diabetes, CHF, and hypertension who presented to the ED with the acute onset of inability to walk. The patient reported that for the previous week he had had some numbness and tingling in his lower extremities, but he had remained ambulatory until he fell that morning. He denied all other symptoms, except for chronic occasional urinary incontinence. On admission he was afebrile, heart rate of 80 BPM, and blood pressure of 120/80. On examination cardiac, pulmonary and abdominal exams were without abnormality. He had intact sensation to light touch, pinprick, and proprioception; motor strength was diffusely mildly reduced at 4/5, except for 3/5 right dorsiflexion. Admission labs were remarkable only for an elevated WBC of 12.3/ mL, neutrophils of 82.9/100 leukocytes, BUN of 26 mg/dl , and creatinine of 1.35 mg/dl, and corrected the following day with hydration. The patient’s EKG was read as without abnormality. A CT of the head and cervical spine revealed some minimal degeneration. An MRI of the thoracic and lumbar spines revealed compression fractures at: T7-8, and T8-T9, pre-existing, and in the lumbar spine severe degeneration at all levels with spondylolisthesis at L5-S1 resulting in severe spinal cord stenosis and narrowing of the right neuroforamen. The patient was not felt to be a surgical candidate because of his co-morbidities. He developed a urinary infection, which was treated, and he was then discharged to a sub-acute rehabilitation facility.

IMPACT/DISCUSSION: Falls in older adults are a significant source of disability, and result in a tremendous use of healthcare resources. A recent large review (1) identified a number of factors that increased the risk of falls, including older age, polypharmacy, malnutrition, and alcohol consumption, as well as medical co-morbidities including diabetes, cardiac disease, stroke, frailty, depression and pain. A thorough admission work-up should include an evaluation for all of these conditions, as well as the socioeconomic factors noted. Traumatic spinal cord injury cases in the older individual are increasing as this segment of the population increases (3). An individual who was previously ambulatory should be worked up for surgical intervention. In-hospital mortality in these cases remains high, but significant recovery can occur with rehabilitation in the more minor cases, such as this patient, who continued to have significant lower extremity neurologic function, and qualified for inpatient rehabilitation.

CONCLUSION: The incidence of traumatic spinal cord injuries, following falls by older adults, is increasing as this demographic increases. Many of these individuals have significant pre-existing spinal degenerative changes. An individual who was previously ambulatory should be worked up for surgical intervention; if not appropriate, significant recovery can still occur with rehabilitation in many cases, and should be routinely offered.

AN UNUSUAL DISEASE IN AN UNUSUAL HOST PRESENTING WITH A COMMON SYMPTOM

Michelle Moffa, Colleen Christmas. Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #4065043)

CASE: A 77-year-old athletic retired lawyer presented with a 3-month history of fatigue and weight loss. He has a history of pituitary microadenoma, prostate cancer (s/p brachytherapy 2009), hypertension and OSA on CPAP. He had no new medications, fever, tremors, change in bowel or bladder, cough, or shortness of breath. 3 months ago he played softball 3 days a week until sudden onset of fatigue progressing to exhaustion with ADLs at presentation. On careful ROS he recalled bilateral neck tenderness 3 months ago with odynophagia and loss of appetite. Physical exam included BP and HR in the normal range, a 12-pound weight loss in less than a month, normal affect, no tremor, unremarkable neurologic, cardiovascular, pulmonary, thyroid, and abdominal exams. MRI of the brain demonstrated no change in the pituitary microadenoma. Labs showed a normal CBC, stable elevated IGF-1 (253 ng/mL), normal growth hormone and prolactin, elevated ESR (25 mm/h), elevated CRP (11.5 mg/L), undetectable TSH (<0.01 mlU/L), elevated free T4 (3.1 ng/dL), elevated total T3 (184 ng/dL), and negative TSI results. Ultrasound revealed a heterogenous thyroid with 2 nodules measuring <1 cm with no concerning features. We diagnosed him with subacute thyroiditis. 2 months after diagnosis and without treatment the patient reported dramatic improvement in his symptoms and he resumed a reduced exercise schedule, gaining 5 lbs. At that time his labs showed elevated TSH (13.58) and normal free T4 and total T3. In the subsequent months, he felt somewhat more fatigued, TSH remained in the mildly hypothyroid range (5.77 -7.66), and low-dose thyroid hormone replacement therapy (50 mcg levothyroxine) was initiated with improved symptoms.

IMPACT/DISCUSSION: Subacute thyroiditis is hypothesized to be triggered by viral infections predominantly in women with an incidence rate of 35/100,000 in middle age. It often presents as thyroid tenderness and thyrotoxicosis with suppressed TSH and elevated T4, ESR, and CRP, followed by months of hypothyroidism, with most people returning to a euthyroid state within 6 months, but 5-26% remain permanently hypothyroid. Only 11% present at the age of 70 or older. Older adults may present with atypical signs or symptoms of hyperthyroidism, such as severe fatigue in the absence of tremors and tachycardia. Presenting symptoms may be atypical in older adults and the presence of comorbidities can complicate the differential, but a very careful history may prompt searching for this diagnosis.

CONCLUSION: While uncommon, older adults often present with atypical presentations of subacute thyroiditis.

The clinical course of subacute thyroiditis is variable, necessitating ongoing monitoring to identify persistent hypothyroidism.

A RARE RENAL RISK: NIVOLUMAB-INDUCED NEPHROTIC SYNDROME WITH MESOTHELIOMA TREATMENT

Emily Wang^1,2; Heet Patel¹; Jiexi Hu¹; Christian Fang¹; Waina Cheng². ¹Rowan University School of Osteopathic Medicine, Stratford, NJ; ²Newton Medical Center, Newton, NJ. (Control ID #4049154)

CASE: Patient is an 82-year-old male with a past medical history of primary epithelial mesothelioma secondary to asbestos exposure while on active duty in the Navy. He was initially treated with neoadjuvant chemotherapy with carboplatin pemetrexed for 4 cycles followed by pleurectomy and talc pleurodesis. Patient had recurrent disease after surgery and was started on palliative nivolumab. He presented to the office with dyspnea and lower extremity edema that began post-cycle 3. Outpatient blood work returned with acutely abnormal renal function, so he was instructed to report to the community hospital. On physical exam, the patient was hypertensive with anasarca. Hospital labs showed creatinine of 3.27 mg/dL, albumin of 2.1 mg/dL and urine protein over 10.0 g, consistent with nephrotic syndrome. Patient was admitted for close follow-up with nephrology and oncology and maintained on oral corticosteroids and IV diuretics. Patient subsequently had a CT-guided kidney biopsy on day six of admission. Biopsy showed diffuse effacement of the foot processes with no evidence of acute or proliferative glomerulonephritis or immune-complex-mediated glomerulopathy. Pathology concluded immunotherapy nephrotoxicity to be the likely culprit. After resolution of dyspnea, anasarca, and stabilization of creatinine levels to 2.13 mg/dL and albumin to 2.9 mg/dL, he was discharged home after one week.

IMPACT/DISCUSSION: This case illustrates a rare potential adverse renal side effect of nivolumab in the treatment of mesothelioma. Nivolumab is a IgG4 monoclonal antibody that inhibits programmed death-1 protein (PD-1) receptors on T-cells. Certain cancer cells express programmed death ligand 1 (PD-L1) that can bind to PD-1 on immune cells, effectively neutralizing tumor-destroying lymphocytes. Nivolumab is used as first-line treatment for unresectable mesothelioma alongside ipilimumab. In this patient, ipilimumab was deferred due to age and increased toxicity. Immune checkpoint inhibitors are known to cause a variety of autoimmune conditions because of their role in deactivating the recognition of self vs. foreign that is typically provided by checkpoint receptors like PD-L1. Although rare, renal toxicity in single agent checkpoint inhibitors has been reported and can lead to nephrotic syndrome, as this patient experienced. Hospitalists should be cognizant of these potential complications during encounters in order to provide better patient care. While the nature of cancer treatment requires high tolerance for side effects, there remain strong indications for stopping immunotherapy, such as nephrotic syndrome.

CONCLUSION: Nivolumab-induced nephrotic syndrome is a rare adverse drug reaction not widely documented outside of case reports. Although highly unusual, physicians should consider this complication in patients with symptoms of nephrotic syndrome, such as renal insufficiency, hypoalbuminemia, or proteinuria, with a prior treatment history of PD-1 inhibitors.

CURIOUS CASE OF HYPONATREMIA AND ACUTE KIDNEY INJURY IN VETERAN WITH METASTATIC CASTRATION SENSITIVE PROSTATE CANCER (MCSPC)

Dileep K. Mandali. Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4065069)

CASE: 76-year-old veteran w/ PMHx of metastatic prostate cancer to spine s/p laminectomy and HFrEF (EF 35-40%), presented for 2-day history of reported anuria, and admitted for severe AKI, severe hyponatremia, and hypotension with BP 88/54. Cr on admission was 3.5 (baseline 0.5). Initially thought hypovolemia, but Cr did not improve with IVF. Renal ultrasound was normal. Differential diagnosis included ATN secondary to abiraterone, given sediment in foley bag and positive RBCs and WBCs on U/A.

His severe hyponatremia etiology was also unclear. On admission, his Na was 115 and improved with fluids. However, it worsened with additional IVF. It also showed no improvement with fluid restriction. Work-up revealed true hyponatremia with low serum Osms 250, high urine osms 176, and low urine Na <12, suggesting hypovolemia or dilutional etiology (CHF, cirrhosis, or nephrosis); however, veteran euvolemic on bedside echo and IVF worsened hyponatremia. ‘Tea and toast’ diet was also considered as possible etiology. Review of outside hospital records suggested a history of sub-acute adrenal insufficiency following his laminectomy.

Due to recent initiation of abiraterone and likely sub-therapeutic prednisone dose, adrenal crisis was suspected. His blood pressures downtrended with MAP <65. He started to become hyperkalemic and increasingly hyponatremic, and his AM cortisol was low. He was stepped up to ICU for hypertonic saline infusion and was started on stress dose steroids. He became hemodynamically stable and was discharged on fludrocortisone and hydrocortisone taper with close outpatient Oncology follow-up.

IMPACT/DISCUSSION: Adrenal crisis is an acute life-threatening condition with a mortality rate of 0.5/100 patient-years. A clear understanding of the pathophysiology remains to be fully elucidated, but clinical manifestations classically present as alterations in glucocorticoid functions (eg, permissive effects of adrenergic receptors, regulation of immune system, suppression of ADH, appetite stimulation via CRH suppression, etc). In recent years, abiraterone rose as a first-line treatment for metastatic castration sensitive prostate cancer (mCSPC) and castration-resistant prostate cancer (mCRPC). It is a 17α-hydroxylase inhibitor that blocks androgen synthesis. It is typically given in conjunction with prednisone 5 mg BID to maintain adequate glucocorticoid functions. Any patients with metastatic castration sensitive prostate cancer presenting with metabolic deragements and hypotension/AKI should prompt immediate endocrinology consult and evaluation/treatment for adrenal crisis.

CONCLUSION: - Have high suspicion of adrenal crisis in patients with metastatic castration sensitive prostate cancer that are on prednisone and abiraterone treatment and/or have history of adrenal insufficiency.

- Ensure that patients with metastatic castration sensitive prostate cancer on abiraterone regimen are placed on prednisone 5 mg BID (vs 5 mg QD or 2.5 mg BID) in order to mitigate the risk of adrenal crisis.

DE- “COAT” -ING A SEVERE CASE OF WHITE COAT HYPERTENSION

Smruti Rath¹; Cary Blum². ¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4064885)

CASE: We present the case of a 78-year-old female with a history of hypertension (HTN) and type 2 diabetes who presented with dizziness and HTN. Her dizziness started when her HTN regimen was enhanced 2 years prior. These symptoms were distressing and impaired her daily activities. The patient had previously trialed many antihypertensives but developed a myriad of side effects including lower extremity edema (nifedipine), hyponatremia (HCTZ and spironolactone), and dizziness (labetalol, hydralazine, etc.). The patient was noted to have in-office blood pressures (BPs) in the range of 140-180’s systolic. She was enrolled in a home BP monitoring program involving telephonic visits with a clinical pharmacist and in person visits with her primary care physician. Over the course of several months, her BP regimen was adjusted to losartan 50 mg and isosorbide mononitrate 60 mg daily and her dizziness resolved. On this regimen, her home systolic BP stabilized in the 120s, yet her in-office systolic BP measurements consistently read 20 to 50 mmHg higher.

IMPACT/DISCUSSION: WCH refers to a pattern of high BP readings in medical settings with normal measurements in non-medical environments. These fluctuations may result from an adrenergic stress response triggered by undergoing a medical procedure in an unfamiliar environment. This case demonstrates the critical importance of home BP monitoring early in the diagnosis and management of HTN. Our patient had mild hypertension with a large white coat effect, but this could not be distinguished from severe HTN until she engaged in home BP monitoring. Data from 51573 patients with hypertension in the Spanish ABPM registry revealed an average difference of 16-23/10-13 mmHg between in office and home measurements. The data revealed a higher prevalence of white coat effects in elderly (27.6%) and female (32.5%) patients. This case also offers a reminder of some of the most common adverse effects of antihypertensives. CCBs cause peripheral edema by reducing arteriolar resistance resulting in intracapillary hydrostatic pressure. Thiazides and other diuretics lower serum sodium by inducing a high ADH state, and other mechanisms. Both adverse effects are seen more commonly in elderly women. Of course, any antihypertensive may cause dizziness resulting from relative hypotension. In this case, the development of dizziness was a clue that her BP was excessively well controlled and could have prompted earlier home monitoring.

CONCLUSION: Providers must appreciate the morbidity that can be caused by side effects of antihypertensives, particularly in the geriatric population. The white coat effect can be large, especially in older women; in these patients, home BP measurements should guide management.

GARDEN OF DELIRIUM: EXPLORING OPIUM’S ROLE IN A CASE OF PSYCHOSIS

Jennifer A. Woodard²; Amy H. Farkas¹. ¹General Internal Medicine, Medical College of Wiscponsin, Milwaukee, WI; ²Geriatrics and Palliative Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4062331)

CASE: Ms. H is a 64-year-old Hmong speaking female without significant psychiatric history who presented with a one-month history of auditory and visual hallucinations, insomnia, and delusions of grandeur. Her vital signs on admission were remarkable for hypertension (212/114), though heart rate and respiratory status were normal.

She had no prior mood concerns, delusions, or hallucinations. Her primary care provider had prescribed risperidone for her hallucinations in the two weeks prior to admission which had been helpful for her sleep but had little effect on her hallucinations. Her family stated that the patient did not have any access to oxycodone at home but also noted that she had a previous incarceration for possession of narcotics in 2004 and had a history of misuse of acetaminophen with codeine. She had often used opium poppy for recreation prior to immigrating to the United States. Family denied any herbal supplement use but remarked that the patient had recently been growing a “plant with flowers for protection.”

On initial workup, metabolic causes were ruled out with normal laboratory findings. A CT head and chest were negative for acute abnormalities. Due to concern for autoimmune encephalitis, MRI brain and lumbar puncture were both performed and found to be unremarkable. Her initial urine toxicology was positive for opiates and oxycodone but negative for all other substances.

During her hospitalization, her mentation improved over four days, but she experienced ongoing hypertension with systolics in the 200s, nausea, vomiting, excessive lacrimation, and diarrhea, which were attributed to opioid withdrawal. She was treated symptomatically and discharged home with a clonidine taper.

IMPACT/DISCUSSION: Older adults who present with paranoia and hallucinations are more likely to have Alzheimer type dementia (prevalence of 4-6%) than a primary psychiatric disorder such as schizophrenia (prevalence of 0.1-0.5%) [1]. In substance-induced psychotic disorders, there is an increased risk of progression to schizophrenia although most research has been conducted on younger people [1,2]. In the Hmong community, opium was grown as a cash crop and the prevalence of opium dependence in pre-war Hmong villages is estimated at 12% [3,4]. In this patient whose psychiatric symptoms rapidly resolved with removal from her home environment, it is more likely that she had a substance-induced psychotic episode, particularly with characteristic symptoms of opioid withdrawal.

CONCLUSION: This case underscores the importance of a thorough collateral history, cultural considerations, and broad differential in the workup of older adults with altered mental status.

HOSPITAL AT HOME: PRIORITIZING WHAT MATTERS MOST

Samantha I. Ing, Cheng-Kai Kao, Elizabeth Zavala. Medicine, The University of Chicago Medicine, Chicago, IL. (Control ID #4033268)

CASE: A 95-year-old male presented to the emergency room with loss of consciousness after choking on a piece of chicken. He received the Heimlich maneuver in the field with expulsion of the chicken and was subsequently taken to the hospital. He had a history of idiopathic dilated cardiomyopathy with an EF of 37%, complete heart block with a dual chamber pacemaker, coronary artery disease, and chronic kidney disease stage 3a. In the emergency room he was found to have significant lower extremity edema in the setting of not taking diuretics for two weeks in the setting of low blood pressure readings. He was diuresed with intravenous diuretics for three days before being offered transfer to the HaH program. He was transported home on 2 liters of oxygen. His daughter served in the caregiver role and received education regarding checking vitals and monitoring for concerning symptoms that would require prompt escalation. A tablet was set up for direct communication with the dedicated HaH triage nurse. RN visited the patient in-person at home twice a day and the HaH attending did virtual visit once per day. With invtravenous diuresis at home, he continued to have sufficient urine output and decreased peripheral edema. The walk test revealed hypoxia (SpO2 86%) with ambulation on room and air, and home oxygen 2L/min with exercise was arranged. On the 8^th day of hospitalization, he was discharged from the HaH with cardiology and primary care follow-up. Both the patient and the caregiver enjoyed the experience in the program. One month and a half from initial admission, he established care with a local geriatrics clinic and discussed what mattered most to him, which included time at home and avoiding hospitalization even if it was life-saving. He was referred to hospice and a POLST documenting his preference of DNR-DNI was completed.

IMPACT/DISCUSSION: This case illustrates the potential for HaH to help older adults who have significant comorbidities. Prior studies have shown improvement in outcomes that matter to geriatric patients including increased mobility and reduction in falls. For this patient HaH allowed him to be treated for his advanced heart failure while remaining at home, a component of What Matters Most.

CONCLUSION: HaH may represent a meaningful transition point for patients with advanced disease, bridging the gap between hospitalization and hospice, while preserving patient-centered outcomes, such as spending time at home with family and reducing risks that are associated with prolonged hospitalization.

I CAN’T STOP CHEWING - A RARE CASE OF WITHDRAWAL-EMERGENT DYSKINESIA WHILE TAPERING ANTIPSYCHOTICS

Thalia Bowie¹; Grace Kenley¹; Cassidy Low¹; Marcus Ruopp¹; Alyssa Moore¹; Sarah King¹; Talya Shahal². ¹Geriatrics and Extended Care, VA Boston Healthcare System Brockton Division, Brockton, MA; ²Mental Health, Veterans Affairs Boston Healthcare System, Boston, MA. (Control ID #4064637)

CASE: A 66-year-old male veteran with neurocognitive disorder was admitted to a VA hospital after being deemed unsafe at home due to worsening cognitive impairment. During admission, he had ongoing behavioral disturbances and in addition to behavioral interventions, he was started on haloperidol titrated to 17.5mg/day and divalproex 1500mg/day. With continued behavioral stability, he was started on a haloperidol taper to 4mg at bedtime over the course of five months. The patient was noted to develop symptoms of resting tremor, cogwheeling and masked facies. Haloperidol was subsequently discontinued out of concern for development of extrapyramidal side effects (EPS). One month after haloperidol cessation, EPS symptoms resolved; however, he developed new tongue fasciculations concerning for tardive dyskinesia. Based on his clinical presentation and collaboration with neurology, it was determined veteran was experiencing withdrawal-emergent dyskinesia (WE-D). Treatment options were discussed, and ultimately with supportive management, the veterans symptoms of withdrawal-emergent dyskinesia slowly self-resolved four months later.

IMPACT/DISCUSSION: Tardive dyskinesia (TD) is a known adverse side effect of antipsychotic use. Withdrawal-emergent dyskinesia (WE-D) is a unique subtype of TD, where new TD symptoms appear following a reduction or discontinuation of an antipsychotic medication. Although rare, WE-D is more common following a rapid taper or sudden discontinuation of an antipsychotic and is self-limited. The underlying pathophysiology of WE-D is not completely understood; however, it is believed to occur during the discontinuation period of a dopamine blocker antipsychotic drug by causing temporary hyperdopaminergic state in the basal ganglia. Early identification of WE-D is important in caring for patients undergoing antipsychotic treatment, dose reductions, antipsychotic discontinuation, and/or medication changes. Treatment options include a partial D2 agonist such as aripiprazole, a vesicular monoamine transporter 2 (VMAT) inhibitor, restarting antipsychotic with slow re-taper, or watching for self-resolution. This case provides further clinical insights into the rare presentation of WE-D.

CONCLUSION: WE-D is a rare side effect that can occur after discontinuation of an antipsychotic. WE-D is a distinct movement disorder that requires prompt identification when caring for patients on antipsychotics, or those changing antipsychotics or beginning a taper.

INCORPORATING FINANCIAL ADVANCE CARE PLANNING INTO MANAGEMENT OF LIFE-LIMITING, PROGRESSIVE DISEASES

Natalie Sohn¹; Katherine Currey¹; Shahla Baharlou². ¹Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY; ²Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4065107)

CASE: A 79-year-old man with a history of mixed Alzheimer’s and vascular dementia with behavioral disturbances and several co-morbidities, presents to his primary care geriatrician with his wife. Diagnosed with dementia four years ago, he is independent in all activities of daily living except for bathing, and fully dependent for all instrumental activities of daily living. He has insomnia and nighttime agitation, and requires constant monitoring for wandering behaviors and confusion. As his sole caregiver, she reports significant caregiver burden.

The patient and his wife immigrated from Belize sixty years ago. He is a veteran and she is a retired home health aide. They have no children or family nearby. They jointly own a condo, which is a fifth floor walk-up. The patient has Medicare and private supplemental insurance. Their assets exceed the limits for Medicaid and they cannot afford to pay out-of-pocket for a home health aide more than once weekly. His wife is overwhelmed and distraught to learn that insurance will not cover caregiving hours. “We spent our whole lives working, saving money, and following the rules of this country. I thought someone would take care of us when we were old.”

IMPACT/DISCUSSION: Dementia is a progressive and costly disease. Average life expectancy after diagnosis ranges from three to eleven years, over which time patients experience marked functional decline. Families of older dementia patients spend nearly a third of their assets on dementia care and formal caregiving. The financial burden of dementia is heavy for middle class members, who do not qualify for Medicaid-funded caregiving or have the means to pay out-of-pocket for substantial caregiving hours. These patients must rely on unpaid, informal caregivers or impoverish themselves by spending down their assets to qualify for Medicaid.

Clinical guidelines for dementia and advance care planning omit recommendations to discuss financial planning with patients. Primary care physicians and geriatricians are uniquely poised to encourage patients with dementia to plan for costs of care. Discussions should include (1) education on the progressive nature and time course of dementia; (2) discussion of what expenses, including long-term care costs, are not covered by major insurers; (3) recommendation to seek legal counsel for estate and financial planning, appointing financial decision makers, and Medicaid pre-planning. This framework can be applied to other costly, life-limiting, progressive diseases including cancer and heart disease.

CONCLUSION: The financial burden of dementia is often inadequately addressed in primary care and geriatric clinics. To help patients and their families plan ahead, clinicians should incorporate financial advance care planning discussions into their routine care.

LONG TERM SERVICE AND SUPPORT NEEDS OF SEXUAL AND GENDER MINORITY OLDER ADULTS

Jennifer Carnahan¹; Joy L. Lee²; Heather A. Sperry⁵; Alexia M. Torke⁴; Michelle M. Hilgeman³. ¹Medicine, Indiana University School of Medicine, Indianapolis, IN; ²General Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; ³Research & Development Service, Tuscaloosa VA Medical Center, Tuscaloosa, AL; ⁴Medicine, Indiana University, Indianapolis, IN; ⁵Richard L Roudebush VA Medical Center, Indianapolis, IN. (Control ID #4029230)

CASE: History of Present Illness: Mr. Smith is a 72 year old, new to primary care clinic, who has a past medical history of prostate cancer. Over the past three months, he has been in the hospital twice and had an additional two Emergency Department (ED) visits. The admissions were both for urinary track infections and ED visits were for falls. Patient was DNR at most recent hospital admission.

Pertinent +/-: No dizziness, legs just seem to “give out,” reports struggling with tasks such as laundry, cooking, and cleaning. Urinary incontinence with nocturia. Neighbors help with grocery shopping. After last hospitalization, did not want home health to come and “bother” his roommate.

Past Medical/Surgical History: hypothyroidism, chronic kidney disease, hypertension, hyperlipidemia, depression

Social History: Lives with a roommate that electronic health record notes indicate is romantic partner who is 20 years older and was diagnosed about a year ago with Parkinson’s. Patient only refers to “roommate” and says roommate owns the home they have shared since the late 1970s. Roommate has also had several recent hospital visits and patient fears that they are nearing end-of-life. Patient has no place to live should roommate pass away. He loves their home, garden, and neighborhood and would like to stay there if feasible. No healthcare power of attorney or living will on file.

Medications: levothyroxine, lisinopril, pravastatin, sertraline

Physical Exam: Vitals-128/82, not orthostatic, heart rate 78, no cogwheeling, walks with cane in right hand

Diagnostic Studies: non-concerning

Interventions:

Short term: Home health referral to support function at home, complete advance directives.

Long Term: Social work and LGBTQ+ care coordinator consult to help identify affirming housing options. Referral to elder law attorney for estate planning. Parkinsonian dementia may complicate roommate’s ability to participate.

IMPACT/DISCUSSION: Lack of age-friendly housing can be a major obstacle to healthy aging for older adults. Sexual and gender minority (SGM) older adults are less likely to access resources to facilitate aging in place early in their aging trajectory. They are also at greater risk of nursing home admission. Finally, SGM older adults may not feel comfortable coming out when they are assigned to a new primary care physician. Respecting their choice regarding outness is a key component of trauma informed care. Changing medical and institutional practices so that there is routine collection of sexual orientation and gender identify information may help to “normalize” diverse identities. This can help providers identify patients at risk of functional decline and long term care placement.

CONCLUSION: SGM older patients are at risk of admission to nursing homes. Referral to community supports as soon as a functional or cognitive decline is noted may delay or prevent long term care placement. An affirming clinical culture facilitates identifying patients at risk.

NEPHROTIC SYNDROME IN A PATIENT WITH LATE-ONSET SYSTEMIC LUPUS ERYTHEMATOSUS

Rhea Patil¹; Jeffrey Redinger². ¹Internal Medicine, University of Washington, Seattle, WA; ²Department of Medicine, University of Washington School of Medicine, Seattle, WA. (Control ID #4061614)

CASE: A 71-year-old male presented to the emergency department with dyspnea on exertion, orthopnea, and peripheral edema. He had gained forty pounds over the last 5 months and had generalized edema on exam. His functional mobility had declined and he was cachectic. Eight months prior to the onset of weight gain, he developed hypoalbuminemia, leukopenia, and anemia with steady, progressive worsening. Notable admission labs included: serum creatinine 1.1 with eGFR 65 and urinalysis showing proteinuria and hematuria. eGFR by cystatin C was 31. His nadir serum creatinine prior to admission was 0.8. Echocardiogram was unremarkable. Nephrotic syndrome was suspected but a spot urine protein/creatinine ratio (UPCR) returned at 1.6. 24-hour urine collection revealed 0.9 grams of proteinuria with adequate creatinine content. His urine sediment showed monomorphic red blood cells. He was ANA +, anti-dsDNA +, anti-chromatin +, and had low C3 and C4 complement levels. Throughout the course of his hospital stay, his serum creatinine fluctuated from 1.0 to 1.67. A week after his initial spot UPCR, a repeat spot UPCR was 8.8. Subsequent kidney biopsy was consistent with class V lupus nephritis.

IMPACT/DISCUSSION: Late-onset systemic lupus erythematosus (SLE), defined as the onset of SLE at age 50 or above, is an uncommon condition that may not manifest with classic SLE symptoms due to immune senescence. In late-onset SLE, renal and cutaneous manifestations are less common while ocular, pulmonary, and cardiovascular symptoms are comparatively more prevalent. The female-to-male ratio is also lower compared to early-onset SLE. In our patient’s case, he met clinical (leukopenia, proteinuria) and immunologic (ANA+ at high titer, low complement, anti-dsDNA+) criteria for definite SLE by 2019 EULAR/American College of Rheumatology criteria. At 71 years old, our patient is one of the oldest documented individuals to be diagnosed with SLE. Importantly, the diagnosis of nephrotic syndrome and subsequent kidney biopsy were delayed in this case due to variation in measured UPCR. Urine protein and creatinine are most reliable when renal clearance is at a steady state. UPCR is affected by multiple factors including acute kidney injury, exercise, water intake, diuresis, positional changes, and fever. Moreover, the UPCR is an accurate estimate of 24-hour proteinuria only in someone who excretes 1000 mg/day of creatinine. This patient’s cachexia, fluctuating acute-on-chronic kidney injury due to SLE, and volume status all affected his urinary excretion of protein and creatinine. It was crucial to repeat his UPCR multiple times to better capture his nephrotic range proteinuria.

CONCLUSION: Keep lupus nephritis on the differential for patients above the age of 50 because late-onset SLE is associated with poorer outcomes and higher mortality rates.

Urine protein and creatinine are most reliable when renal clearance is at a steady state. If the clinical presentation does not fit the results of the UPCR, repeat the test.

NOT ON THE OUTSIDE: A GERIATRICIAN'S ROLE IN SECURING MEDICAL RELEASE FOR AN INCARCERATED MAN WITH DEMENTIA

Emily K. Jones¹; Maria Burnett². ¹Geriatrics, Boston Medical Center, Boston, MA; ²Illinois Prison Project, Chicago, IL. (Control ID #4064903)

CASE: A 71-year-old man incarcerated in Illinois presented with a rapid decline in cognitive and functional status over 18 months. His medical history included diabetes, Hepatitis C, opioid use disorder in remission, osteoarthritis, and macular degeneration. Prior to his sentencing 14 years prior, his cognitive abilities were normal, he was independent in activities of daily living (ADLs) and he spoke regularly with family members. Over time, his family noted that he called less frequently, seemed more forgetful, and progressively lost verbal coherence. He lost 32 lbs over 5 months from forgetting to eat. He was disciplined for getting lost and failing to follow directions. He was incontinent of stool and urine and became dependent on cellmates for bathing, dressing, toileting and eating. A SLUMS (St. Louis University Mental Status) exam score was 17/30, indicating dementia. Brain MRI showed global cerebral volume loss with no evidence of stroke, bleeding or trauma.

In Illinois, a person is eligible for medical release if they are "medically incapacitated," i.e., their medical condition prevents them from completing more than one ADL independently. His initial petition for release was denied.

A medical-legal nonprofit connected his lawyer with a geriatrician who volunteered to review the case. The physician reviewed medical records and conducted a 30 minute video call with the client. The geriatrician found the client to be aphasic, unable to consistently follow one-step commands, and physically frail. In a timed-up-and-go test, it took 25 seconds for the man to rise from sitting, gripping the table to transfer to a cane, his feet shackled. The geriatrician submitted a written statement detailing the client's comorbidities, care needs and risk of falls with costly injury. The petition was then granted and the client released to the care of his family.

IMPACT/DISCUSSION: In 2021, the number of incarcerated people over age 55 was 228,300. Correctional facilities lack the expertise, personnel and finances to safely house the aging prison population. Most U.S. states have legal pathways for medical release in cases of terminal illness, medical incapacitation or functional impairment. However, the majority of those eligible are not released.

Internists can play a major role in helping sick or frail incarcerated older adults return to the community. Geriatric assessments can be adapted to virtual settings when clinicians lack access to correctional facilities. Future scholarly efforts should be directed at expanding virtual geriatric assessment tools and calculating the cost-effectiveness of medical release. Advocacy efforts should focus on strengthening medical-legal partnerships and advocating for expansion of medical release programs.

CONCLUSION: - Physician input is crucial for medical release of incarcerated people with terminal illness, medical incapacitation or functional impairment.

- Geriatric assessments can be performed virtually for incarcerated older adults seeking medical release.

OPTIMIZING RELIEF THE POWER OF SPLIT DOSING METHADONE FOR ENHANCED PAIN MANAGEMENT IN CANCER CARE

Shaber Seraj, Andrew Ng, chidubem Ezenna, Kathryn Jobbins. Internal Medicine, University of Massachusetts Chan Medical School - Baystate Regional Campus, Springfield, MA. (Control ID #4064769)

CASE: A 67-year-old male with a past medical history of opiate dependence on methadone, liver transplantation secondary to hepatitis C, recently diagnosed pancreatic adenocarcinoma, hypertension, hyperlipidemia, and diabetes mellitus presented to the ER with shortness of breath. Initial evaluation revealed a large left pleural effusion with near complete left lung collapse, rightward mediastinal shift, and downward displacement of the left hemidiaphragm. The patient was hemodynamically stable, and a chest tube was placed with a return of 1 liter of fluid and symptomatic improvement. Fluid studies confirmed the diagnosis of metastatic malignant pleural effusion. Due to the aggressive nature of the disease, the patient was placed on hospice care with Aspira drain placement. The patient’s hospital course was complicated by uncontrolled abdominal and chest pain secondary to his pancreatic cancer and chest tube. He was managed with intravenous (IV) and oral hydromorphone on a rotating schedule for pain management as well as an increase in his home methadone to 135mg daily. His course continued to be complicated by somnolence and difficulty assessing how adequately his pain was controlled. After consulting with Palliative care, his pain regimen was changed to split dosing methadone with 90mg in the AM and 45mg in the PM with significant improvement in pain control and somnolence.

IMPACT/DISCUSSION: Methadone’s long, but variable half-life between 5 to 130 hrs enables its once-daily dosing. In patients being treated with methadone for opioid use disorder or chronic pain who continue to have persistent cravings, withdrawal, and/or pain, increasing the dosage is often appropriate. However, with increasing dosage, there is an increased risk of oversedation during peak hours after dosing. Additionally, it has also been established that there is a subset of patients who despite increasing dosage continue to have breakthrough opioid use disorder (OUD) symptoms. This is further complicated when patients have a new cancer diagnosis or terminal illness requiring escalating doses. For these patients, splitting their daily methadone into two doses a day can lead to better control of symptoms while also limiting the side effects of treatment.

CONCLUSION: In patients with chronic pain and/or OUD with uncontrolled symptoms secondary to a new diagnosis of cancer or terminal illness, consider splitting a once-daily dose into twice-daily dosing instead of increasing methadone dosage. This consideration can be made in patients who have already been titrated up without improvement or inadequate improvement in symptoms, sedation shortly after receiving a dose, and those experiencing withdrawal before their next dose.

POLYPHARMACY: A GROWING CONCERN OF AN AGING POPULATION

Jacob T. Plaisted¹; Susan M. Nikels². ¹University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²GIM, University of Colorado Denver, Aurora, CO. (Control ID #4062006)

CASE: DB is a 63-year-old male with a history including treatment-resistant depression (TRD), trigeminal neuralgia (TN), SVT, and HTN, who presented to his PCP with chronic insomnia and a diffuse rash. His medical record contained a list of 30 medications prescribed by several different providers. He denied allergies, recent illness, new products, or any other symptoms. Antihistamines, topical steroids, and oral steroids provided no relief. The rash began shortly after starting quetiapine 3 months prior as an adjunct for his TRD. The physical exam was notable for diffuse erythematous patches with excoriation covering his trunk and upper extremities.

A thorough medication review established that only 16 medications listed in his chart were active. The most likely etiology of both his persistent insomnia and new rash was a drug-drug interaction (DDI). The carbamazepine that he was taking to treat his TN has been documented to decrease the efficacy of quetiapine, a component of his TRD regimen. The combination has also been shown to cause a rash. Through shared decision-making, both drugs were discontinued. On follow-up 2 weeks later, he reported a significant improvement in his sleep quality and his rash.

IMPACT/DISCUSSION: This case highlights the dangers of polypharmacy: the regular use of 5 or more medications. As a person ages, the increased risk of multi-morbidity leads to a greater chance of being prescribed multiple medications, resulting in an increased risk of adverse drug effects and related hospital admissions. These outcomes can be due to physiological changes such as impaired metabolism that occur with aging or because of DDIs. Misinterpreting new symptoms as the onset of a new disease process can lead to further harm and prescribing cascades.

The need to address polypharmacy is becoming increasingly important as the median age of the U.S. continues to rise and 34.5% of elderly adults routinely use ≥5 prescription drugs. One of the biggest challenges is balancing effectively treating a patient’s co-morbidities and avoiding medication-induced harm. This can be partly attributed to treatment guidelines focusing on a single condition and management of common chronic conditions requiring the use of multiple drugs. Many interventions have been developed to target polypharmacy, including educational programs for prescribers, use of computer feedback and regular medication reconciliation. However, there are no high-quality studies proving they lead to clinically significant improvement. Further research with collaboration between providers and patients is needed to identify optimal solutions to reduce harmful polypharmacy.

CONCLUSION: Polypharmacy is often an unavoidable reality- particularly in older patients with multiple co-morbidities. It is crucial to assess existing medications and for the presence of adverse drug effects when caring for these patients.

STITCHING TOGETHER COGNITION: UTILIZATION OF THE ALLEN COGNITIVE LEVEL SCREEN (ACLS) TO STRATIFY FUNCTIONAL COGNITION

Cassidy Low, Thalia Bowie, Grace Kenley, Sarah King, Alyssa Moore, Marcus Ruopp. Geriatrics and Extended Care, VA Boston Healthcare System Brockton Division, Brockton, MA. (Control ID #4064668)

CASE: A 71 year-old male veteran with a history of bilateral frontal encephalomalacia due to traumatic brain injury and neurocognitive decline was admitted to the inpatient medical service after experiencing orthostatic hypotension, syncope, and failure to thrive (FTT) at home. Based on his presentation, history, and multiple hospitalizations for FTT, clinicians identified a need for further assessment of his ability to live at home independently. To determine capacity, a battery of skill-based and performance-based tests were administered. For example, the veteran completed a Montreal Cognitive Assessment (MoCA) and scored an 18 out of 30, indicating mild to moderate cognitive impairment. To help determine the least restrictive environment for this veteran, an Allen Cognitive Level Screening (ACLS) was performed. The ACLS includes a series of increasingly complex leather lacing stitches to evaluate learning and problem-solving skills. The veteran was able to perform a running stitch and whip stitch but was unable to stop without cues. He was unable to complete a single cordovan stitch after two demonstrations. In addition, he had difficulty navigating untwisting of stitches. His ACLS score was 4.2, which signifies a need for increased supervision, assistance with medication management and increased support for safety awareness. The veteran was ultimately discharged to a more structured environment.

IMPACT/DISCUSSION: Medical providers are important advocates for patients with neurocognitive disorders, and it is essential that providers are aware of the plethora of skill based and performance-based tests supporting capacity assessments. The ACLS is simple to administer and can be performed by any clinician. A numerical score ranging from 1 to 6 indicates how accurately a patient can reproduce the stitches. A score of less than 6 indicates the need for additional assistance at varying degrees. The ACLS model is based on strengths to promote the highest possible functional level.

The ACLS is a reliable, valid tool to aid the clinician in further delineating various degrees of cognitive impairment. For example, a recent study of 255 people found a positive correlation (r = 0.55, p = < 0.01) between functional cognition and level of independence using the ACLS. The tool is applicable in a variety of different clinical settings.

In this case, incorporating results from ACLS guided necessary support and planning for discharge, in addition to other assessments of capacity.

CONCLUSION: Performance-based cognitive function screening tests are useful in the assessment and screening of patients with cognitive impairment. The results from an ACLS test can assist with developing interventions, determining appropriate supports, and evaluating decision-making capacity.

SUCCESSFUL MANAGEMENT OF SUBARACHNOID HEMORRHAGE WITH CONCURRENT DURAL VENOUS SINUS THROMBOSIS IN A GERIATRIC PATIENT

Pranav Chalasani, Gagandeep Singh, Tamara Altaweel, Joseph Vercellone. Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4062774)

CASE: A 78-year-old female with no past medical history presented with altered mental status. The patient had been complaining of a headache for a week before admission. On the day of admission, she was minimally responsive with a fixed left eye gaze, urinary incontinence, and a temperature of 101.6 °F. On physical and neurological examination, she was obtunded, responding only to painful stimuli and Babinski’s sign was sluggish bilaterally. Labs are pertinent for troponin of 0.22ng/mL, and D-dimer of 1855 ng/m. While in the emergency department, she developed a 1-minute episode of grand mal seizure. Computed tomography (CT) head showed a subarachnoid hemorrhage (SAH) in the right frontal and temporal lobes with surrounding edema. CT head angiography revealed diminished opacification of the right transverse venous sinus and sigmoid sinus compared to the left, raising concern for dural venous sinus thrombosis. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) of the brain confirmed the finding of dural venous sinus thrombosis of the right sigmoid sinus and right transverse sinus thrombosis. Neuroendovascular surgery did not recommend venous thrombectomy as she has not failed medical management. Hematologist was consulted for further hypercoagulable work up and anticoagulation management. She was started on an intravenous heparin drip and closely monitored for neurological changes. Hypercoagulable workup included myeloproliferative neoplasms, JAK2 mutation, anti-cardiolipin antibodies, beta-2 glycoprotein was ordered in the meantime. She was noted to have elevated beta-2 glycoprotein IgM, anticardiolipin IgM antibodies. She was transitioned to oral coumadin after reaching the target INR between 2-3. She was discharged a week later with no evidence of worsening SAH or any focal neurological deficits.

IMPACT/DISCUSSION: The association between subarachnoid hemorrhage (SAH) due to cerebral venous thrombosis (CVT) is rare, despite the possible interplay. Approach to management is difficult as there is concern about subarachnoid hemorrhage expanding. Upon diagnosis, it is crucial to conduct a thorough investigation into thrombophilia and procoagulative pathways to identify reversible causes. For this case, the patient is recommended to get repeat testing for Antiphospholipid syndrome in 12 weeks. Early initiation of anticoagulant therapy is emphasized, contingent on the stability of the bleeding. Geriatric patients are more prone to falls, leading to serious bleeding consequences if they are on anticoagulants. Studies showed patients on anticoagulation had better outcomes and anticoagulation appeared to be a safe option despite the cerebral hemorrhage.

CONCLUSION: Cerebral venous thrombosis is a potentially life-threatening yet manageable condition. When SAH is limited to cerebral convexity, a prompt suspicion of underlying CVT is crucial to prevent unnecessary delays in treatment. It is important to start anticoagulation for patients presenting with SAH and CVT.

THE SKIN FLAP SUNK?

Shaiv Patel, Saleem Qureshi, Danna H. Weathers. Geriatrics, Oklahoma University Medical Center, Oklahoma City, OK. (Control ID #4063504)

CASE: A 61-year-old right-handed male, with a medical history marked by the complication of a subdural hematoma requiring evacuation, encountered subsequent challenges. Despite a cranioplasty performed one month post-evacuation due to re-accumulation, the patient presented with a complex clinical picture in a nursing home setting. Manifestations included global aphasia, ideational apraxia, and right hemiparesis. Further complicating matters, the patient underwent a craniotomy flap wound revision and debridement three weeks prior to the onset of symptoms, with subsequent complications such as a cerebrospinal fluid (CSF) leak attributable to skull osteomyelitis. Magnetic resonance imaging (MRI) revealed a discrete area of mild diffusion restriction in the left frontal lobe, indicative of acute to subacute ischemia. Clinical examination unveiled a sunken cranial flap on the left side, coupled with right arm weakness and exacerbated aphasia. In response to these challenges, a decision was made to pursue another revision and repair of the cranial flap, complemented by intravenous antibiotic therapy. In the ensuing weeks following these interventions, there was a notable improvement in the patient's neurological function.

IMPACT/DISCUSSION: Sunken skin flap syndrome, also known as "sinking skin flap syndrome" or "syndrome of the trephined," is a rare neurological complication that can occur after a craniectomy, a surgical procedure in which a portion of the skull is removed. This syndrome is characterized by the sinking of the skin and soft tissues overlying the area where the craniectomy was performed. The craniectomy creates a void, leaving the brain unprotected by bone. In some cases, atmospheric pressure may exert its force on the exposed brain tissue, causing it to sink or collapse. This can lead to a variety of neurological symptoms, including changes in cognitive function, motor deficits, and severe neurological decline. The clinical presentation of sunken skin flap syndrome can vary from asymptomatic cases to those with significant neurological impairment. Symptoms may include weakness, cognitive deficits, headaches, and changes in sensation. Management of sunken skin flap syndrome involves surgical intervention to address the cranial defect and restore protection. This may include the placement of a bone flap or the use of synthetic materials to reconstruct the missing portion of the skull. Additionally, addressing any underlying issues, such as infection or complications from the initial surgery, is crucial for optimal recovery.

CONCLUSION: Sunken skin flap syndrome constitutes a rare and potentially life-threatening complication that may manifest subsequent to a sizable craniectomy. This phenomenon is attributed to the atmospheric pressure surpassing the intracranial pressure within the region of the craniectomy. Clinical presentations range from being completely asymptomatic to pronounced neurological deterioration.

UNMASKING GERIATRIC FEVER

Vanessa Vakili¹; Ian Odland²; Noelle Marie Javier¹; Shahla Baharlou¹; Martine Sanon¹. ¹Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²School of Medicine, Medical Student, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4064023)

CASE: An 89-year-old male with a complex medical history, including heart failure (EF 34%), complete heart block status post pacemaker placement, type 2 diabetes, hyperlipidemia, and chronic cervical/lumbar spinal stenosis presented to an academic emergency department with two weeks of acute on chronic lower back pain. Patient reported fatigue, anorexia, and chills. Denied chest pain, shortness of breath, lightheadedness, gastrointenstinal or neurologic deficits. Socially, the patient was previously independent of ADLs/iADLs, no family hx of cancer, no high-risk behaviors. A few months prior he underwent pacemaker placement for complete heart block.

Admission vitals: temperature 99.3°F, blood pressure 161/74 mmHg, heart rate 85 bpm, respiratory rate 20 breaths per minute, and SpO2 99% on room air. Physical exam: patient supine, appeared uncomfortable with movement, no abnormalities on CVS, Respiratory, GI, Skin exam. MSK exam with 5/5 strength and sensation preserved in upper and lower extremities, normal reflexes and muscular tone. Remainder of exam limited by severe pain.

Admission labwork: stable WBC, serum creatinine and LFTs. Initial CT spine revealed severe lumbar spinal canal stenosis, prompting an MRI recommendation. Neurosurgical consultation recommended pain control.

Despite escalating PCA opioid and adjuvants, the patient's pain worsened. Inflammatory markers obtained: ESR/CRP (>120/250) and blood cultures drawn. Fever curve (99.2-100.2°F) over subsequent days. Follow-up MRI indicated fluid signal within the L4-L5 disc space, raising concern for inflammation or early discitis. Neurosurgery recommending spinal decompression surgery for pain. Blood cultures positive for E. faecalis. Echo obtained showing tricuspid vegetation, Duke’s criteria met. Cardiology consulted in setting of Infective Endocarditis; shared decision regarding source control. Patient amenable to prolonged course of intravenous antibiotics for treatment with decision to later re-implant new pacemaker.

IMPACT/DISCUSSION: Geriatric fever is commonly missed as a sign of early infection in older adults. The prevalence of implanted devices and prosthetics increase with older age. Complications such as infective endocarditis in this population confers a five fold higher risk than the general population. Discussion among future clinicians regarding the utility to adjust SIRs criteria based on age and frailty of patient should be considered given physiological changes of aging. Consideration of a diagnosis of systemic cardiac implantable electronic device infection in patient's with bacteremia with/without known source whe lead/valvular vegetations are observed.

CONCLUSION: 1) Frail older adults with serious infections may lack conventional fever in 30-50% of cases

2) Lower fever thresholds are applied in this population:Single oral temperature >100°F, Persistent temperature >99°F, or temperature change of >=2°F from baseline

3) Classic clinical signs of infective endocarditis are less common with advancing age

WEATHERING OF MENTATION - SUMMER'S UNSEEN INFLUENCE IN THE MANAGEMENT OF AN OLDER ADULT WITH TERMINAL CANCER

Emilin Pandian, Harshit Khosla, Rex Paulino. Palliative Medicine, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX. (Control ID #4063799)

CASE: A 74-year-old man with castration-resistant prostate cancer and widespread metastasis presented with deteriorating mental status. Vital signs on presentation include BP 160/81, heart rate of 121, respiratory rate of 13, and temperature of 100.6°F. The patient appeared lethargic, and oriented only to himself. Complete blood count, electrolytes, kidney, and liver function tests were within normal limits. Urinalysis demonstrated bacteriuria. He was admitted him for management of UTI and Palliative Care was consulted to assist with goals of care.

He started broad-spectrum antibiotics. Urine culture reported 100-1000 CFU/mL of Klebsiella pneumoniae. Collateral information obtained from the patient's family revealed that he lived independently before this incident and denied urinary symptoms, fever, nausea or vomiting. He was started on transdermal fentanyl 25 mcg/hr every 72 hours due to cancer-related back pain one month prior. Due to uncontrolled pain, his daughter replaced the transdermal patch every 48 hours with hydrocodone for breakthrough pain. He had worsening somnolence and poor oral intake one week later. Additionally, she reported that he covers himself with blankets and stays outside their home because he prefers to stay warm. Record-setting high temperatures in Houston, TX during the summer of 2023 have ranged between 100 to 109°F.

The patient was moved to a room with an average ambient temperature of 65 to 75°F. His pain was better controlled, and his mental status improved to baseline after 24-36 hours of close observation and opioid rotation from transdermal fentanyl and hydrocodone to long and short-acting oxycodone.

IMPACT/DISCUSSION: Cognitive decline in older adults with terminal malignancies is complex. This case emphasizes considering external environmental factors in cognitively impaired individuals. Transdermal fentanyl, ideal for long-term cancer pain control, requires patch replacement every 3 days. In vitro studies reveal a 3°C body temperature increase increases fentanyl blood concentration by 25%, risking overdose and unpredictable pain control. Asymptomatic bacteriuria in older adults is often overtreated. The Infectious Disease Society of America advises evaluating other causes for acute mental status change in older patients with delirium before initiating antimicrobial treatment. Asymptomatic bacteriuria in older cancer patients may mimic disease progression, prompting untimely goals of care discussions.

CONCLUSION: When caring for older patients with acute encephalopathy, obtaining collateral information, practicing vigilant medication reconciliation, carefully considering altered pharmacokinetics and pharmacodynamics, and utilizing proper antibiotic stewardship are vital steps to providing comprehensive and goal-concordant care. When exposed to elevations in temperature, transdermal fentanyl requires proper attention due to altered pharmacokinetic and pharmacodynamic properties, which increases its absorption rate, leading to fentanyl intoxication.

WHEN SCREENS FALL SHORT: FROM CONSTIPATION TO CARCINOMATOSIS

Eva Gaufberg²; Vassiliki Pravodelov¹. ¹Department of Medicine, Section of Geriatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ²Boston University Chobanian & Avedisian School of Medicine, Boston, MA. (Control ID #4063969)

CASE: A 91-year-old female with type 2 diabetes mellitus, hypertension, postsurgical hypothyroidism and chronic hypocalcemia presented to the hospital with concern for constipation. The patient noted that for several weeks prior to presentation, she had been passing gas regularly but only having two small bowel movements per week. She had a sense of fullness in her abdomen but no discomfort. She did not report hematochezia, changes in appetite, early satiety, or recent weight changes. She had no known history of cancer. Her last in-person visit with her PCP was 7 months prior to presentation. The patient had several telemedicine visits since the in-person visit, including one appointment 3 days prior to admission at which time she was started on a bowel regimen for constipation. Her past surgical history included a thyroidectomy for multinodular goiter and a supracervical hysterectomy for an unknown indication. On exam, her vitals were stable. The abdominal exam showed marked distension, a fluid wave, and shifting dullness, without tenderness to palpation. Sclerae were anicteric and there was no appreciated hepatosplenomegaly. A CT Abdomen/Pelvis showed large volume ascites, nodular contour of liver, and heterogeneously enhancing structures in the lower abdomen/upper pelvis. A CT Chest had findings concerning for pleural metastasis. An MRI of the pelvis showed a large left adnexal mass. Labs on admission showed hypocalcemia consistent with prior values. The CA-125 level was markedly elevated (434 U/mL). She had a diagnostic and therapeutic paracentesis noting WBC of 893 cells/uL, PMN of 5%, a SAAG of 0.4g/dL and protein of 4.7g/dL. Ascitic fluid cytology showed high grade Mullerian serous adenocarcinoma consistent with peritoneal carcinomatosis (PC) from advanced ovarian cancer. The patient was connected with gynecologic surgical oncology and medical oncology services for further evaluation and management.

IMPACT/DISCUSSION: Our patient presented with concern for constipation, but was ultimately found to have PC from ovarian adenocarcinoma. PC is a form of metastatic malignancy with poor prognosis due to often late detection and nonspecific symptom profile. It is characterized by ascitic fluid analysis with >500 WBC, <50% PMN and a positive cytology. The SAAG value depends on whether portal hypertension is present. In females, the most common cause of PC is ovarian adenocarcinoma. In addition to appropriate time-to-benefit cancer screening, maintaining a high index of suspicion for PC in at-risk patients with seemingly benign symptoms is essential in prompt diagnosis and management, especially when primary care visits are held via telemedicine and physical examination may be limited.

CONCLUSION: This case identifies the importance of maintaining a broad differential for patients with common symptoms. It also highlights the limitations of telemedicine and the importance of an in-person physical examination in the clinical evaluation of older adults with complex conditions.

WHICH CAME FIRST – THE EVOLVING METASTATIC CANCER OR THE POLYPHARMACY?

Patricia Lee¹; Pramod Patel^1,2; Stacie Levine¹. ¹Section of Geriatrics and Palliative Medicine, University of Chicago Department of Medicine, Chicago, IL; ²University of Chicago Department of Anesthesia and Critical Care, Chicago, IL. (Control ID #4055247)

CASE: A 64-year-old man with metastatic prostate cancer to liver and bone, complex regional pain syndrome, and depression presented with fatigue, abdominal pain, nausea with vomiting, and exacerbated leg shaking. 1 month prior to admission he started a BET inhibitor and pembrolizumab as part of a clinical trial, last administered 10 days ago. His nausea was treated with ondansetron 4 mg PRN and prochlorperazine 5 mg PRN regularly for a year, more frequently in the past month. No vertigo or headaches, with last bowel movement 3 days ago. Home medications included transdermal fentanyl 50 mcg/hr, duloxetine 60 mg BID, bupropion 300 mg daily, which were continued in the hospital. Exam revealed normal vital signs, diaphoresis, suprapubic tenderness, and mild leg shaking. CT abdomen showed extension of prostate nodule into the bladder, liver metastases, and stool burden without obstruction. CT head was unremarkable. The inpatient team was concerned for akathisia and thus held prochlorperazine and scheduled ondansetron 4 mg TID and bowel regimen. The fentanyl patch was increased to 62 mcg/hr and hydromorphone PRN was added with improvement in abdominal pain. However, leg restlessness and nausea did not resolve. Olanzapine, trimethobenzamide, and metoclopramide were trialed but ineffective. He then developed afib RVR, hypercalcemia, and acute somnolence, partially responsive to naloxone. The fentanyl patch was removed and then restarted at 25 mcg/hour for persistent leg pain. Dexamethasone 5 mg BID was added for refractory nausea after decision was made to stop the clinical trial. 2 days later he developed agitation and within 12 hours, he developed a fever to 102.8F, displayed seizure-like activity, and subsequently died.

IMPACT/DISCUSSION: Antiemetics have many mechanisms of action and should be chosen based on the most likely cause. Etiologies in this patient included pelvic metastases, anticipatory nausea, and anticancer drug therapies. However, he also had symptoms concerning for extrapyramidal side effects. This can be worsened by antidopaminergic antiemetics such as metoclopramide and prochlorperazine. He was also on high dose bupropion and duloxetine for neuropathic pain and severe depression. These medications and some opiates, including fentanyl, exert a serotonergic effect through the 5-HT1A receptor. This case suggests a potential contribution of serotonin syndrome to his demise, exacerbated by the patient's polypharmacy. Serotonin syndrome is a potentially life-threatening condition precipitated by serotonergic drugs and classically includes altered mental status, autonomic dysfunction, and neuromuscular excitation. Since many cases are drug-related, the physician and pharmacist must be aware of potential drug interactions, and frequent medication review is paramount.

CONCLUSION: This case highlights the importance of careful medication review and knowledge of pharmacology when managing symptoms such as nausea in multimorbid patients with cancer.

Clinical Vignette - Healthcare Delivery and Redesign

CARE COORDINATION FOR INCARCERATED PATIENTS INPATIENT: A CASE OF CROHN’S CARE DEFERRED

Jelani H. Regan, Mariano Iberico, Willam Costa. School of Medicine, Tulane University, New Orleans, LA. (Control ID #4046258)

CASE: A 45-year-old currently incarcerated patient with a history of Crohn’s disease was admitted to the hospital for a Crohn’s flare and symptomatic anemia. They endorsed a long-standing history of blood in stool and reported passing 8-9 bloody stools per day. He stated that he was on Humira prior to his incarceration, but the medication was discontinued in prison.

Notably, Mr. U___ had been recently hospitalized and discharged within the last month prior to this admission for the same diagnosis. Upon discharge, the initiation of infliximab treatment had been planned but the patient did not receive this medication. He endorsed dizziness, lightheadedness, and weakness. Physical exam was positive for abdominal pain and blood in stool.

Gastroenterology, once again, recommended starting infliximab, but for insurance reasons it was not approved inpatient. Upon further investigation, it was discovered that additional coordination by the clinical team with the infusion center had been missing and was necessary in order for them to be able to schedule a date with the patient’s correctional facility.

Notably the prison had approved infliximab itself but had not been able to schedule said appointment because of the missing elements in the complex process of care coordination for incarcerated patients. Outpatient treatment was eventually approved but took a high degree of communication between the infusion center and correctional facility to ensure appropriate treatment.

IMPACT/DISCUSSION: Coordinating between the in-house infusion center, correctional facility, social workers, and the specialists consulted also resulted in a prolonging discharge by several days.

Administering treatment for patients who are incarcerated with chronic conditions requires significant extra work for coordination in care between facilities. There is a need to create more efficient avenues for incarcerated patients to obtain treatment in a reasonable timeframe.

Although the reason for readmission was clinical, as a result of missed infliximab doses, the picture that emerged was a more than that, reflecting one of the challenges of care coordination for incarcerated patients.

CONCLUSION: Incarcerated patients who suffer from chronic conditions deserve improved access to treatment and more direct means of communication between facilities. Failures in coordinating care for those who are unable to do so themselves further perpetuates poor health outcomes among this vulnerable population. This case highlights these challenges and reveals bilateral room for improvement both on the side of clinical teams preparing to discharge clinically complex patients and the need for improved communication from carceral facilities when delays in care are noticed.

CRITICAL EXAMINATION OF A NOVEL POLICY WHICH ENABLES COMPASSIONATE SHACKLE REMOVAL: DEFENDING THE HUMANITY AND HUMAN RIGHTS OF PATIENTS WHO ARE INCARCERATED

Nisha Mathur¹; Neil Singh Bedi^3,5; Judy Wang²; Sondra S. Crosby^4,5. ¹Medical Student, Boston University School of Medicine, Boston, MA; ²School of Medicine, Boston University, Boston, MA; ³Medicine, Boston University Medical Campus, Boston, MA; ⁴General Internal Medicine, Boston Medical Center, Boston, MA; ⁵Center for Health Law, Ethics, and Human Rights, Boston University School of Public Health, Boston, MA. (Control ID #4063908)

CASE: JD was an incarcerated male with encephalopathy and hepatocellular carcinoma who was found unresponsive at a carceral facility and brought to our academic hospital with altered mental status and oxygen desaturation to the 80s. He was intubated and transferred to the Medical Intensive Care Unit for mechanical ventilation under sedation with propofol. When sedation was temporarily stopped for neurologic assessment, JD did not respond to noxious stimuli, follow commands, nor respond to blink to threat. He had no corneal reflex to saline and negative oculocephalic reflex, but retained a cough reflex. He was placed on a palliative care protocol.

The admission nursing note stated, “shackles in place, to discuss with attending removing them - plan for possible shackle removal tomorrow.” On Hospital Day (HD) two, the attending documented skin irritation and erosions due to the shackles. The patient continued to meet shackle removal criteria on HD three because he was intubated and sedated. The attending called the correctional facility requesting removal but encountered resistance from the on-shift watch commander. Later that day, another attending made a second, successful request from a new on-shift watch commander. The accompanying correctional officers were ordered by their supervisor to remove the shackles. JD eventually recovered, and after his extubation and stabilization, he no longer met criteria for shackle removal and shackles were reapplied.

IMPACT/DISCUSSION: Incarcerated patients in the US are routinely shackled when they are admitted to the hospital, regardless of clinical condition. This year we led the adoption of a hospital policy that allows for shackle removal in incarcerated patients that meet certain clinical criteria (intubation, sedation, inability to ambulate, palliative care). This case marks the inaugural instance of compassionate shackle removal for the purpose of preserving human dignity at our institution following the policy change. The care team assessed the patient for eligibility, executed protocol, and documented the case: a success of in-hospital education initiatives.

Communication with carceral facilities remains a fundamental challenge; our team has since engaged with the superintendent of a regional correctional facility to develop a collaborative protocol. This effort is ongoing across all correctional facilities associated with the hospital.

CONCLUSION: This case showcases the first-ever success of compassionate shackle removal in our institution following implementation of the new policy, and highlights the necessity for further collaboration with correctional facilities.

HOME IS WHERE THE HEART IS

Colette Fritsche¹; Richard Wu²; Alain Chaoui^1,2. ¹School of Medicine, Tufts University School of Medicine, Boston, MA; ²Boston University Chobanian & Avedisian School of Medicine, Boston, MA. (Control ID #4064767)

CASE: An 87 year old man arrived in clinic for follow-up after hospitalization for stroke accompanied by his wife of 70 years pushing his wheelchair. PMHx included CHF, COPD, asthma, T2DM, CKD, AFib, and hemiplegia. He appeared tired, but alert and oriented. He was hypotensive at 90/50. He and his wife were unable to confirm his medications, but had blister packs at home they adhered to religiously. They were instructed to halve his amlodipine, then a few days later, his breathing worsened. They were adamant about not returning to the hospital as it had already stolen so much of their time. Do we increase his furosemide and risk lowering his BP? We needed to lay eyes on the patient, so we made a home visit. His BP was 116/80 and he had bilateral wheezing. As we talked at his kitchen table, he described racing thoughts each night since his stroke that made sleep evasive, as well as frustration about mobility challenges preventing him from driving his car or walking downstairs to his beloved sunroom.

IMPACT/DISCUSSION: We are trained with a framework of patients coming to us for care. When we interview standardized patients during clinical skills exams in medical school, we do so in the context of our mock exam rooms, not the comfort of their homes. We have home field advantage, but these are unfamiliar and stressful environments for patients, let alone frequently prohibitive due to lack of access to transportation or mobility difficulties - both of which are prevalent in our aging population.

Had we never stepped into his home, he may never have told us about his fear of dying keeping him up at night, prompting us to start him on sertraline in addition to treating his HF exacerbation. Unfortunately, he passed away not long after our visit, but the gratitude his wife expressed made our impact apparent.

Home visits have been shown to provide high-quality care and improve health outcomes, especially for patients who are frail, emotionally vulnerable, or disproportionately impacted by social determinants of health, though this form of healthcare delivery declined sharply after pre-industrial times. Caring for a patient in their home environment allows us to see the whole person and how best to care for them as providers. As medical students, this experience humanizes patients and provides a formative experience that shapes future practice. Our anatomical donors taught us about the physicality of death, but by inviting us into their home, this patient and his wife taught us about the humanity of it.

CONCLUSION: Home visits give us invaluable insight into factors outside of medical diagnoses influencing patient wellbeing, enabling us to provide better tailored care.

All physicians and students should have a home visit experience as it provides formative lessons to become a more holistic provider.

INAPPROPRIATE DELAYS IN CARE DUE TO MEDICARE ADVANTAGE PRIOR AUTHORIZATION PROCESSES

Alia Abiad¹; Caleb Murphy²; Venkatesan R. Krishnamoorthi². ¹Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Medicine, University of Chicago, Chicago, IL. (Control ID #4065065)

CASE: A 65-year-old woman with diabetes and hypertension presented to the ED after being found down by her family. No specific cause was identified for her condition, but she was found to have generalized weakness from physical deconditioning. Physical therapy, occupational therapist, and physician all recommended transfer to a skilled nursing facility for subacute rehabilitation, but her Aetna Medicare Advantage plan required prior authorization first. The insurance then denied their request for prior authorization. The care team appealed the denial, involving a process that took two hours for the physician to complete. Aetna responded two days later, finally approving the transfer to the rehabilitation facility. The patient was in the hospital for one week during this approval process, with worsening of deconditioning.

IMPACT/DISCUSSION: Unlike traditional Medicare, private Medicare Advantage (MA) insurers require prior authorization for many healthcare services. Although insurers state that prior authorization requirements ensure that care is medically necessary, many lead to harmful delays in or inappropriate denials of care.

Out of over 35 million prior authorization requests in 2021, MA plans denied over 2 million (1). A 2022 report by the Department of Health and Human Services Office of Inspector General (HHS OIG) indicates that many prior authorization requests are wrongfully denied; after analyzing 250 denials, HHS OIG found that 18% should have been approved, according to Medicare coverage criteria and MA billing rules (2).

Many of the denials analyzed by the HHS OIG refused coverage for stays in post-acute facilities, as seen in this case (2). Post-acute services are often costly, incentivizing MA plans to reject them; however, HHS OIG physician reviewers noted that denials often did not come with a sufficient alternative level of care (2).

The low proportion of denials appealed — just 11% in 2021 (1) — may reflect how difficult the appeals process can be. As this case demonstrates, appeals cost patients and healthcare personnel resources, stress, and time. Life-threatening delays or changes in patient care can result.

1. Biniek JF, Sroczynski N. Over 35 Million Prior Authorization Requests. Kaiser Family Foundation; 2023.

2. Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns. U.S. Department of Health and Human Services Office of Inspector General; 2022.

CONCLUSION: With Medicare Advantage plans gaining popularity, prior authorization processes have the potential to harm increasing numbers of patients with errors and delays, as the patient in this case experienced. Appealing inappropriately denied requests can help patients access necessary care, but the appeals process is challenging and often underutilized. Policy solutions should aim to require MA plans to streamline prior authorization and appeals processes and apply them only in appropriate contexts, to minimize negative impact on patient care and health.

SYSTEMIC BARRIERS TO REHABABILLITY

Spencer Asay¹; Ethan Molitch-Hou²; Venkatesan R. Krishnamoorthi². ¹University of Chicago Pritzker School of Medicine, Chicago, IL; ²Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4064434)

CASE: A 71-year-old man with a history of hypertension was admitted for altered mental status and leg pain. Work-up revealed an acute internal capsule infarct causing left leg weakness without sensory loss. He was also noted to have cognitive impairment. He was transferred for acute inpatient rehab and discharged after 14 days with home health services. Ten days later, he was readmitted for acute kidney injury in the setting of C. difficile colitis and was discharged to a skilled nursing facility (SNF) for subacute rehab (SAR). During SAR, he lost further functionality, becoming no longer able to ambulate independently. He was discharged home but the intended home health services were not arranged. Three weeks later, he was readmitted for altered mental status in the context of a urinary tract infection (UTI), which resolved with antibiotics. He was again recommended for SAR due to his inability to ambulate and was accepted by a SNF; however, he was deemed not to have rehab potential by his Medicare Advantage plan and was denied. Without Medicaid or means to self-pay, he did not qualify for custodial care. He was discharged home with home health services and required a Foley catheter for urinary retention. With limited support at home, he removed his catheter, developed a UTI and was readmitted and ultimately discharged again to SAR.

IMPACT/DISCUSSION: This patient’s poor clinical course is inextricably tied to systems-level issues. First, low-quality SNF care has been well-documented in recent years and may have influenced his further decline during SAR. Indeed, the for-profit SNF at which he received SAR has an above-average rate of rehospitalization. Much of the SNF quality crisis stems from understaffing, which correlates with increased private equity entry into the market and numerous reports of intentional understaffing to maximize profits. In response, the Centers for Medicare and Medicaid Services issued a proposed rule to establish minimum nurse staffing standards. Kaiser Family Foundation estimates that fewer than 20% of facilities would currently meet these requirements.

Secondly, this patient’s SAR denial directly influenced his third readmission. In the absence of universal guidelines, private insurance rehab denials vary widely and may dictate access to rehab more than clinical indicators. One private insurer has been sued for using artificial intelligence algorithms in lieu of clinical judgment to deny rehab.

Lastly, this patient’s recurrent readmissions were driven by social isolation and lack of access to long-term services and supports (LTSS). LTSS, including custodial care, are critical solutions for social isolation among older adults; however, LTSS are rarely covered by Medicare, leaving many beneficiaries facing unmet care needs.

CONCLUSION: -Pervasive SNF understaffing influences poor quality and rehospitalization

-Evidence suggests private insurers may arbitrarily deny medically indicated rehab

-Lack of Medicare coverage for LTSS can exacerbate social isolation

Clinical Vignette - Health Equity, Diversity, and Inclusion

A NARRATIVE OF DIAGNOSIS IN A REFUGEE PATIENT THROUGH INTERDISCIPLINARY COMMUNICATION AND THOROUGH HISTORY-TAKING

Keshav Dixit¹; Alexander J. Nagourney¹; Laura Bock¹; Deborah Edelman². ¹Internal Medicine, Mount Sinai Morningside Hospital, New York, NY; ²Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4059324)

CASE: 23-year-old female with a past medical history of urinary tract infection (UTI) initially presented to our clinic six months after traveling by land from Ecuador to the United States. She endorsed mild unintentional weight loss and generalized fatigue. She denied any current medications aside from occasional ibuprofen. The rest of her family and social history were non-pertinent. Initial laboratory tests showed abnormal liver function tests (LFTs) with an ALT of 123 U/L and AST of 76 U/L. Two weeks later, LFTs increased ten fold, ultimately peaking at an ALT of 2070 U/L and AST of 1042 U/L. She was referred to the hospital with new symptoms of decreased oral intake, nausea, and vomiting. The inpatient workup revealed elevated iron saturation and ferritin levels, positive Epstein-Barr Virus IgG antibodies. CT abdomen was unremarkable and MRI cholangiogram was negative for iron deposition. Extensive workup, including tests for acute hepatitis, multiple antibodies (anti-smooth muscle, anti-mitochondrial, anti-nuclear, anti-liver kidney microsomal), Chagas, ceruloplasmin, HIV and liver toxins was unremarkable. Her LFTs continued to fluctuate for several months. Further detailed history revealed remote use of nitrofurantoin, fluconazole and metronidazole several months prior for treatment of UTI and vaginitis. Given an unremarkable workup, as her LFTs began improving, her clinical presentation was attributed to a drug-induced liver injury (DILI) .

IMPACT/DISCUSSION: Refugee patients frequently undergo extensive workup for uncommon diagnoses, given a higher prevalence of infectious diseases and limited access to medical records. However, a detailed history often remains the key to diagnosis. Our patient underwent multiple rounds of repetitive lab workup due to initial lack of communication between hospital departments. Subsequently, the outpatient and hospital team discussed her medical history and the history of antibiotic use was reframed as a potential cause of liver toxicity.

Our clinic has experienced a large influx of refugee patients over the past year, as have several major cities in the United States. Initial evaluations at our clinic consist of extensive laboratory testing, including a broad infectious disease panel. This aids in gaining an overall understanding of the patients’ health, but should not replace taking a thorough history when investigating a patients’ symptoms. While our patient underwent a broad workup, it was only when we revisited the history and evaluated more common causes that the diagnosis emerged.

CONCLUSION: Communication between providers to combine history from the clinic with the high-acuity hospital history is essential in patients with language barriers, which may complicate their self advocacy.

Given the ubiquity of antimicrobials, DILI must not be overlooked when evaluating liver injury of unknown origin.

BEHIND BARS AND BEYOND REACH: SYSTEMIC BARRIERS TO PREVENTATIVE HEALTHCARE AND PALLIATIVE STRATEGIES FOR THE JUSTICE-INVOLVED

Kriti Prasad^1,2; Sophia Kerman^1,2; Ricardo Cruz³. ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ³General Internal Medicine, Boston Medical Center, Boston , MA. (Control ID #4063965)

CASE: A 65-year-old incarcerated male with history of HTN, necrotizing pneumonia, anemia, and 20 pack-year smoking history presented to the ER with acute left-sided chest pain, exertional dyspnea, 35-lb weight loss, and hematochezia. Vitals were significant for tachycardia. Physical exam revealed mild crackles at lung bases. Labs showed microcytic anemia (Hb 9.5, MCV 70), WBC 13, AST 82, ALP 685, and high-sensitivity troponin of 1028. EKG showed ST depression in leads V4-V6. TTE showed LVEF of 39% with LV hypokinesia. CTPA was negative for PE but showed hepatic masses and osseous lesions consistent with metastatic disease. CTAP confirmed a rectal tumor. Cardiology was consulted for coronary angiography, which was deferred to pursue biopsy of the liver mass as coronary intervention would require prolonged antiplatelet therapy. Biopsy confirmed diagnosis of metastatic colorectal carcinoma. Per patient, he never had colorectal cancer screening. Coronary angiography ultimately showed 80% stenosis of the Left Main, LAD and LCX arteries. CT surgery was consulted for CABG, but he was deemed a poor surgical candidate given metastatic cancer and poor postoperative prognosis. He subsequently developed acute hypoxemic respiratory failure due to multifocal pneumonia and ARDS requiring intubation. Following a goals-of-care discussion with family, he transitioned to comfort measures and passed away shortly thereafter.

IMPACT/DISCUSSION: This case underscores the consequences of delayed care for preventable and early identifiable conditions like CAD and colorectal cancer. Access to quality healthcare in carceral settings is fractured due to the lack of mandatory quality standards and the contracting of healthcare to for-profit companies without incentives for providing preventative care. Research shows that both screening-detectable and non-screening-detectable cancers are diagnosed at more advanced stages in incarcerated patients. Moreover, the absence of shared health records, inefficient care transitions, and structural and interpersonal stigma further contribute to poor health outcomes. This case also reveals challenges in addressing goals of care for currently incarcerated individuals. Important considerations include identifying appropriate surrogate decision makers, addressing patient mistrust of medical staff, and contending with diminished sense of autonomy. This case poignantly demonstrates failings of preventive healthcare within carceral settings, prompts key considerations for providing quality palliative care to justice-involved individuals, and urges clinicians to advocate for improved correctional healthcare.

CONCLUSION: Carceral settings often fail to provide preventive healthcare to incarcerated patients due to structural, financial, and regulatory issues, thereby delaying care and exacerbating preventable conditions. Goals of care discussions for justice-involved individuals should account for provider bias, system-related mistrust, and diminished sense of autonomy.

BEYOND DIAGNOSIS: NAVIGATING THE EVOLVING REALITIES OF AN HIV DIAGNOSIS IN THE POST-ART ERA

Anne A. Richardson¹; Sarah A. Tilstra^2,1. ¹Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh School of Medicine/Medical Center, Pittsburgh, PA. (Control ID #4059697)

CASE: A 47 year old woman experiencing homelessness presented multiple times to the emergency department (ED) over a few days after noticing a painful lump on the back of her neck with accompanying orthostasis and an unintentional 60-pound weight loss. She did not take any medications and endorsed remote non-intravenous methamphetamine use. She was sexually active with a single, but not monogamous, partner. Upon her third ED visit, labs were drawn and showed pancytopenia; CT scans showed diffuse lymphadenopathy in her neck, chest and abdomen. Other labs including a peripheral blood smear were unrevealing. Workup was sent for infectious, malignant and autoimmune causes, and was notable for a positive HIV 1 antibody, viral load of >10 million copies, and CD4 count of 57, meeting criteria for AIDS. She developed bilateral throbbing headaches. Head imaging and cryptococcal serum antigen were recommended to evaluate for cryptococcal meningitis prior to initiating anti-retroviral therapy (ART), which were negative. An excisional biopsy was unable to be performed, and a core needle biopsy of an inguinal lymph node was unrevealing. She was started on ART and antibiotic prophylaxis, her cell counts improved, and she was discharged with scheduled follow-up with plan for repeat biopsy if lymphadenopathy did not improve with ART, with the presumed diagnosis of pancytopenia and diffuse lymphadenopathy due to advanced AIDS. She was lost to follow-up.

IMPACT/DISCUSSION: While the prognosis of a new HIV diagnosis has changed dramatically over the last 40 years, there remain significant disparities in outcomes. As HIV/AIDS related mortality has declined, the differences have widened between Black and White Americans and between low-SES and high-SES populations. Prior to ART, Black Americans were 5x as likely as White Americans to die from HIV/AIDS, and after, are now 8x as likely. Patients with low SES before ART were 1.4x as likely to die from HIV/AIDS, and after are now 2.7x as likely.

Rapid initiation of ART after HIV diagnosis improves virologic outcomes and retention in care, however, there are certain opportunistic infections that require special consideration prior to starting ART. In patients with cryptococcal meningitis, a delay of ART initiation leads to improved survival, primarily because of the risk of immune reconstitution inflammatory syndrome if ART is not delayed. Although this patient ultimately did not have cryptococcal meningitis, her headaches and advanced disease were concerning, and it is important to recognize opportunistic infections that may necessitate treatment prior to initiation of ART.

CONCLUSION: 1) HIV prognosis has dramatically changed over the last 40 years, but there remain disparities in outcomes for racial minorities and those of lower socioeconomic status.

2) Rapid initiation of ART is important for virologic outcomes and retention in care, but there are cases in which delay of ART is crucial for improved survival, particularly for cryptococcal meningitis.

COULD COMPLEMENTARY MEDICINE HAVE DROPPED A 62-YEAR-OLD MAN’S PSA BY >70 NG/ML?

Elizabeth Huang, Jake Wong, Theresa M. Rohr-Kirchgraber. Medicine, Augusta University and University of Georgia Medical Partnership, Athens, GA. (Control ID #4062342)

CASE: A 62-year-old Chinese male presented to his physician with a painless supraclavicular mass (SCM). Otherwise healthy, he is a nuclear medicine technician with a family history of prostate cancer. Medical history, review of systems, and exam demonstrated no other significant findings. A biopsy of the mass revealed malignant tissue consistent with a prostatic origin and staining positive for PSA and PSAP.

The initial PSA results were 87 ng/mL and 135 ng/mL. CBC and CMP were unremarkable. CT showed six prostatic metastases to retroperitoneal, pelvic, and left supraclavicular lymph nodes. Bone scan showed no bony metastases. He was diagnosed with stage IV prostate cancer (PC).

The patient was prescribed leuprolide and Taxotere but turned to traditional medicinal herbs instead while awaiting insurance approval. He self-medicated each meal with a blended cup of Clinacanthus nutans, Orthosiphon stamineus, ginger, manuka honey, flaxseed, raw dandelion leaves and roots, and pH 11.5 water. Two months later, his PSA dropped to 9.9 ng/mL.

After insurance approval, the patient started Taxotere with pre-cycle dexamethasone. He terminated Taxotere therapy after 5/6 cycles due to neuropathy. He then started leuprolide as maintenance therapy. His final PSA was 0.5 ng/mL.

IMPACT/DISCUSSION: Metastatic prostate cancer (mPC) presents mostly in men >65 years old with other symptoms pre-diagnosis, such as fatigue, sexual dysfunction, urinary problems, and bone pain. This unique case of a SCM in an otherwise asymptomatic patient is a reminder that mPC can present atypically and silently.

There is a paucity of studies on clinical applications of complementary medicine for mPC treatment in the US. C. nutans is popularly used in Malaysia, but studies found insignificant immunomodulatory effects on PC cells. O. Stamineus is common in Asian medicinal teas, and experiments found significant antiproliferative and cytotoxic effects on PC cells¹. Ultimately, it is difficult to isolate the cause of the patient’s >70 ng/mL PSA drop, but at least one of the herbs he consumed is likely contributory.

Complementary medicine is often overlooked in the US due to stigma and lack of regulation, but patients may explore this route due to cultural significance, distrust of the medical system, or desire to explore nonpharmacological routes. This case reminds physicians to partner with patients in their care by reviewing treatments patients have voiced interest in and by evaluating possible adjunct treatments for patients with difficulty accessing care.

1. Prieto JM, Hanafi MMM. Advances in Molecular Regulation of Prostate Cancer Cells by Top Natural Products of Malaysia. Current Issues in Molecular Biology. 2023; 45(2):1536-1567.

CONCLUSION: Metastatic prostate cancer may present atypically with supraclavicular adenopathy without constitutional or local symptoms. Complementary medicine may serve as a bridge to care for interested patients with mPC when healthcare gaps affect access to immediate pharmacological therapy.

HLA-B*5801 SCREENING: A QUESTION OF INCLUSIVITY

Linda Yu, Peggy B. Leung. Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #4061137)

CASE: A 70-year-old man with a history of hypertension and diabetes presents to the hospital with a diffuse desquamating rash after being prescribed allopurinol for presumed gout. Biopsy of his rash confirms a diagnosis of severe allopurinol-associated hypersensitivity.

He is initiated on high-dose steroids with minimal improvement. His hospital course is complicated by acute hypoxic respiratory failure requiring intubation, acute renal failure requiring CRRT, multiple systemic infections (including Candida auris fungemia, VRE bacteremia and CMV viremia), GI bleeding, and non-operable duodenal perforation.

The patient is a first-generation immigrant from the Philippines. His family abroad is notified of his critical condition and they agree to a comfort-based approach to his care given his multi-organ failure. He ultimately passes peacefully in the intensive care unit.

IMPACT/DISCUSSION: This vignette presents the harrowing case of a fatal allopurinol-associated hypersensitivity reaction. The HLA-B*5801 allele is strongly associated with allopurinol hypersensitivity reactions, with hazard ratios estimated to be in excess of 100.

Current national guidelines from the American College of Rheumatology (ACR) conditionally recommend HLA-B*5801 testing prior to allopurinol initiation for “patients of Southeast Asian descent (e.g. Han Chinese, Korean, Thai) and African American patients,” given a higher prevalence of HLA-B*5801 amongst these groups. They conditionally recommend against testing “in patients of other ethnic or racial backgrounds.” Based on these guidelines, our patient qualifies for HLA-B*5801 testing on the basis of his Southeast Asian descent.

There are, however, several noteworthy limitations to consider. First, these guidelines are not inclusive of certain populations known to have an increased prevalence of HLA-B*5801, such as those of Native American/Pacific Islander ancestry. Additionally, they misidentify Han Chinese and Korean patients as being of Southeast Asian descent, resulting in a lack of clarity regarding the intended groups for inclusion. Finally, ethnicity – as a social construct related to cultural heritage – is inherently an imperfect proxy for genetic ancestry, and there is a paucity of data regarding HLA-B*5801 prevalence amongst populations underrepresented in global genotypic studies. These limitations suggest that re-evaluation and revision of these guidelines must be undertaken in order to ensure that higher-risk individuals are appropriately screened.

CONCLUSION: The HLA-B*5801 allele is a well-documented genetic variant associated with severe and potentially fatal allopurinol hypersensitivity reactions. The current national screening guidelines utilize an ethnicity-based approach to risk stratification, which carries both fundamental and practical limitations. With advances in pharmacogenetic testing, greater inclusivity of HLA-B*5801 screening beyond the groups as specified should be considered.

KNOWING WHERE TO LOOK: CANCER SCREENING IN TRANSGENDER PATIENTS

Dania Taylor, Margot Valme, Gavin Truong, Jillian S. Catalanotti. Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4028183)

CASE: A 68-year-old transgender woman was seen for a health maintenance exam. She felt well. She had no history of hormone use or gender-affirming surgery. Vital signs and physical exam were unremarkable. Upon discussion, the patient indicated she had never been offered prostate cancer screening and opted for PSA testing. PSA was 5.8ng/mL; repeat was 6.4ng/mL. Prostate MRI revealed 2 lesions. Biopsy confirmed prostate adenocarcinoma.

IMPACT/DISCUSSION: “Transgender” describes individuals whose gender identity does not align with assigned sex at birth. Transgender individuals may experience unique challenges, including locating physicians who practice trans-competent care. Gender affirming care should be guided by patients and may or may not include hormone therapy or surgeries.

Cancer rates do not differ among transgender versus cisgender patients. Cancer screening for transgender patients depends on both natal and altered anatomy; medical, hormonal and surgical history, including organ inventory, must be obtained. It is also important to know which organs are typically retained or removed during gender affirming surgery. Age-appropriate cancer screening for transgender patients follows usual guidelines with consideration of hormonal or surgical organ changes from gender affirming care.

Estrogen-enhanced breasts require mammography after at least 5 years of therapy regardless of age, with repeat annually. Testosterone therapy does not alter mammogram recommendations. “Top” surgery for female-to-male transgender patients retains some breast tissue; screening mammography remains indicated.

Male-to-female “bottom” surgery may include penectomy, bilateral orchiectomy, partial urethrectomy (removal of penis, testes/scrotum, part of urethra), and creating a vaginal canal, labia and clitoris. The prostate is retained. Prostate cancer screening guidelines are unchanged.

FTM “bottom” surgery may include phalloplasty (creation of functional penis, glans, neourethra). Scrotoplasty, vaginectomy, and hysterectomy with BSO may or may not be performed. Patients with a cervix require pap smears per usual guidelines.

Our patient did not undergo hormone treatment or gender-affirming surgery and retained all organs of a biological male. She did not have estrogen-enhanced breasts so did not require mammogram. Previous providers may not have considered her prostate. Patient-centered discussion regarding prostate cancer screening should occur annually between 55-70 years of age. Our patient’s first discussion occurred 13 years later than indicated.

The health maintenance exam is an opportunity to perform an organ inventory and ensure transgender patients are offered appropriate cancer screening. Using EMRs to document organ status may prompt physicians to close these care gaps.

CONCLUSION: Appropriate cancer screening for transgender patients includes an individualized, organ-based approach, following routine guidelines informed by hormonal or surgical treatments.

LIMITED “ACCESS”: DELAYS IN ARTERIOVENOUS FISTULA REVISION FOR HEMODIALYSIS DUE TO A NARROW PROVIDER NETWORK FOR A DUAL-ELIGIBLE PATIENT WITH MEDICARE-MEDICAID MANAGED CARE PLAN

Nihar Rama¹; Shannon Martin²; Venkatesan R. Krishnamoorthi². ¹Pritzker School of Medicine, The University of Chicago, Chicago, IL; ²Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4063771)

CASE: A 34-year-old man with end-stage renal disease (ESRD) on hemodialysis (HD) presented to a community hospital affiliated with a Mid-West academic medical center (AMC) with 1 week of pain and edema around his left upper extremity arteriovenous fistula (AVF). His AVF was found to be clotted. A Perma-cath was placed following several unsuccessful thrombectomies by interventional radiology (IR). On day 3, the patient self-directed his discharge due to dissatisfaction with pain control. Two days later, he presented to the AMC for persistent pain. IR attempted stenting the AVF but was unsuccessful. Vascular surgery recommended outpatient follow-up to plan revision of the AVF. However, the team’s patient navigator discovered the AMC was out of his new insurance plan’s network, which the patient was not aware of. They made an appointment with his prior surgeon at the community hospital, who was now out of network. The appointment was canceled. Ultimately, the patient was scheduled with a new in-network PCP and instructed to obtain a referral to an in-network vascular surgeon. The patient understood the plan and was committed to outpatient follow up, but expressed frustration given his prior relationship with a surgeon and did not understand why he was unable to follow with either system.

IMPACT/DISCUSSION: This case demonstrates barriers to specialty care for a young patient dually-eligible for Medicare and Medicaid and the disruption of coverage when insurance changes. Dual-eligible patients have among the highest healthcare utilization and therefore incur very high costs for state and federal government. To address this, his state created the Medicare-Medicaid Alignment Initiative (MMAI). Managed care organizations (MCOs) design MMAI plans that they claim both improve care coordination and save money using blended capitation rates to mitigate the financial misalignment between Medicare and Medicaid. Eligible patients are mandated to enroll in MMAI but can opt-out at any time. This patient was auto-enrolled into an MMAI plan that did not contract with the AMC where he presented, but he was not aware of the change. Due to this, securing outpatient specialty care was delayed, and the patient’s relationship with his prior physician was disrupted. Despite MMAI programs purporting to provide more seamless coverage and more coordinated care, research has not consistently shown that managed care is associated with lower spending or improved quality compared with fee-for-service Medicaid.

CONCLUSION: Efforts by states to save expenses on dual-eligible patients can delay and disrupt care due to limited network coverage and poor patient awareness. General internists taking care of medically complex patients face system-level barriers beyond their control, even with a dedicated patient care navigator. More data is needed to understand the impact of MMAI on clinician and hospital networks available to patients managed by general internists.

LOOKING FOR ANSWERS: COMMUNICATING WITH A PATIENT WITH LOCKED-IN SYNDROME

Kanika Gupta¹; Elijah D. LaSota²; Brett Wilkinson¹. ¹Internal Medicine, Tulane University, New Orleans, LA; ²Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4024014)

CASE: A 59-year-old patient with a 10-year history of locked-in syndrome due to a basilar artery stroke presented to the ED for a worsening sacral wound complicated by osteomyelitis. Their home eye-tracking communication device was cumbersome to transport so not initially available. The patient’s sister and devoted caregiver provided the initial history and explained the patient indicated ‘yes’ with superior gaze but could not be present during the patient’s stay. In the several hospital days before the patient’s eye-tracking device could be delivered, the care team experienced stepwise improvements in their trialed communication techniques. This also had to be communicated with each new team member which led to frustration and often inefficient care for the patient. The initial yes-no questioning was eventually applied to a letter grid the patient had memorized, allowing the patient to spell words and provide more nuanced responses. The grid was arranged in alphabetical order, with each vowel starting a new row. Row numbers were listed until an affirmative response was received, followed by its constituent letters. The home device was eventually delivered but the care team continued to benefit from their acquired communication skills while setting up and periodically troubleshooting the patient’s device.

IMPACT/DISCUSSION: The many forms of interpersonal communication, from verbal to body language, are restricted to only subtle eye movements for patients with Locked-in Syndrome (LiS) and other severe motor disabilities. Most often caused by vertebrobasilar stroke, classical LiS impairs all voluntary motor control except vertical gaze and superior eyelid movement. The disease ranges from complete to incomplete, characterized by total loss of voluntary movement and movement beyond the classical distribution respectively. Based on the degree of disability, communication might rely on pupillary dilation and restriction, eye-tracking devices that control a keyboard in cases with increased extraocular degrees of freedom, or, more recently, Brain-Computer Interfaces for communication (CBIs) that involve neurological implants. Our experience navigating communication challenges during the hospital course for this patient with classical LiS and subsequent review of communication techniques for severe motor disabilities revealed a variety of options and exciting new developments. We describe an overview of these options to improve awareness and facilitate communication in the health care setting for patients with severe motor disabilities.

CONCLUSION: Though rare, patients with locked-in syndrome might present in a variety of clinical settings and benefit from improved awareness of communication styles. While advanced technologies including eye-tracking communication devices and emerging Brain-Computer Interfaces for communication (CBIs) offer promise, awareness of more rudimentary or analog strategies could be beneficial when those methods are not available.

MANAGEMENT OF GENDER AFFIRMING HORMONE THERAPY IN TRANS-FEMININE ADULTS

Stephanie Clark, Caroline Bockus, Jillian S. Catalanotti. Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4028187)

CASE: A 56 year-old transgender woman with HIV, hypertension, hyperlipidemia, pre-diabetes, and OSA presented to clinic for hormone therapy management. An endocrinologist had initiated hormone therapy years ago, and her medications were estradiol 2mg PO BID and conjugated equine estrogen (Premarin) 0.9mg PO BID. No recent hormone levels were documented. She denied history of VTE, CVD, or CAD.

Anti-androgen therapy was started with spironolactone 50mg PO BID. Premarin was stopped due to the increased risk of VTE on two estrogens. After-visit labs demonstrated estrogen of 448 pg/mL and testosterone of 103.1 ng/dL. With levels above goal, estradiol was decreased to 2mg BID MWF and daily other days. One month later, her potassium and creatinine were in normal range at 4.1 mmol/L and 0.73 mg/dL respectively. Her testosterone was 48ng/dL, and estrogen was 367pg/mL. On discussion, she was mistakenly taking estradiol BID, and was re-educated. Two months later, her testosterone was 250ng/dL and estrogen was 360pg/mL. Estradiol was decreased to 2mg PO daily, and spironolactone was increased from 50mg BID to 100mg qAM and 50mg qHS with plans to continue lab monitoring every 3 months.

IMPACT/DISCUSSION: Gender affirming hormone therapy in trans-feminine patients consists of estrogen and anti-androgens to sufficiently reduce testosterone levels. Prior to initiation, patients should be counseled on fertility options, side effects, risk reduction, and realistic goals of therapy.

Estrogen options include estradiol in PO, SL, IM, and transdermal forms. Ethinyl estradiol and conjugated equine estrogens should be avoided due to increased risk of VTE. For those >45 years old or with prior VTE, transdermal estrogen is recommended and should be discussed with this patient. Anti-androgen therapies include spironolactone and GnRH agonists such as leuprolide. Due to cost, spironolactone is commonly used.

Serum estrogen and testosterone should be checked every 3 months for 12 months, then every 6-12 months. At these times, physiologic changes and adverse effects should be assessed, and if on spironolactone, potassium and creatinine should be monitored. Estrogen and anti-androgen therapy should be titrated to the lowest effective dose to obtain serum estradiol levels between 100pg/mL and 200pg/mL, which is normal premenopausal female range, and testosterone less than 50ng/mL. Preventative care for transfeminine patients should include routine cancer screening (including breast and prostate cancers), cardiovascular risk reduction and baseline bone density scanning.

CONCLUSION: Gender affirming medications help trans-feminine adults achieve desired secondary sex characteristics by establishing normal female hormone levels. These patients require close follow-up to adjust hormone therapy, monitor effects including adverse events, and complete screening.

NOWHERE TO GO: CHALLENGES OF CHRONIC DISEASE MANAGEMENT FOR UNDOCUMENTED IMMIGRANTS AND SYSTEMIC INTERVENTIONS TO ADDRESS THEM

Priscilla S. Molina¹; Vanshika S. Narala¹; Andrew W. Schram²; Venkatesan R. Krishnamoorthi³. ¹Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ³Medicine, University of Chicago, Chicago, IL. (Control ID #4065036)

CASE: Ms. J is a 20-year-old female with a history of syphilis (treated at age 16) who presented to the Emergency Department (ED) with a progressive rash. Ms. J immigrated to the US from Peru 4 months ago. Her journey consisted of traveling long stretches on foot, crossing many bodies of water with no ability to launder her clothes and limited access to medication. Ms. J first developed a small pruritic rash in her left axilla during this trip. The lesion was stable in size until 1 month ago when it spread to her left breast, then over her chest, abdomen, and limbs, becoming increasingly pruritic. She tried steroid cream and topical garlic with no relief. She presented to the ED and was admitted to the hospitalist service. After initial concern for parasitic infection, Dermatology diagnosed Phytophotodermatitis, caused by contact with plants, foliage, and sun exposure. Lesions resolved with clobetasol ointment. Also, blood cultures grew Methicillin-Resistant Staph. Aureus, for which Infectious Disease recommended 2 weeks of IV Vancomycin. Home IV Antibiotics or Skilled Nursing Facility were considered, but neither could be financed due to the patient’s undocumented and uninsured status. The administrative decision was to keep Ms. J in the hospital for the duration of the antibiotic course.

IMPACT/DISCUSSION: Approximately 11 million undocumented immigrants currently reside in the U.S, 53% of whom reported having no access to health insurance¹. In the 2023 fiscal year, 2.5 million new migrants arrived at the U.S-Mexico Border, many currently with limited healthcare access². Generally, immigrants have lower healthcare expenditures compared to the U.S-born population due to low access and use³; however, many uninsured immigrants enter the ED with life-threatening conditions, leaving the hospitals with mean inpatient charges over $27,000⁴. Still, undocumented immigrants contributed $11.74 billion to state and federal taxes in 2017 and further contribute to the U.S. economy ⁵.

A federal infrastructure to provide low-income undocumented immigrants with health coverage for hospitalizations would prove a sound investment for the U.S, decrease healthcare expenses and promote quality health for more U.S residents. Full Scope Medi-Cal Expansion in California,⁶ which will provide full Medicaid coverage to low-income, undocumented individuals of all ages, serves as an example of potential federal legislation.

CONCLUSION: High rates of uninsurance in the undocumented immigrant population place them at a higher risk of refraining from or delaying utilizing hospital services, leading to worse long-term health outcomes. Healthcare for these individuals, who contribute to the U.S. economy and subsidize healthcare for the entire U.S. population, can be supported through federal programs. Expansion of state-level initiatives that address this issue to a national program may provide the care necessary for these patients.

RECOGNIZING INEQUITIES IN THE INPATIENT MANAGEMENT OF INCARCERATED PATIENTS

Akash Oza¹; Nicole Mushero². ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Department of Medicine, Boston University School of Medicine, Boston, MA. (Control ID #4064020)

CASE: A 62-year-old incarcerated man with diabetes complicated by neuropathy, end-stage renal disease, COPD, and hypertension presented to the hospital from a prison medical facility for concern for osteomyelitis in the setting of a diabetic foot ulcer. Initial examination was performed in the emergency department hallway and was limited due to shackling of the patient. Two security guards were present throughout admission at bedside and frequently answered for the patient. Podiatry performed lateral foot excision to the level of the muscle and patient was discharged. He represented 6 days after discharge with necrosis of the surgical wound and concern for osteomyelitis. On that admission, the patient reported receiving only 5 of 7 days of antibiotics and less than the recommended dressing changes. Amputation as source control of infection was delayed due to concern for availability of appropriate wound care at his facility. He eventually received amputation and was discharged to his facility.

IMPACT/DISCUSSION: This case demonstrates the complexity of structural disparities faced in delivery of medical care to incarcerated patients. Shackling represents a unique physical challenge towards examination, limiting the ability to physically move and examine patients properly. This patient was under constant surveillance by two officers at bedside, obscuring accurate history taking and raising concerns about privacy violations. Issues of patient autonomy are also raised by the security officers’ answering for him. These issues threaten the safety and autonomy of the patient and the ability to craft a physician-patient therapeutic alliance.

Moreover, this case further raises concerns about the standard of care provided in prison settings. It is estimated that more than 20 percent of incarcerated people go without routine health care for chronic health conditions (1). This patient received an inadequate course of antibiotics and limited wound care resulting in re-hospitalization and amputation which may have been avoided otherwise. In light of this, hospital teams need to be more vigilant in advocating for our patients and ensuring correctional facilities have the ability to provide the post-acute care required.

References:

1. Wilper AP, Woolhandler S, Boyd JW, Lasser KE, McCormick D, Bor DH, Himmelstein DU. The health and health care of US prisoners: results of a nationwide survey. Am J Public Health. 2009 Apr;99(4):666-72.

CONCLUSION: 1. Shackling is a physical restraint that limits appropriate care of patients without clearly improving safety and policies around routine shackling should be re-examined.

2. Constant surveillance of incarcerated patients within the hospital setting damages the therapeutic provider-patient relationship and raises questions of patient privacy.

3. Healthcare providers need education around decision making ability of incarcerated patients.

4. Providers should advocate for the appropriate post-acute care for our incarcerated patients when planning disposition.

STRUCTURAL BARRIERS TO CARE FOR INCARCERATED PATIENTS WITH SICKLE CELL DISEASE

Rahael Borchers. Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4064462)

CASE: This vignette compares and contrasts the clinical courses for two patients, men about 30 years old with severe sickle cell disease (SCD), who presented to the same hospital service with vaso-occlusive pain crises. Patient A is 34 years old with excellent health literacy and access to care. His SCD has previously been complicated by acute chest, stroke, priapism, and avascular necrosis. He is on hydroxyurea and vocelotor as disease-modifying treatments (DMTs) with excellent response, and under consideration for curative gene-editing therapies. His hematologist visited him inpatient. The patient partnered with the team to direct pain management. He worked remotely, rapidly weaned off PCA, and was discharged within 6 days on his home opioid regimen. He followed up with hematology and psychology, was offered long-acting opioids in addition to immediate-release, and is planning for gene therapy.

Patient B is 29 years old and incarcerated. His SCD has also been complicated by acute chest, stroke, priapism, and avascular necrosis. He is not well connected with outpatient hematology and not on DMT. He requires monthly apheresis, but routinely misses appointments, and currently has no hematologist. He reports missing appointments due to prison staff shortages. His prison does not provide opioids for pain control. He has recurrent hospital admissions for uncontrolled pain. This admission was complicated by acute chest and strep throat. Hematology was consulted, but could not initiate DMTs without follow-up. He received apheresis, antibiotics, and a dilaudid PCA. Weaning off opioids was difficult due to uncontrolled pain. After 16 days, he was discharged on a non-opioid regimen (ibuprofen, acetaminophen, baclofen, diclofenac gel), which he did not find to be sufficient pain control. Attempts to coordinate with the prison medical team were unsuccessful, and unfortunately the patient was lost to follow up again.

IMPACT/DISCUSSION: The juxtaposition of these cases highlights unacceptable healthcare disparities, and challenges us to investigate pain control options for incarcerated patients with SCD. There is limited literature on the availability of opioids for incarcerated patients with SCD. Recognizing potential challenges with administration, oral liquid formulations and suboxone should also be considered. Given that African Americans face disproportionate rates of both SCD and incarceration, it is critical to recognize their pain control needs, identify barriers to care, assess policy environments, and advocate for the standard of care. Treating acute and chronic pain from SCD is essential, both to prevent further health complications and to ensure this human right.

CONCLUSION: Incarcerated patients with SCD face unique challenges in accessing pain control, DMTs, and follow-up.

Access to pain control is a human right, and standard of care for patients with SCD.

More research and advocacy is needed around institutional, local, and national policies for pain control for incarcerated patients.

TIME: AN INCARCERATED FIASCO

Isabel M. Lopez¹; Mark Spencer²; Alex Galloway³. ¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²General Internal Medicine, Emory University School of Medicine, Atlanta, GA; ³Internal Medicine, Emory University, Atlanta, GA. (Control ID #4064910)

CASE: Mr. F is a 51-year-old male with schizoaffective disorder and cirrhosis, who presented from the county jail for acute encephalopathy. This was his sixth hospitalization in the past year for acute encephalopathy, each time presenting from the county jail. On exam, he appeared cachectic, somnolent, was not oriented or able to follow direction. His baseline, on discharge from prior admissions, he was fully orientated. Labs showed evidence of chronic cirrhosis. CT head was negative for acute pathology. Given objective data, there was high clinical suspicion for hepatic encephalopathy (HE) secondary to missed lactulose doses. Mr. F’s family revealed his unfortunate mental and physical decline in the county jail. Prior to his incarceration, he was well connected with mental health services and adequately treated for cirrhosis. His mother, whom he was living with, relocated due to medical illness. Mr. F was subsequently arrested under unclear circumstances. He remained detained, deemed ineligible for the bond by the court and awaited psychiatric competency evaluation. Despite his family’s relentless advocacy efforts, Mr. F was in a county jail for four years without adequate mental or medical health services. The medical team expressed concern at his increased risk of mortality with each readmission for HE and the facility’s inability to meet his medical needs. Concurrently, his lawyer presented another case dismissal request to the judge, who granted the request while he was hospitalized. His shackles were removed, and he was discharged home with family. On a follow up appointment, his family noted psychosocial and physical decline from his pre-incarceration baseline.

IMPACT/DISCUSSION: Incarceration is known to have numerous adverse health consequences and to markedly reduce life expectancy. Rates of readmission from carceral settings are exceptionally high for those with psychiatric comorbidities. Mr. F’s case is a clear demonstration of the reported statistics; HE has a significant impact on the risk of hospitalization with a mortality rate of ~60% at one year. It also demonstrates the medical community's limited knowledge of the legal and ethical principles governing care of incarcerated patients. Despite widespread confusion, incarcerated patients are legally entitled to make medical decisions and appoint a surrogate decision maker. If the patient lacks capacity, physicians must feel empowered to advocate for incarcerated patients. According to our state regulations, the facility Warden is obligated to notify next of kin if an incarcerated person develops acute illness and shall keep such individuals apprised of medical updates. Clinicians should be ethically motivated to ensure patients' rights are respected and to illuminate readmission mortality rates.

CONCLUSION: Patients who are incarcerated with medical and psychiatric comorbidities face high rates of readmission. Clinicians have an important role to advocate for individual patients and recognize the harms of incarceration.

WHEN WORDS AREN’T ENOUGH: EXPLORING HIGH-STAKES MISCOMMUNICATION IN A PATIENT WITH LIMITED ENGLISH PROFICIENCY

JENNY WEN^1,2. ¹Medicine, Massachusetts General Hospital, Boston, MA; ²Harvard Medical School, Boston, MA. (Control ID #4064765)

CASE: 55 year old Spanish-speaking man with decompensated cirrhosis from alcohol use disorder (AUD) hospitalized for hepatic encephalopathy (HE) without a clear trigger. His complications included diuretic resistant ascites, grade III esophageal varices, and HE on lactulose. Per chart review, despite alcohol cessation since diagnosis, strict adherence to medications and follow up, his MELD score was baseline 20s, up to 32 this admission.

I encountered the patient as the hospitalist after his encephalopathy resolved. Multiple prior notes documented his transplant evaluation is on pause because of "lack of addictions counseling", along with conversations encouraging the patient to follow up.

With the help of a phone interpreter, I sought to clarify his understanding of his illness and the transplant candidacy criteria. He expressed strong motivation for transplant because 'it means life or death". He did not enroll in an AUD program because he does not struggle with abstinence, has transportation challenges, and other medical appointments to prioritize. I explained in clear, direct terms to the patient he is currently ineligible because of lack of formal addictions counseling. He and his wife were shocked and angry, and said no one had told them this before. I clarified this miscommunication with them, the transplant team, and ultimately the patient was set up with outpatient addictions support with social work help.

IMPACT/DISCUSSION: Unfortunately, patients frequently report they have never been told crucial information that clinicians have shared and documented. Bioethicists describe current framing of informed consent focuses on what physicians need to disclose rather than what patients need to understand. Cox (2023) recommends that clinicians in assess "grasping" or ability to "appreciate how pieces of information relate to each other" (eg, no AUD program means no eligibility for transplant) rather than "knowing in the information" (eg, physicians want me to enroll in an AUD program").

Communication barriers are further amplified when treating patients with LEP which often co-occur with other structural barriers such as limited health literacy or systems-knowledge. Clinicians should also use the principle of "proportionality" to prioritize high-stakes conversations involving potentially life-saving interventions and system navigation.

Cox CL. Patient understanding: How should it be defined and assessed in clinical practice? Journal of Evaluation in Clinical Practice. 2023;29(7):1127-1134.

CONCLUSION: 1. Healthcare workers should recognize the potential impact of Limited English Proficiency (LEP) as a social determinant of health and how to mitigate these negative effects.

2. Generalists have the opportunity and imperative to catch missed opportunities in communication, particularly for patients with LEP.

3. To be actively anti-inequity, physicians need to have a heightened sensitivity to high-stakes clinical scenarios by assessing patient grasping, particular those with LEP.

Clinical Vignette - Hospital Medicine

"FROM TRAVEL FATIGUE TO TERMINAL ILLNESS: A CASE OF AGGRESSIVE EBV POSITIVE NK/T-CELL LYMPHOMA WITH DIC "

Ameera Mistry, TUSHAR MENON. Internal Medicine, Abrazo Health Care, Phoenix, AZ. (Control ID #4059891)

CASE: A 69-year-old male with hypertension, hypercholesterolemia, vitiligo, and prediabetes presented with the following symptoms: fatigue and night sweats after traveling, developing thrombocytopenia, elevated lactic acid, and a petechial rash, which progressed to metabolic acidosis, liver dysfunction, and respiratory distress. Despite negative tests for infectious diseases, his condition deteriorated, leading to ICU admission due to changes in mental status, respiratory issues, and hypoglycemia.

Further tesiting, including a bone marrow biopsy, diagnosed an EBV-positive NK/T-cell malignant lymphoproliferative disorder, a rapidly progressing and poor-prognosis malignancy. The situation was complicated by disseminated intravascular coagulation (DIC), a serious complication causing both clotting and bleeding, which led to multi-organ dysfunction and worsening thrombocytopenia. Despite aggressive treatment like CRRT and transfusions, his condition declined. Ultimately patient was made comfort care and passed away.

IMPACT/DISCUSSION: EBV, a common herpesvirus, is a key factor in the development of NK/T-cell lymphomas, driving the transformation of NK or T cells into aggressive malignancies. This patient's rapid progression from general symptoms like fatigue and fever to severe conditions such as thrombocytopenia, metabolic acidosis, and respiratory distress is characteristic of the aggressive nature of EBV-positive NK/T-cell lymphomas.

Diagnosis of this rare lymphoma, confirmed through a CT-guided bone marrow biopsy, is challenging due to nonspecific early symptoms. The presence of EBV in malignant cells is a critical diagnostic indicator. The patient's condition was further complicated by disseminated intravascular coagulation (DIC), a common and severe complication in such malignancies, leading to systemic coagulation and bleeding issues.

Despite intensive treatments, the patient's condition deteriorated, reflecting the high mortality rate and aggressive nature of EBV-positive NK/T-cell lymphoproliferative disorders. The decision to transition to comfort care, made in consultation with the Palliative Care team and family, highlights the poor prognosis of this malignancy. This case emphasizes the need for early detection and aggressive management of such complex, virally-driven malignancies.

CONCLUSION: In summary, this case underscores the complexities of diagnosing and managing a rare hematological malignancy, particularly in an elderly patient presenting with non-specific symptoms post-international travel. The diagnosis of an EBV-positive NK/T-cell lymphoproliferative disorder exemplifies the difficulty in identifying such aggressive cancers that can mimic benign conditions. The patient's development of disseminated intravascular coagulation (DIC) further highlights the unpredictable and severe complications of hematological malignancies, complicating treatment and reflecting the malignancy's aggressiveness and its associated high mortality risk.

"MY LEG FEELS LIKE CEMENT”: COMPARTMENT SYNDROME WITH NON-TRAUMATIC RHABDOMYOLYSIS AND ACUTE DEEP VEIN THROMBOSIS

Jenna Benge, Reagan Moak, Namrata Paladugu, Margaret Cosnahan, Jasmine Kency. Medicine, The University of Mississippi Medical Center, Jackson, MS. (Control ID #4064951)

CASE: We describe the case of a 47-year-old male who presented to the ED with lower extremity pain following loss of consciousness of unknown duration secondary to alcohol and methamphetamine intoxication. He reported rapidly progressive pain, weakness, paresthesias, swelling, and redness of the right lower extremity. Labs were significant for CK >100,000 U/L, AST/ALT 2,248/887 U/L, potassium 4.6 mmol/L, WBC 9.6 TH/cmm, and BUN/Cr 45.4/4.36 mg/dL. Venous ultrasound revealed chronic DVT in the right proximal, middle, and distal popliteal veins and acute, occlusive thrombosis of the right middle peroneal vein. Prior to our exam, fluid resuscitation was initiated for rhabdomyolysis resulting in increased edema. On exam, his affected extremity was circumferentially edematous and taut, tender, warm, and erythematous with pallor of the foot. The dorsalis pedis pulse was palpable, but sensation was decreased below the knee. Surgery consult was promptly obtained due to concern for compartment syndrome and resulted in an emergent fasciotomy followed by serial debridement with staged closure. His hospital course was complicated by acute kidney injury secondary to rhabdomyolysis that improved with intravenous fluids.

The significance of patient teaching and effective communication was displayed during this patient’s care. Due to a prior history of cellulitis, the patient felt his ailment would resolve with antibiotics and initially declined surgical intervention. Following education regarding the severity of his condition, he consented to surgical intervention likely saving his limb.

IMPACT/DISCUSSION: Acute compartment syndrome occurs when pressure builds within a fascia enclosed compartment. It can result in ischemia and loss of limb if not quickly recognized and is a surgical emergency. Most cases are associated with lower extremity fractures. Less commonly, it is associated with drug overdose, deep vein thrombosis (DVT), and strenuous activity. This case presents a unique instance of non-traumatic compartment syndrome in a patient with acute DVT and rhabdomyolysis, which can both separately lead to compartment syndrome. The presence of both simultaneously is rare. It is difficult to determine whether either condition was solely responsible for the development of compartment syndrome or if the combination contributed. Literature review yielded one case of concurrent phlegmasia alba dolens and rhabdomyolysis, but no other cases that resulted in compartment syndrome. Severe manifestations such as compartment syndrome or phlegmasia cerulea dolens are typically associated with large iliofemoral or popliteal clots. Our patients’ symptoms in the presence of a peroneal clot presented an unusual scenario.

CONCLUSION: Complication rates following fasciotomy in the setting of compartment syndrome increase when treatment is delayed. Prompt intervention is crucial in patients presenting with multiple potential causes of compartment syndrome.

"UNRAVELING THE MYSTERY OF NEUROSARCOIDOSIS: A COMPLEX CASE STUDY”

Ameera Mistry, TUSHAR MENON. Internal Medicine, Abrazo Health Care, Phoenix, AZ. (Control ID #4062230)

CASE: A 37-year-old woman experienced persistent headaches, photophobia, intermittent nausea, left-sided weakness, and vision changes over months. Neurological exams and an MRI revealed abnormalities in the pons and medulla, suggesting basilar meningitis. Additional scans indicated ethmoid sinus disease and multiple lung nodules, the largest being 16 mm in the right upper lobe. An abdominal CT scan also found a significant vascular nodule.

Her lumbar puncture showed high white blood cell count, low glucose, high cerebrospinal fluid protein, and elevated cerebrospinal fluid ACE level, pointing towards neurosarcoidosis, a condition present in her family history. A pulmonary biopsy revealed chronic inflammation with granulomatous reaction, supporting this diagnosis. Despite positive West Nile Virus IgG in her CSF, lack of IgM ruled out active infection. Tests for other infections like HSV, syphilis, and tuberculosis were negative.Given her neurological symptoms, lung findings, and lumbar puncture and biopsy results, neurosarcoidosis is the likely diagnosis, requiring collaborative care from neurology, pulmonology, and rheumatology specialists.

IMPACT/DISCUSSION: Neurosarcoidosis, a challenging and multifaceted condition, is a rare manifestation of sarcoidosis, occurring in approximately 5-15% of patients with sarcoidosis. This disorder primarily involves the central nervous system (CNS) and can affect any part of the nervous system, including the brain, spinal cord, and peripheral nerves. It often presents with diverse, non-specific symptoms that vary based on the affected CNS region. Common symptoms include cranial nerve palsies, headache, seizures, and cognitive dysfunction.

The diagnosis of neurosarcoidosis is complex due to its variable presentation and the absence of a definitive diagnostic test. It often requires a combination of clinical assessment, imaging, and laboratory findings. MRI is the most sensitive imaging modality, revealing lesions with signal abnormalities, particularly in the basal meninges. Elevated cerebrospinal fluid (CSF) protein and a lymphocytic pleocytosis are common but non-specific findings. Elevated levels of angiotensin-converting enzyme (ACE) in the CSF can be suggestive but are not definitive for neurosarcoidosis.

The management of neurosarcoidosis typically involves corticosteroids as the first-line treatment to reduce inflammation and control symptoms. In cases where steroids are ineffective or cause significant side effects, other immunosuppressive agents like methotrexate or infliximab may be used.

CONCLUSION: The case discussed highlights the diagnostic challenges and the necessity of a multidisciplinary approach in managing neurosarcoidosis. It emphasizes the importance of considering this condition in patients presenting with unexplained neurological symptoms, especially when accompanied by a history of sarcoidosis. Long-term monitoring and treatment adjustments are essential due to the potential for relapse and the chronic nature of the disease.

"UNVEILING UNCOMMON PRESENTATIONS: BUDD-CHIARI SYNDROME MASQUERADING THROUGH DIARRHEA"

Elizabeth Zakka¹; Micah Chaiprakorb³; Mariel Duchow²; Abanoub Zakka⁴. ¹INTERNAL MEDICINE RESIDENCY PROGRAM, University of Miami, Coral Gables, FL; ²Internal Medicine, University of Miami School of Medicine, Miami, FL; ³INTERNAL MEDICINE RESIDENCY PROGRAM, HCA Florida JFK Hospital, Atlantis, FL; ⁴Cairo University Kasr Alainy Faculty of Medicine, Cairo, Egypt. (Control ID #4062876)

CASE: A 51-year-old female with a history of mood disorder and obesity presented to the Emergency Room (ER) with a 3-day history of loose diarrhea and epigastric pain. Denying nausea, vomiting, shortness of breath, hematochezia, melena, or chest pain, she had no records of recurrent miscarriages, autoimmune diseases, oral contraceptive pill use, recent long flights, leg swelling, calf muscle tenderness, or family history of coagulopathies. However, her father had cerebrovascular disease at age 30, and her sister had a Pulmonary Embolism secondary to breast cancer. She denied constitutional symptoms.

Remaining hemodynamically stable in the ER, she had epigastric tenderness. Laboratory tests (CBC, CMP, coagulation) were normal. A contrast-enhanced CT scan revealed right hepatic vein thrombosis extending into the Inferior Vena Cava (IVC) and right atrium. Commencement of a heparin drip for anticoagulation ensued.

Consultations were sought from vascular surgery, hematology, and interventional cardiology. Upon multidisciplinary evaluation, immediate intervention wasn't recommended due to the extensive right atrial extension of the thrombus. Heparin therapy continued. Further workup unveiled positive antiphospholipid antibodies.

Post stabilization, the patient was discharged with oral anticoagulation for preventing thrombus progression and thromboembolic risks. Scheduled outpatient follow-ups aimed to monitor therapy response and potential complications.

IMPACT/DISCUSSION: Budd-Chiari syndrome (BCS) displays varied clinical presentations, from asymptomatic to severe liver failure. Identifying hypercoagulable states or indicators is pivotal for diagnosis, though cases may lack such markers.

In this case, non-specific symptoms led to the CT diagnosis. Utilizing ultrasound initially might have been a radiation-sparing approach. Managing BCS involves halting clot progression and considering interventions for liver congestion. Chronic anticoagulation, thrombolytic therapies, angioplasty with stenting, and Transjugular Intrahepatic Portosystemic Shunts (TIPS) are management options.

CONCLUSION: BCS poses diagnostic challenges due to its varied presentations, often lacking clear hypercoagulability signs. Using ultrasound first for abdominal pathology investigation is prudent, followed by CT if inconclusive.

Liver congestion management may necessitate interventions like angioplasty, stenting, or TIPS. Post-intervention vigilance and appropriate anticoagulation are vital, given the potential for complications. Optimal outcomes demand a multidisciplinary approach for comprehensive patient care.

(NOSE)DIVING INTO A RARE ETIOLOGY OF ORTHOSTATIC HYPOTENSION

Hirva Joshi. Internal Medicine, Washington University in St Louis, St Louis, MO. (Control ID #4064925)

CASE: Patient was a 74 y/o man with a PMH of syncope, paroxysmal afib who presented to ED after two syncopal events at home. He stated both events occurred as he was standing up. Upon standing, he had lightheadedness and eventual LOC. He regained consciousness within one minute of losing it; no confusion afterwards. He denied associated chest pain, dyspnea, muscle weakness, and paresthesias. He did not drink alcohol. His home medications were digoxin 125 mcg daily and apixaban 5 mg BID. Orthostatic vitals showed supine BP 139/76 with HR 85, sitting 89/49 with HR 75, standing 72/46 with HR 76. Labs revealed Hgb 12.1 g/dL, total protein 6.4 g/dL, albumin 3.7 g/dL, HIV nonreactive, B12 and folate within normal limits. Carotid Dopplers were normal. Telemetry showed NSR. EEG did not reveal seizure activity. Patient was given compression stockings and a fluid intake goal of 3L daily. Midodrine 10 mg TID was added. These things did not improve his orthostatic hypotension. Evaluation for amyloidosis was then pursued. Serum kappa light chains were 31.1 mg/dL, with kappa/lambda ratio 21. Abdominal fat pad biopsy did not show amyloid. BM biopsy showed MGUS. Cardiac MRI did not show evidence of amyloidosis. At this point, ROS was revisited, and patient endorsed urinary incontinence and vivid dreams concerning for a Parkinsonian CNS disorder. Neurology was consulted; recommended skin biopsy, which revealed a-synuclein inclusions in epidermal nerve fibers consistent with MSA. He required pyridostigmine 60 mg BID and fludrocortisone 0.2 mg daily to control his orthostatic hypotension.

IMPACT/DISCUSSION: If hypovolemia, anemia, peripheral neuropathy, and drugs are thought to be less likely causes of orthostatic hypotension, consider neurogenic causes such as Parkinson disease, Lewy body dementia, and multiple system atrophy. A biopsy is necessary for definitive diagnosis of MSA. Alpha synuclein inclusions in neurons are pathognomonic. Management of MSA is geared towards symptom relief. Notably, levodopa does not have a significant positive effect in MSA. If orthostatic hypotension symptoms are refractory to conservative strategies (increased salt and fluid intake, compression stockings, midodrine), additional medical therapies are available. Options include fludrocortisone (0.05-0.3 mg daily), which increases intravascular volume but may also lead to supine hypertension and hypokalemia; pyridostigmine (30-60 mg twice daily or three times daily), which inhibits acetylcholinesterase; droxidopa (100-600 mg TID), a norepinephrine precursor; atomoxetine (18 mg daily), a norepinephrine reuptake inhibitor; octreotide; desmopressin; and ephedrine/pseudoephedrine.

CONCLUSION: 1. Neurogenic causes of orthostatic hypotension may not be apparent at first, but should be investigated based on careful ROS exploration and elimination of other etiologies.

2. If orthostatic hypotension symptoms are not responsive to conservative management, there are several pharmacologic options available for further relief.

AN ATYPICAL CASE OF BULLOUS PEMPHIGOID IN A 45-YEAR-OLD MAN

Nicole Remmert¹; Kanishk Goel¹; Jesse Neely¹; Barath Rangaswamy². ¹Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ²internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX. (Control ID #4064750)

CASE:A 45-year-old male with hypertension and hypothyroidism, who was non-compliant on thyroid hormone replacement therapy, presented with a generalized vesicular rash with greatest density in the bilateral hands and thighs. Of note, he had a recent hospitalization a month prior for a similar presentation, which was treated as cellulitis based on wound culture. He had an elevated TSH (210 mIU/mL) and positive ANA titers. The autoimmune workup for Hashimoto's thyroiditis was negative. He was discharged home with oral antibiotics and levothyroxine. After a month, he presented to the ER again with worsening symptoms including a scaly and vesicular generalized rash that spared his oral mucosa. He had mild pruritus and sloughing of skin. The vesicles varied in turgor, were up to 1 cm in size, had a negative Nikolsky sign, and were bordered by diffuse confluent ulcers and hyperpigmented patches. Labs revealed an improved yet suboptimal thyroid profile (TSH: 7.98 mIU/mL). Punch biopsy of the right third digit and left anterior thigh was performed. He was treated empirically with steroids and antibiotics, with his rash improving over the next five days. He was discharged home with a methylprednisolone dose pack and improved substantially with outpatient azathioprine treatment. Skin biopsy results revealed subepidermal vesiculobullous dermatosis with eosinophils. Direct immunofluorescence (DIF) showed linear IgG and C3 depositions along the basement membrane zone consistent with bullous pemphigoid.

IMPACT/DISCUSSION: Bullous pemphigoid (BP), an autoimmune subepidermal blistering disorder, is typically observed in older patients (>60 years), rarely affecting people under 50, with an incidence of less than 0.5 cases per million population globally below 50 years of age. While BP presents on a spectrum of clinical appearances, it commonly manifests as a pruritic eruption of large, tense blisters. Though our patient had a negative Nikolsky sign, his vesicles varied in turgor, were only mildly pruritic, and were smaller than usual for BP (1-4 cm). Histopathological examination showing a subepidermal split with numerous eosinophils and a subepidermal split with superficial perivascular inflammatory infiltrate and Direct Immunofluorescence (DIF) testing help to differentiate bullous pemphigoid from other subepidermal blistering disorders. The primary BP treatment is steroids, and other anti-inflammatory agents for moderate to severe disease, in addition to supportive treatments like antihistamines and antibiotics. Immunosuppressants are usually reserved for patients with severe disease.

CONCLUSION: Bullous pemphigoid is a polymorphic disease that may have a misleading clinical presentation. Clinicians must remain vigilant for BP when confronted with young or middle-aged adults presenting with diffuse blistering eruptions. Diagnostic evaluation with histopathologic and DIF of perilesional skin and characterizing circulating autoantibodies is imperative.

69-YEAR-OLD MALE WITH FEVER AND RASH

Greeshma Erasani¹; Vinay jahagirdar¹; Sanjana Perumalla¹; Kaanthi Rama²; Sai Kumar Reddy Pasya³; Ryan Lustig⁴. ¹Internal Medicine, University of Missouri-Kansas City, Kansas City, MO; ²Gandhi Medical College, Secunderabad-Padmarao Nagar, Telangana, India; ³neurology, The University of Kansas Hospital, Kansas City, KS; ⁴Nephrology, Saint Luke's Health System, Kansas City, MO. (Control ID #4065137)

CASE: A 69-year-old African American male presented to the ED with vomiting, diarrhea, and worsening fatigue over the past four days. His medical history included metastatic papillary renal cell cancer treated with immunotherapy (cabozantinib) and chronic kidney disease stage 3b. He was febrile (102.1°F) upon presentation. Labs were notable for an elevated creatinine of 2.4 mg/dL (baseline 1.4-1.6) and a WBC count of 6.48

TH/uL. The patient was started on empirical antibiotic therapy with cefepime and vancomycin. On hospital day 3, a rapid response was called due to the patient's acute hypoxemic respiratory failure and altered mental status (AMS). A CT chest scan revealed bilateral infiltrates, prompting the broadening of antibiotic coverage with the addition of doxycycline.

Creatinine, which had improved to 2.1, rose to 2.9 by day 5. Concurrently, a maculopapular rash appeared on his upper extremities. Suspecting an allergic reaction to vancomycin, it was replaced with linezolid. Cefepime was switched to piperacillin-tazobactam due to concerns of neurotoxicity. Despite these changes, the patient remained febrile, and the rash expanded.

On day 6, creatinine peaked at 3.7. Eosinophilia was noted on the CBC (12%, with an absolute eosinophil count of 0.92 TH/uL). Given the triad of fever, rash, and eosinophilia, the patient was diagnosed with AIN. All antibiotics were discontinued, and methylprednisolone was initiated.

By hospital day 12, the patient's creatinine trended down to baseline, and he was discharged with instructions for primary care physician follow-up.

IMPACT/DISCUSSION: Acute interstitial nephritis (AIN) is a condition characterized by an inflammatory response within the kidney interstitium. Medications are the most frequent cause of AIN, but it can also arise from autoimmune conditions and infections. Common drugs causing AIN include NSAIDs, penicillins, cephalosporins, antimicrobial sulfonamides, ciprofloxacin, and loop diuretics. The classic triad of drug-induced AIN (fever, rash, and eosinophilia) occurs in only 10% of cases. The time of onset varies, ranging from three days to several months. Although eosinophilia (≥ 500 eosinophils/microL) is observed in only about a quarter of cases, its presence in a patient with AKI without another apparent cause should alert providers to the possibility of drug-induced AIN. Urinalysis may reveal sediment with white cells and white cell casts, proteinuria, and a high fractional excretion of sodium. Renal biopsy, while the gold standard for diagnosis, is not required in patients who improve after discontinuation of the offending agent. Discontinuing the culprit drug is the mainstay of treatment. The entire class of related medications may need to be avoided in the future.

CONCLUSION: The classical presentation of fever, rash, and eosinophilia is present in only 10% of patients with AIN. A high index of suspicion can lead to the timely termination of the offending agent in cases of drug-induced AIN.

ABDOMINAL PAIN AND THE ENIGMA OF AORTITIS: A DIAGNOSTIC ODYSSEY

Alberta Negri Jimenez¹; Harnoor Mann¹; Rashmi Rao²; Sarah B. Merriam³. ¹Internal Medicine, UPMC, Pittsburgh, PA; ²University of Pittsburgh School of Medicine, Pittsburgh, PA; ³Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4032465)

CASE: A 57 year-old veteran with history of GERD presents with 2 days of intermittent abdominal pain, nausea, and emesis provoked by bowel movements. He has no associated fevers/chills, headache, jaw pain, vision changes, joint pain, or radiation of his pain to the back. He is a retired prison guard who traveled extensively related to his military service, formerly used tobacco, and currently resides on a farm with frequent insect/animal exposure. Two immediate family members had cerebral aneurysms. On arrival, vital signs were within normal limits. Labs showed WBC 11.4, CRP <0.2, ESR 16, and blood cultures were drawn. CT A/P demonstrated a 3.1 cm inflammatory infrarenal abdominal aortic aneurysm with periaortic stranding involving the inferior mesenteric artery.

He was empirically treated with IV vancomycin/ceftriaxone and IV steroids with prompt resolution of symptoms. CTA chest/abdomen/pelvis and contrasted brain MRA revealed no other large vessel involvement. Infectious workup for Bartonella, Coxiella, Brucella, Histoplasma, TB, Lyme, HIV, Hepatitis, and Syphilis was unremarkable. TTE was negative for infectious endocarditis and blood cultures had no growth. SPEP, IgG, IgA, IgM, C3, C4, and ANCA profiles were unremarkable. The veteran was discharged with a steroid taper for presumed idiopathic isolated aortitis (IIA).

IMPACT/DISCUSSION: This case represents a unique presentation of an uncommon condition, IIA, which generally presents with abdominal or lower back pain. We suspect our patient’s nausea, diaphoresis, and vomiting were triggered by increased vagal stimulation resulting from aneurysmal inflammation involving the mesenteric artery proximal to the celiac plexus. A diagnosis of exclusion, IIA requires comprehensive evaluation informed by personal, family, and social histories, adjunctive imaging, and targeted infectious/rheumatologic testing given that vessel biopsy is often not a viable option. Our patient’s history was rife with risk factors for various infectious and rheumatologic etiologies that comprise the differential diagnosis of IIA. While infectious etiologies are less common, they must be ruled out due to increased risk of aortic rupture and mortality. His unremarkable inflammatory markers did not rule out large vessel vasculitis, which may present as such in up to 1/3 of cases. Empiric treatment with IV steroids and broad-spectrum antibiotic therapy to include coverage of culture-negative and fastidious organisms is warranted.

CONCLUSION: IIA, a rare diagnosis, most often presents with non-specific symptoms. Findings concerning for inflammatory aortitis should prompt broad evaluation of the patient’s histories to guide further diagnostic testing and imaging to evaluate for other large vessel involvement to guide further management.

ABDOMINAL PAIN IN THE SETTING OF MYELODYSPLASTIC SYNDROME

Abijha Boban¹; Moyan Sun²; Vikas Kilaru¹; Steven Barker¹. ¹Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; ²Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #4064875)

CASE: A 73-year-old man presented to the ED with a 2-day history of abdominal pain, nausea, vomiting, watery diarrhea, and a feeling of malaise. His past medical history includes chronic obstructive pulmonary disease, chronic kidney disease stage 2, hypertension, type II diabetes mellitus, myelodysplastic syndrome (MDS), and psoriasis. He was on cycle 4 of azacitidine for MDS but denies any previous adverse reactions to his infusions. Complete blood count showed hemoglobin 7.4, white blood cell count 2.3, platelets 68, and absolute neutrophil count 1100. CT abdomen and pelvis showed marked abnormal thickening localized to the cecum and a small segment of the terminal ileum without any perforation, abscess, or pneumatosis intestinalis. With a history of myelodysplastic syndrome, the differential was narrowed down to typhlitis. General surgery declined surgical intervention due to lack of perforations, abscess or bleeding. The patient remained on complete bowel rest, started on IV fluids, and was treated with piperacillin-tazobactam and metronidazole. The patient was also started on filgrastim per oncology recommendations. Patient improved and was discharged with 2 weeks of outpatient antibiotics.

IMPACT/DISCUSSION: Typhlitis (neutropenic enterocolitis) is a life-threatening diagnosis in an immunocompromised patient. It is known to have a mortality rate of 50% or higher. The symptoms that are associated with typhlitis can be misdiagnosed as bacterial colitis or inflammatory colitis. While CT is the gold standard, bedside ultrasound can be used to narrow down the differential quickly. An ultrasound would show circumcisional wall thickening with predominant mucosa, a finding that is characteristic of typhlitis.

The management of typhlitis is twofold. If without complication, a nonsurgical option involves broad-spectrum antibiotics, bowel rest, NG suction, IV fluids, nutritional support, and blood support, including PRBC and FFP. Antibiotics are recommended to be continued for 14 days after neutropenic recovery. In the setting of free perforation or persistent bleeding, surgery would be the best option. Since the management of typhlitis differs from the management of bacterial colitis, diverticulitis, or inflammatory colitis, correct diagnosis is important. This involves thorough history taking, including current medications and past medical history, as this will help narrow the differentials.

CONCLUSION: Recognizing neutropenia as the contributing factor to typhlitis is essential to treatment, as it requires management of the infection in conjunction with treatment of the neutropenia. Furthermore, understanding surgical versus nonsurgical approaches is paramount in achieving a successful recovery.

A BROKEN HEART CAUSED BY A POTENTIALLY AGGRESSIVE PHEOCHROMOCYTOMA

Harmeet Sohal¹; Chelsea Benmessaoud¹; Nosher Ali². ¹Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; ²Internal Medicine, Indiana University, Bloomington, IN. (Control ID #4065131)

CASE: We report the case of a 58 year old woman with a past medical history significant for hypertension, hyperlipidemia, obstructive sleep apnea, and type 2 diabetes mellitus who presents with complaints of episodic hypertension, diaphoresis, facial flushing, and a throbbing chest. Initial labs showed elevated troponin, hypokalemia, and leukocytosis. EKG showed ST elevation in leads 1-3, aVF, V3, V4. Patient underwent cardiac catheterization which found no significant coronary atherosclerotic disease. Echocardiogram revealed findings suggestive of Takotsubo cardiomyopathy, with an ejection fraction of 35%. Also known as stress-induced cardiomyopathy, this condition results in a transient left ventricular systolic dysfunction that can mimic an acute myocardial infarction.

Laboratory investigation of pheochromocytoma was initiated which revealed significantly elevated serum metanephrines (1100 pg/mL), normetanephrine (7666 pg/mL), total metanephrines (8766 pg/mL) and urine metanephrines (982 mcg/24hr), normetanephrines (3019 mcg/24hr) and total metanephrines (4001 mcg/24hr). Subsequent imaging revealed an asymmetric enlargement of the right adrenal gland measuring up to 5.2 cm. She was empirically started on prazosin and scheduled for Endocrinology evaluation. Testing for Multiple Endocrine Neoplasia was negative. Prazosin was held and she was started on phenoxybenzamine. She ultimately underwent surgical resection. Surgical pathology revealed pheochromocytoma with the potential for biologically aggressive behavior based on a pheochromocytoma of the adrenal gland scoring scale (PASS) score of 6.

IMPACT/DISCUSSION: This case adds to the body of literature describing the presentation and evaluation of pheochromocytoma. A systematic review published in the Journal of the Endocrine Society found that the incidence of pheochromocytomas and paragangliomas over the last 70 years ranged from 0.04 to 0.95 cases per 100,000 per year, with an upward trend over the years. While pheochromocytomas are quite rare, they are certainly important to include in the differential for patients presenting with episodic hypertension and symptoms suggestive of acute coronary syndrome. Although stress-induced cardiomyopathy secondary to a pheochromocytoma has been described before, it is an exceedingly rare presentation that may have devastating consequences if not identified and treated promptly, including arrhythmias and sudden cardiac death. The potential for the involvement of multiple organ systems requires a multidisciplinary approach to the management of patients with pheochromocytomas.

CONCLUSION: - Pheochromocytomas can result in a stress-induced cardiomyopathy that mimics an acute myocardial infarction.

- Patients should be started on an alpha adrenergic receptor blocker prior to beta blocker therapy to avoid unopposed alpha adrenergic activity.

ABSCESS-ING OVER YOU: HEPATIC ABSCESS FROM AN UNUSUAL CAUSE OF CHOLECYSTITIS

Emily Jezewski, Jess Dreicer. Internal Medicine, University of Virginia, Charlottesville, VA. (Control ID #4063850)

CASE: A 67-year-old woman presented with one-month of intermittent, sharp right upper quadrant (RUQ) pain with radiation to her right shoulder and fevers. Her primary physician ordered a magnetic resonance image (MRI) of the abdomen and pelvis (A/P), which demonstrated a liver mass and advised her to present to the hospital. On arrival she was tachycardic, normotensive, afebrile and reporting severe RUQ abdominal pain. Labs showed a leukocytosis to 13.75 K/UL, AST 36 U/L, and alpha fetoprotein <2ng/mL. The outside MRI A/P showed a large multiseptated peripherally enhancing cystic mass with poor visualization of the gallbladder. A contrasted computed tomography scan of the A/P at our hospital described the cystic mass as an abscess and characterized the gallbladder as adherent to the liver, suggesting xanthogranulomatous cholecystitis. Interventional radiology performed fluid drainage revealing purulent fluid from the abscess which grew Streptococcus anginosus and a Jackson-Pratt drain was left in place. The patient was started on intravenous (IV) ceftriaxone, vancomycin and oral metronidazole. The hepatopancreaticobiliary surgery team considered immediate cholecystectomy as treatment but elected for interval cholecystectomy given gallbladder adherence to the liver wall, inflammation and hepatic abscess. She was discharged with six weeks of IV ceftriaxone and oral metronidazole and plan for infectious disease follow-up.

IMPACT/DISCUSSION: Xanthogranulomatous cholecystitis (XGC) is an inflammatory process of the gallbladder that is often misdiagnosed as malignancy. This condition is driven by local inflammation via macrophages/fibroblasts. The inflammatory reaction trigger is unknown but thought to be related to extravasation of bile from ruptures of the gallbladder sinuses. Cases usually present with typical symptoms of acute cholecystitis including RUQ pain, nausea/vomiting, and a positive Murphy’s sign. Imaging findings demonstrate diffuse gallbladder wall thickening, intramural nodules, and a smooth gallbladder wall; these image findings are often also described in gallbladder malignancy. Up to 30% of patients with XGC have complications including gallbladder perforation, bile duct obstruction, and hepatic abscesses. The treatment is cholecystectomy. In cases with dense local adhesions or inflammation, cholecystectomies are usually open procedures. The recommendation is to perform surgery as soon as antibiotic therapy is finished, which in our case, this was a minimum of six weeks given the hepatic abscess formation.

CONCLUSION: - Xanthogranulomatous cholecystitis is a rare, benign disorder, often mistaken for malignancy, triggered by a local inflammatory process that is treated with cholecystectomy.

- Common complications of xanthogranulomatous cholecystitis include gallbladder perforation, bile duct obstruction and hepatic abscesses.

A CASE OF ANAPLASMOSIS-INDUCED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) SUCCESSFULLY TREATED WITH A NOVEL IMMUNOSUPPRESSIVE REGIMEN

Rebecca Kim, Madeline Miceli, Dalia Littman, Maya Rosenberg, David Kudlowitz. Internal Medicine, NYU Langone Health, New York, NY. (Control ID #4062082)

CASE: An 83-year-old male with a history of Lyme disease presented for 1 week of fever and malaise. He lives in upstate New York and frequently spends time outdoors. He was evaluated in clinic and was empirically treated for tick borne illness with cefuroxime, atovaquone and azithromycin, given a doxycycline allergy. His initial workup was notable for negative Anaplasma serology and buffy coat smear. Labs on hospital presentation revealed pancytopenia, acute kidney injury and elevated liver enzymes. For pancytopenia with fulfillment of HLH diagnostic criteria, he was treated with dexamethasone, intravenous immunoglobulin (IVIG), and anakinra. Repeat buffy coat smear was positive for Anaplasma. He was treated with doxycycline after undergoing desensitization. Upon improvement, HLH treatment was tapered. On day 2 of taper, he developed hemorrhagic shock. The original treatment plan was resumed with clinical improvement.

IMPACT/DISCUSSION: There are only 7 published cases of anaplasmosis-induced HLH. The diagnosis and management of this disease is therefore limited. We present an 8th case of anaplasmosis-induced HLH.

Diagnosis of anaplasmosis can be challenging, leading to treatment delay and poor clinical outcomes. PCR has excellent sensitivity and specificity during the first week of testing. Serology has a sensitivity of 84%, and can be negative early in the course of infection. Thus, a combination of PCR and serology is ideal for diagnosis. Blood smear can confirm diagnosis, but has a sensitivity range of 21-60%. In our case, serology and buffy coat smear on day 7 of symptom onset were negative, but repeat smear on day 12 was positive. Healthcare providers should have a high index of suspicion for tick-borne illnesses based on patient history and presentation. Appropriate diagnostic workup should be completed without delay in early initiation of antibiotics.

The HLH-94 induction therapy regimen includes etoposide and high dose steroids (HDS). Our patient was treated with a novel immunosuppressive regimen of HDS, IVIG and anakinra. This patient experienced clinical and laboratory rebound when this regimen was halted, with improvement upon resumption, suggesting a role for immunosuppressive therapy in this primarily immune-mediated process. Of the above 7 reported cases, less than 50% were treated with immunosuppression. With a rise in cases, rare sequelae of infection will become more common, creating a need for new therapeutic approaches.

CONCLUSION: - Anaplasmosis-induced HLH is rare but should be considered in cases of HLH due to unknown etiology, particularly in populations with a high incidence of tick borne disease.

- Repeat PCR and serology testing may be indicated if initial testing for Anaplasma is negative.

- There is a role for treatment with a novel immunosuppressive regimen, including HDS, IVIG and anakinra, in anaplasmosis-induced HLH.

A CASE OF ANTI-HMGCR IMMUNE-MEDIATED NECROTIZING MYOPATHY: ILLUSTRATING A RARE BUT SERIOUS SIDE EFFECT OF STATIN USE

Stefan Preisendörfer²; David Lacomis^1,3; Matthew N. Metzinger². ¹Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²Internal medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ³Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4064111)

CASE: A 68-year-old female with hypertension, hyperlipidemia and hypothyroidism presented with bilateral, proximal muscle weakness. Three months prior, she had developed weakness involving her bilateral thighs and shoulders with associated creatine phosphokinase (CPK) elevation. Despite discontinuation of atorvastatin, which she had been taking for 3 years without complications, her symptoms progressed leading to ambulatory dysfunction and prompting presentation to the ER. She denied associated muscle tenderness or recent infections.

On admission, she was found to be hypoxemic with an oxygen saturation of 83%. Physical exam revealed decreased strength involving her bilateral deltoids and biceps muscles (3/5) as well as her bilateral hip flexors (2/5) without associated tenderness, sensory deficits or distal muscle weakness. Laboratory testing was notable for CPK of 6722 U/L (normal <200 U/L), ALT 268 U/L and AST 212 U/L with normal ESR and CRP. Nerve conduction studies (NCS) and electromyography (EMG) as well as muscle biopsy were consistent with proximal-predominant necrotizing myopathy. Serum anti-3-hydroxyl-3-methylglutaryl coenzyme A reductase (anti-HMGCR) antibody levels were highly elevated (93 U/mL; normal <20 U/mL), later confirming a diagnosis of anti-HMGCR immune-mediated necrotizing myopathy (IMNM). The patient received 5 doses of intravenous immunoglobulin (IVIG) and was started on prednisone and methotrexate, leading to improvement in her muscle weakness with normalization of CPK as well as resolution of hypoxemia.

IMPACT/DISCUSSION: Statins constitute one of the most prescribed medicine classes in the US, with anti-HMGCR IMNM being an extremely rare but serious side effect. In contrast to other statin side effects, anti-HMGCR IMNM usually occurs after years of uncomplicated statin use, as seen in this case, and can even develop in patients who have discontinued statins years ago or never received statins. Notably, patients with anti-HMGCR IMNM require immunosuppressive therapy and fail to improve solely upon statin discontinuation, underscoring the importance of establishing a correct diagnosis.

This case demonstrates the potential severity of anti-HMGCR IMNM, with her symptoms not only being confined to proximal muscle weakness, but also affecting her respiratory mechanics. Rapid administration of IVIG and immunosuppressive therapy resulted in improvement within days, highlighting the role of immunosuppressive treatment.

CONCLUSION: Progressive muscle weakness with persistent CPK elevation despite discontinuation of statin therapy should raise suspicion for anti-HMGCR IMNM and prompt diagnostic work-up with EMG/NCS, muscle biopsy, and assessment of anti-HMGCR antibody levels. Treatment includes discontinuation of the offending statin and immunosuppressive therapy.

A CASE OF BRONCHOPULMONARY DYSPLASIA IN A PATIENT WITH PIK3CA-RELATED OVERGROWTH SPECTRUM (PROS)

Phillip L. Anjum¹; Niraj Gowda²; Darlington Pobee¹; Muhammad Naeem³; Micah Fisher². ¹Internal Medicine, Emory University, Atlanta, GA; ²Division of Pulmonary, Allergy, Critical, and SleepD Medicine, Emory University School of Medicine, Emory University School of Medicine, Atlanta, GA; ³Division of Cardiovascular and Thoracic Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4049976)

CASE: A 37-year-old male presented for lung transplant evaluation for end-stage COPD. He was admitted from clinic following a six-minute walk test where he desaturated to 72% O2 D. The patient reported he was born with cystic hygromas on his neck and chest that required surgical removal shortly after birth. He also reported persistent, progressive shortness of breath since childhood that had been diagnosed as asthma. He had previous PFTs showing severe air-flow-limitation, a CT chest with upper-lobe predominant “emphysema”, and a negative alpha-1-antitrypsin. He was diagnosed with severe emphysema despite his < 15 pack-year smoking history. The physical exam on admission was notable for right upper and lower extremity enlargement and café au lait spots. A CTA-thorax was obtained that showed emphysematous changes with scattered areas of ground glass in the lungs as well as a large left hemiazygos vein found to be continuous with the supra-hepatic IVC, and the pulmonary left venous structures were found to be continuous with the left atrium. PFTs confirmed a severe obstructive ventilatory defect. Congenital cardiology reviewed the patient’s imaging and surmised the large left hemiazygos vein to be a levo-atrial cardinal vein draining into the left upper pulmonary vein. Repeat A1AT testing was normal. Genetics evaluated the patient and identified his presentation as a segmental overgrowth syndrome, most consistent with PROS with severe bronchopulmonary dysplasia. The patient received a new home oxygen machine and was discharged safely to home with plans to follow up with pulmonology, congenital cardiology, genetics, and his primary care physician, as well as ongoing evaluation for lung transplantation.

IMPACT/DISCUSSION: PIK3CA-related overgrowth spectrum (PROS) is a collection of clinical syndromes caused by somatic, gain-of-function mutations in a single signaling pathway: phosphatidylinositol-3-kinase (PI3K). PROS presents with focal outgrowth of various limbs; the associated vascular malformations and bronchopulmonary dysplasia can be misinterpreted as alternate respiratory conditions in an adult patient. This patient’s progressive emphysema and hypoxemia was due to right to left shunt physiology—related to his venous malformations--that worsened with exertion. His degree of hypoxemia, however, was seemingly out of proportion to his anatomy. Additionally, his lung transplant status remains pending given the question of feasibility of a transplant in this patient. The primary treatment for PROS spectrum is supportive therapy.

CONCLUSION: Adult patients presenting with respiratory distress and atypical features, such as persistent and progressive symptoms inconsistent with common diagnoses like COPD/asthma, should prompt clinicians to consider rare syndromes like PROS, which may require additional resources for supportive therapy.

A CASE OF BRUGADA PATTERN UNMASKED BY ADRENAL INSUFFICIENCY

Priya Desai¹; Sharjeel Hassan². ¹Internal Medicine, Scripps Mercy Hospital San Diego, San Diego, CA; ²Internal Medicine, Scripps Health, San Diego, CA. (Control ID #4059794)

CASE: A 38-year-old cachectic woman with premature ovarian failure at age 32 was admitted to the intensive care unit due to encephalopathy and hypotension as low as 55/43 mmHg, following a brief cardiac arrest in the emergency department. A Brugada pattern was discovered on her electrocardiogram. She had hypokalemia to 2.8 mmol/L. Family members reported that she had a 4 month history of unexplained weight loss, nausea, vomiting, generalized pain, worsening skin hyperpigmentation, and anorexia. Stress dose dexamethasone was initiated for suspected adrenal crisis. Serum cortisol and morning aldosterone levels were undetectable, with a plasma renin activity level elevated at 29 ng/mL/hr. While on stress dose steroids, she developed significant hyperglycemia to 396 mg/dL, necessitating the use of an insulin drip. TSH was elevated, with a normal free T4 level. Subsequent investigations revealed markedly elevated 21-hydroxylase, thyroid peroxidase (TPO), and glutamic acid decarboxylase (GAD) antibodies. She was diagnosed with primary adrenal insufficiency (AI), Hashimoto’s thyroiditis, and latent autoimmune diabetes mellitus. These findings were collectively indicative of polyglandular autoimmune syndrome type 2. Computed tomography of the adrenal glands was normal. Dexamethasone was changed to hydrocortisone, and fludrocortisone was added. Genetic testing returned positive for an abnormal cardiac sodium channel gene, and an implantable cardioverter-defibrillator (ICD) was placed for secondary prevention of sudden cardiac death.

IMPACT/DISCUSSION: Traditionally, primary AI is associated with hyperkalemia, but in this case, it coexisted with hypokalemia. Severe anorexia, resulting in a prolonged malnourished state causing body depletion of potassium stores, is believed to have played a significant role, likely compounded by gastrointestinal potassium losses due to vomiting. In patients with primary AI, negative feedback causes the release of high levels of corticotropin releasing hormone (CRH), which then causes increased production of a prohormone proopiomelanocortin (POMC). POMC is then cleaved into melanocyte stimulating hormone (MSH) and adrenocorticotropin (ACTH). High levels of MSH cause progressive skin darkening, and high levels of POMC and its derived peptide MSH both cause significant appetite suppression via anorexic effects in the brain. Furthermore, Brugada pattern is provoked by electrolyte derangements, particularly hyperkalemia, as well as fever and certain antiarrhythmic medications.

This case underscores the importance of not disregarding the possibility of primary AI and Brugada pattern in the setting of hypokalemia.

CONCLUSION: 1. While Brugada pattern and adrenal insufficiency are usually associated with hyperkalemia, coexisting anorexia can precipitate hypokalemia instead.

2. Autoimmune adrenal insufficiency, thyroid disease and diabetes mellitus are the hallmark features of polyglandular autoimmune syndrome type 2.

A CASE OF CARDIAC ARREST AND PERICARDITIS FOLLOWING LEADLESS PACEMAKER PLACEMENT IN AN ELDERLY PATIENT

Jaeine Lee²; Fadila Noor²; Fairouz Hasselmark¹. ¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Internal Medicine Residency, Nuvance Health, Poughkeepsie, NY. (Control ID #4027802)

CASE: An 89-year-old female with history of atrial fibrillation, coronary artery disease, and dementia was admitted for recurrent syncope and falls secondary to sinus bradycardia and sinus arrest. She was not on rate or rhythm control agents due to her recurrent symptoms. Initially, she exhibited positive orthostatic vital signs, bradycardia in 40s, and EKG notable for sinus bradycardia with intermittent 2:1 AV block with junctional escape rhythm. Given her low activity level and underlying dementia, a leadless pacemaker was placed to prevent further episodes. After the procedure, she had multiple presyncopal episodes associated with hypotension. EKG taken 21 hours post-procedure showed findings consistent with pericarditis. She had a subsequent 30-second PEA cardiac arrest 53 hours post-procedure. She was successfully resuscitated only with chest compressions. Transthoracic echocardiogram performed after resuscitation showed a small circumferential pericardial effusion without evidence of tamponade. She was started on colchicine for the management of pericarditis and was discharged 5 days later without further complications.

IMPACT/DISCUSSION: Leadless pacemaker (LP) has a comparable level of safety and efficacy as conventional pacemakers. However, some studies indicate that the short-term complication rate was slightly higher, mostly related to the implant procedure. Although rare, pericarditis and cardiopulmonary arrest can occur in 0.2%, pericardial effusion in 0.96%, and syncope/presyncope in 0.2% of the patients. These higher risks of short-term complications in the LP system can be attributed to the implanter learning curve. Complications decrease with implanter experience, and with preoperative preparation such as a CT scan to assess venous approach, cardiac structure, and implantation location. Risk factors for cardiac injury in LP procedures include age above 85, body mass index less than 20 kg/m², female gender, and comorbidities such as chronic heart failure, dialysis, hypertension, and lung disease. Elderly patients are at a higher risk given they are more likely to have comorbidities, cognitive impairment, anatomical variations and poor nutritional status. Despite a higher risk in the elderly, the advantages of LP, shorter procedure duration, shorter hospital stay post-procedure, and no mobility restrictions, potentially outweigh the risks. This is especially beneficial to patients with dementia who cannot comply with post-procedural instructions. In this case, the patient was offered LP given her age and comorbidities but experienced rare but critical complications. Fortunately, the complications manifested clinically, allowing for timely detection of pericarditis, which was sufficiently managed only with medical management.

CONCLUSION: LP is an important treatment option for the elderly population but given the high rate of immediate postoperative period complications, careful pre- and post-procedure imaging to guide and assess early complications would be crucial.

A CASE OF CARDIOGENIC SHOCK DUE TO ISCHEMIA WITH NO OBSTRUCTIVE CORONARY ARTERY DISEASE (INOCA)

Saher Siddiqui¹; Renato Cerna-Viacava¹; Ryhm Radjef². ¹Internal Medicine, Henry Ford Hospital, Detroit, MI; ²Clinical and Non-Invasive Cardiology, Henry Ford Hospital, Detroit, MI. (Control ID #4063952)

CASE: A 25-year-old white gentleman with a past medical history of a traumatic brain injury after a motor vehicle accident and previous tobacco use presented to the Emergency Department with a chief compliant of subacute dyspnea on exertion associated with palpitations and nausea with vomiting. He was initially found to be hemodynamically stable and tachycardic with workup showing an elevated BNP, mildly elevated troponins and electrocardiogram demonstrating sinus tachycardia. His transthoracic echocardiogram (TTE) revealed a newly decreased ejection fraction (EF) of 15%, a large 3.3 cm left ventricular (LV) thrombus, right ventricular dysfunction, and estimated pulmonary artery pressure of 33 mmHg. He quickly decompensated and required increasing oxygen supplementation and invasive ventilation, as well as vasopressor and inotropic support. His labs were suggestive of end-organ dysfunction including high anion gap metabolic acidosis, azotemia, transaminitis, abnormal coagulation profile, severely elevated BNP and elevated lactate. Following stabilization, he underwent a Cardiac MRI (cMRI) that showed a severely dilated and hypokinetic LV, decreased perfusion of the basal anterior wall, transmural late gadolinium enhancement in the basal anterior and antero-septal wall with central low sign suggesting acute necrosis and/or microvascular obstruction. Due to these results, he underwent a left heart catheterization, which showed non-obstructive coronary artery disease and no signs of an acute plaque rupture or thrombus.

IMPACT/DISCUSSION: INOCA is caused by a lack of perfusion into the myocardium with normal or near normal coronary arteries shown in coronary angiography. This condition has several potential etiologies including coronary vasospasm, spontaneous coronary artery dissection, microvascular dysfunction and coronary artery embolism (CE). CE is a rare cause of INOCA and has a prevalence of around 3%. According to the criteria proposed by Shibata et al, this would be a case of probable CE based on two minor criteria: less than 25% of coronary artery stenosis and evidence of embolic source based on TTE, transesophageal echocardiography, computed tomography, or cMRI.

CONCLUSION: Myocardial infarction or ischemia in the absence of obstructive coronary artery disease (INOCA) is still under-diagnosed, and its complications can be devastating. CE is a rare cause of INOCA, and should be part of the differential diagnosis, especially in the presence of embolic risk factors.

A CASE OF COMMON VARIABLE IMMUNODEFICIENCY (CVID) DIAGNOSED UNEXPECTEDLY AMIDST NUTRITIONAL DEFICIENCIES AND NEW BICYTOPENIA

Matthew E. Glasgow¹; Elizabeth McDonald²; David Haak¹; John Gerstenberger¹. ¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²internal medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4062287)

CASE: A previously healthy 29-year-old male presented with a three-day history of vomiting and acute-on-chronic nausea. The emesis was non-bloody and non-bilious, accompanied by an inability to tolerate oral intake and subjective fevers. The patient reported months of preceding symptoms, including easy bruising, nausea, and bleeding gums. He denied any history of prior sinopulmonary or other infections.

In the ED, vital signs were remarkable for fever (38.5°C) and tachycardia (108 bpm). Examination revealed pallor, scattered ecchymoses, gingivitis, and mild epigastric abdominal pain to palpation. Laboratory results showed leukopenia and neutropenia (1.43 k/uL leukocytes, 0.4 k/uL neutrophils), and anemia (Hgb 8.3 g/dL). An abdominal CT scan was unremarkable. The patient was admitted for neutropenic fever and evaluation of new bicytopenia.

A diagnostic workup evaluated for nutritional deficiencies, malignancies (leukemia, myelodysplastic syndrome, lymphoma), infections (HIV, parvovirus, EBV), and autoimmune diseases (SLE). Testing revealed deficiencies in copper, iron, and vitamins B1, B12, A, D, and B6. Further evaluation was directed towards understanding the etiology of multiple micronutrient deficiencies. A celiac panel showed low IgA levels but negative tTG antibodies. Subsequent quantitative immunoglobin levels were ubiquitously low (IgA 34 mg/dL, IgG 489 mg/dL, IgM 18 mg/dL). After micronutrient supplementation, his bicytopenia began to resolve, and he was discharged home. Hypogammaglobulinemia persisted on repeat evaluation. An immunization challenge demonstrated a deficient response, and he was diagnosed with CVID.

IMPACT/DISCUSSION: Classically, patients with CVID present with recurrent sinopulmonary infections. The patient’s presenting syndrome of cytopenias due to nutritional deficiencies in the absence of a history of recurrent infections is an uncommon presentation of CVID. The association between CVID and micronutrient deficiencies is well documented. However, these cases are typically associated with chronic diarrhea due to CVID enteropathy or infections such as chronic giardiasis, norovirus, and small intestinal bacterial overgrowth. Interestingly, the patient's only gastrointestinal symptom was acute-on-chronic nausea which had resolved at the time of follow-up. Endoscopic evaluation is being considered to assess for CVID enteropathy but has not been completed as of the writing of this vignette. This case adds to the literature regarding uncommon presentations of CVID and its association with enteropathies and nutritional deficiencies.

CONCLUSION: This case emphasizes the importance of keeping a broad differential in patients with new cytopenias. Additionally, it highlights the importance of consideration of CVID in the differential diagnosis for nutritional deficiencies, even in patients who lack a typical history of recurrent infections. In this case, low total IgA on the celiac panel was an important clue to the unexpected diagnosis of CVID.

A CASE OF DISSEMINATED BLASTOMYCOSIS IN AN IMMUNOSUPPRESSED PATIENT

Vanessa Murray. Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4065014)

CASE: 65M with a history of NICM s/p OHT (2015), T2DM, CKD3 presents to an academic medical center in the Mid-Atlantic. He reported 1 week of shortness of breath, fevers/chills, productive cough, and stabbing left-sided abdominal pain. He denied chest pain, GI/GU symptoms, rash, joint pain. He is adherent to his immunosuppression medications. He lives alone in a rural area with no recent travel outside of the Mid-Atlantic, sick contacts, outdoor or animal exposures. On arrival he is found to be febrile to 100.5F with other vitals including HR 106, RR 28, BP 160/78, and SpO2 of 94% on 4L NC. Labs notable for leukocytosis, chronic anemia, and AKI on CKD. Respiratory viral panel and legionella urine negative. Chest x-ray showed a RUL opacity, CT chest/abdomen/pelvis revealed right upper lobe consolidation and numerous round hypodense lesions throughout the spleen. Vancomycin, cefepime, and azithromycin were started for pneumonia. Despite antibiotics, 24H later he experienced worsening respiratory distress requiring intubation and ICU transfer with course further complicated by 4-pressor septic shock. In this setting antibiotics were broadened to meropenem, and additional workup was sent including tracheal aspirate and testing for fungal/mycobacterial infections. From this workup, urine Blastomyces antigen resulted positive, at which point he was started on amphotericin B. The diagnosis was confirmed when tracheal histopathologic staining revealed fungal organisms morphologically consistent with Blastomyces, further confirmed with ribosomal DNA sequence analysis on sputum sample. A splenic lesion was sampled by Interventional Radiology with histopathology again revealing Blastomyces, confirming disseminated infection. He was maintained on amphotericin B for 4 weeks with eventual clinical improvement, then transitioned to itraconazole. Plan at discharge was itraconazole therapy for at least one year with possible extension of therapy due to need for ongoing immunosuppression.

IMPACT/DISCUSSION: This case underscores the importance testing for endemic mycoses in immunocompromised patients presenting with severe pneumonias who are not improving despite broad bacterial coverage. Immunocompromised patients without evidence of CNS disease are typically treated with Amphotericin B for 1-2 weeks (or until clinically improving), then itraconazole for at least 12 months, though some patients require life-long therapy. Finally, this case highlights a rare manifestation of disseminated blasto: splenic lesions.

CONCLUSION: 1. Maintain a high index of suspicion for endemic mycoses in immunosuppressed patients. 2. Screen with urine antigen testing, confirm diagnosis with fungal culture or histology; initial treatment with Amphotericin B. 3. Recognize splenic lesions as a rare but possible site of disseminated blastomycosis.

A CASE OF DRUG RASH WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS) MASQUERADING AS A VIRAL EXANTHEMA

Ryan Ripperdan¹; Katherine Frishe². ¹Internal Medicine, Keck Hospital of USC, Los Angeles, CA; ²Los Angeles General Medical Center, Los Angeles, CA. (Control ID #4065115)

CASE: A 32-year-old female with a history of epilepsy presented with three days of body rash and subjective fevers. The patient first noted a red, painful, maculopapular rash around her scalp, which then spread downward to involve her face, neck, torso, and extremities.

On presentation, the patient reported taking levetiracetam that was newly prescribed two months prior, in addition to a stable dose of valproic acid prescribed by her neurologist in Peru before moving to the US one year prior. She denied sick contacts, new sexual partners, weight loss, cough, or diarrhea. Her vital signs were within normal limits and her CBC and CMP were unremarkable.

The dermatology and ID services were consulted, who advised a broad infectious workup for a presumed a viral exanthema. The patient then developed fevers, along with transaminases to the 300’s and an absolute eosinophil count of 900. Concurrently, the infectious workup was unrevealing, including negative MMR serologies. The concern for DRESS then rose, levetiracetam was held, and empiric intravenous glucocorticoids were given. The patient defervesced and her transaminases and eosinophilia decreased markedly thereafter. The patient was discharged on an oral glucocorticoid taper with close follow-up.

IMPACT/DISCUSSION: DRESS is a drug-induced hypersensitivity reaction characterized by a diffuse rash, fever, lymphadenopathy, visceral organ involvement, and hematologic abnormalities. The culprit medication is often an anti-epileptic, sulfonamide, or allopurinol, although other medications have been implicated; interestingly, levetiracetam is rarely attributed as a cause.

Given the constellation of findings and often remote temporal relation with the offending medication, prompt evaluation for other differentials including viral infections, malignancy, and rheumatologic disease is indicated. Dermatology consultation is advised for skin biopsy, as histologic findings can support the diagnosis. The RegiSCAR score can also aid in diagnosis but should not preclude empiric treatment if clinical suspicion is high.

Cessation of the offending agent and glucocorticoid therapy are the mainstays of treatment, with the use of topical versus systemic therapy dependent on the degree of visceral organ involvement. Other immunosuppressive agents have been proposed, but their efficacy has only been demonstrated in isolated case reports. Even the benefit of glucocorticoids for isolated hepatic involvement is not well supported, with current guidelines being based mainly on expert opinion. As such, further work exploring the management of DRESS is needed.

CONCLUSION: DRESS is a drug-induced hypersensitivity reaction characterized by a diffuse cutaneous eruption, fever, lymphadenopathy, hepatic involvement, and eosinophilia, with anti-epileptics as the most common offending agents. Prompt evaluation for other systemic conditions is advised while also maintaining a low threshold to initiate empiric immunosuppressive therapy given the syndrome’s high mortality rate.

A CASE OF ENIGMATIC ANEMIA

Devika Das¹; Lai Jiang²; Ioannis Kournoutas¹; Robert A. Churchill³; Dylan J. Goings¹; Michael Mueller⁴. ¹Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Anesthesiology, Mayo Clinic Minnesota, Rochester, MN; ³Mayo Clinic Alix School of Medicine, Rochester, MN; ⁴General Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4063901)

CASE: A 64 year old female with no documented medical history presented to the ED with palpitations. She was mildly tachycardic upon presentation, but hemodynamically stable and requiring 1 L of oxygen. Exam revealed palmar and conjunctival pallor without icterus and tenderness of the bilateral ankles. A few weeks prior to presentation, she started feeling weak and had flu-like symptoms. She denied hemoptysis, hematochezia, unintentional weight loss, or melena. She had been eating very poorly. She was born in Mexico, but had spent most of her adult life in the U.S. and had not seen a doctor in two decades. She reported being told she was anemic in the past, but no family history of anemia or malignancy.

Her initial evaluation revealed a severe microcytic anemia with a hemoglobin of 3.1 g/dL with no prior labs to compare to. Her platelet and leukocyte counts, liver function tests, and kidney function testing were within normal limits. Initial peripheral smear revealed anisocytosis and polychromasia but no evidence of hemolysis. Her reticulocyte index was found to be hypo-proliferative at 0.38. LDH was mildly elevated, but haptoglobin and total bilirubin were within normal limits. Her direct antiglobulin test was negative. Celiac serologies were negative with a normal ESR and TSH. Zinc, copper, vitamin B12, lead, and folate levels were normal. Her ferritin was found to be low at 6 mcg/L with a TIBC of 7%. CT Scan showed diverticulosis. Fecal occult blood testing and H. pylori testing were negative. She tested negative for Hepatitis B, C, and HIV. Parvovirus B19 IgG antibody returned positive with an equivocal IgM antibody.

She was transfused with 5 units of blood and received iron sucrose transfusions during her hospitalization with appropriate response and resolution of her symptoms. An EGD and colonoscopy were scheduled in the outpatient setting as well as follow-up with Hematology.

IMPACT/DISCUSSION: This was a case of a hypo-proliferative anemia attributed to likely parvovirus B19-induced pure red cell aplasia (PRCA) in the background of chronic iron deficiency anemia and diverticulosis given the patient’s recent flu-like symptoms and arthropathy. Parvovirus B19 is thought to cause PRCA through destruction of proerythroblasts via attachment to the blood group P antigen receptor. PRCA usually occurs insidiously, and predominantly in patients with pre-existing hematologic disorders or immunocompromising conditions. Diagnosis can be made with Parvovirus B19 DNA PCR, serologic testing, and strong consideration for bone marrow biopsy in all cases of PRCA.

CONCLUSION: Acquired PRCA should be suspected in patients with isolated anemia with severe reticulocytopenia and severe anemia without a clear etiology. Causes of acquired PRCA include drugs, infections, immune disorders, neoplasms, and pregnancy.

A CASE OF ESCITALOPRAM INDUCED SIADH

Eyrica Sumida²; Joseph Lee¹; Yusuke Hirao¹; Ronald Pangilinan³. ¹Internal Medicine, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, HI; ²John A. Burns School of Medicine, University of Hawai'i at Manoa, Honolulu, HI; ³Kuakini Medical Center, Honolulu, HI. (Control ID #4063328)

CASE: An 88 year old male with a past medical history of follicular lymphoma and anxiety presented with a three week history of dizziness and weakness. Three months prior to admission, the patient was found to have follicular lymphoma recurrence in his cervical lymph nodes. He was started on rituximab-cyclophosphamide-doxorubicin-vincristine-prednisone (R-Mini-CHOP) chemotherapy with his last dose given two months prior to admission. Five days prior to admission, he was started on escitalopram 5 mg due to anxiety. He also self initiated a low sodium and fluid diet. His daughter noted mild cognitive changes such as memory deficits and slowed thinking over several days prior to admission. The patient denied fever, chills, headache, seizures, nausea, muscle aches, and salt craving.

On presentation, the patient’s physical exam was significant for orthostatic hypotension. He was oriented to person, place, and date, and his neurologic exam was normal. Baseline laboratory testing showed a serum sodium 117 mmol/L, BUN 11 mg/dL, creatinine 1.1 mg/dL, serum osmolarity 242 mOsm/kg, urine osmolarity 309 mmol/kg, and urine sodium 90 mmol/kg. His other serum electrolytes and glucose were normal except for mild hypochloremia. Thyroid-stimulating hormone and morning cortisol were normal. Orthostatic hypotension and hyponatremia were refractory to an initial 2L bolus of normal saline.

The escitalopram was held, and he was treated initially with multiple 100 mL boluses of 3% saline with no change to serum sodium. Eventually, he was given continuous infusions of 3% saline in addition to a 1L fluid restriction, which improved his sodium slowly to 120 mmol/L. On day three of admission, his sodium recovered to 127 mmol/L, so the 3% saline was discontinued and he was started on oral salt tablets daily.

IMPACT/DISCUSSION: The presentation of hyponatremia can range from asymptomatic to nausea and vomiting to seizures and coma. In our case, multiple etiologies of hyponatremia were possible; however, his persistent hyponatremia despite volume repletion and characteristic urine studies suggested a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Hyponatremia is a well-known but rare side effect of selective serotonin reuptake inhibitors (SSRIs), especially in newer SSRIs such as escitalopram. There have been less than 20 cases of escitalopram-induced SIADH in the literature. The proposed mechanism of SSRI-induced SIADH is serotonin-mediated stimulation of antidiuretic hormone, which results in inappropriate reabsorption of free water in the collecting duct. Onset of hyponatremia is proposed to occur within days to months of starting the medication. This case demonstrates a rare example of SIADH caused by escitalopram, which is often considered a safer SSRI.

CONCLUSION: Escitalopram is a rare cause of SIADH and can occur within one week of starting the medication

Hyponatremia that is refractory to volume resuscitation should increase the suspicion for SIADH

A CASE OF GENERALIZED LYMPHADENOPATHY WITH TWO "NEGATIVE" BIOSIES

Robert Short¹; Siavash Zamipour²; Alexander Conway¹; Aylin Ulku¹. ¹Medicine, University of California San Francisco, San Francisco, CA; ²University of California San Francisco, San Francisco, CA. (Control ID #4061083)

CASE: A 78-year-old woman with a remote history of breast cancer presented with three months of generalized lymphadenopathy and two month of night sweats, fatigue, and anorexia. She was seen by her PCP prior to admission and was referred to the emergency department for serum Na of 116 and WBC of 32.6.

Ten weeks prior to admission, the patient underwent FNA of a right axillary lymph node which showed “scant sample with heterogenous lymphocytes” without "immunohistochemical findings of carcinoma." Two weeks later, a core biopsy of an additional axillary node showed zonal necrosis and histiocytic inflammation suggestive of necrotizing granulomatous lymphadenitis, with no carcinoma identified; stains for fungal and AFB stains were negative.

She took no medications or supplements and had no sick contacts. She had never smoked. Family history was non-contributory. The patient was a retired English professor. She was born and raised in South Africa, with recent travel to Greece and Italy. She had no exposures to livestock or other animals.

Physical examination revealed frail appearance, tachycardia, enlarged, non-tender lymph nodes occipital, cervical, supraclavicular, axillary regions, and lower extremities with petechiae.

On admission, CRP and ESR were 126 and 67, respectively. Blood cultures, serologies for HIV, hepatitities, endemic mycoses, and tuberculosis were negative. Peripheral blood flow cytometry was normal. CT chest, abdomen and pelvis showed extensive lymphadenopathy involving the mediastinum, bilateral hila, bilateral axilla, retroperitoneum, periportal region, pelvis, as well as mild splenomegaly and multiple pulmonary nodules. Serum EBV DNA was 48,209 IU/mL, with positive EBV IgM and IgG antiboties.

The patient ultimately underwent excisional LN biopsy, which showed mature B cell lymphoma. She was promptly started on rituximab, with final pathology pending.

IMPACT/DISCUSSION: This case illustrates the poor sensitivity of FNA[1] in the diagnosis of lymphoma. Single core biopsy is more sensitive,[2] but excisional lymph node biopsy or multiple core biopsies are preferred for proper diagnosis of lymphoma.[3] Despite initially negative pathology on single FNA and core biopsies, our team maintained a high index of suspicion for lymphoma in this patient, prompting eventual excisional biopsy which finally yielded the previously elusive diagnosis. Further, our broad infectious, rheumatologic and oncologic differential diagnosis for generalized lymphadenopathy led us to diagnose concomitant EBV viremia.

CONCLUSION: If excisional biopsy had been performed rather than FNA in the initial outpatient workup, this patient would likely have been diagnosed 10 weeks sooner. By the time of our evaluation, the patient was experiencing multiple complications from bulky lymphadenopathy, such as severe hyponatremia and broncho-vascular compression leading to respiratory failure. In the furture, we will prioritize excisional lymph node biopsy for patients in whom we suspect lymphoma.

A CASE OF GROWING GRANDGORE

Dier Hu¹; Ayesha H. Sundaram¹; Jordan Cahn¹; Linda Shipton². ¹Internal Medicine, Cambridge Health Alliance, Cambridge, MA; ²Infectious Diseases, Cambridge Health Alliance, Lincoln, MA. (Control ID #4062429)

CASE: We present the case of a male in his 50s with two months of generalized pruritus, malaise, light colored stools and bilateral hearing loss and tinnitus. He was hospitalized due to mixed-pattern liver injury with peaks of ALT 1309 U/L, AST 520 U/L, alkaline phosphatase 1018 U/L, and total bilirubin 4.8 mg/dL, mostly direct. He was tested for viral hepatitis, autoimmune, toxin mediated, and structural causes of liver injury which were unremarkable. The etiology of liver injury remained unclear in the hospital, though after discharge, a slightly elevated CMV IgM antibody prompted a referral to the infectious disease clinic. At follow-up with the infectious disease physician, the patient endorsed two months of mental fog, flickering lights in peripheral vision, and hair loss in addition to symptoms described at hospitalization. He also disclosed oral and anal sex with a new partner prior to symptom onset. Exam was notable for several painless ulcerations on the posterior oropharynx and tongue, prompting testing for gonorrhea/chlamydia, HIV, HSV, MPox, and syphilis. Only the treponemal antibody was positive with an RPR of 1:512. A lumbar puncture was offered for further evaluation of neurosyphilis, which the patient declined. The presence of otic and ocular symptoms were sufficient to treat for neurosyphilis. Post-treatment RPR titer decreased and transaminases normalized. Everything but the otic symptoms have resolved. He and his partner are currently undergoing surveillance post-treatment.

IMPACT/DISCUSSION: Often dubbed the “great masquerader,” syphilis can present with a wide array of clinical manifestations, often leading to delay in identifying the disease. Reported cases of syphilis in the United States have risen 74% from 2017 to 2021 and continue to increase, highlighting the importance of a high index of suspicion and a thorough sexual history. Our patient underwent a broad hepatitis workup during his hospitalization with no consideration of syphilis. It was later determined that his oral ulcers, malaise, hair loss, hepatitis, brain fog, ocular, and otic symptoms were all manifestations of syphilis. Syphilitic hepatitis is a rare complication presenting with a cholestatic pattern of liver enzyme abnormalities and positive syphilis diagnostics in the absence of alternative causes. It is also important to note that while neurosyphilis can vary in presentation, otic and ocular syphilis are diagnostic of and should be treated as neurosyphilis. Extragenital chancres should always be investigated if thought to be a possible site of inoculation.

CONCLUSION: This rare case demonstrates syphilitic hepatitis with neurosyphilis in an immunocompetent patient, highlighting the importance of a differential inclusive of syphilis.

A CASE OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS TRIGGERED BY EHRLICHIA CHAFFEENSIS

Wint Yan Aung¹; Margaret Locke¹; Lilly Hou^3,1; Maria Nieto². ¹Internal Medicine, Northwell Health, New Hyde Park, NY; ²Northwell Health Center for Advanced Medicine,, RJ Zuckerberg Cancer Center, New Hyde Park, NY; ³Department of Medicine, Northwell Health, New Hyde Park, NY. (Control ID #4055298)

CASE: A 30-year-old male with no known past medical history presented with fever, chills, diarrhea, and night sweats. Laboratory investigations revealed pancytopenia with severe thrombocytopenia (plt 5000). Imaging studies showed bilateral perinephric stranding and gallbladder wall thickening; however, patient did not have clinical signs of pyelonephritis or acute cholecystitis. Despite being started on broad-spectrum antibiotics, his condition deteriorated the next day. He developed septic shock and multisystem organ failure, requiring vasopressor support. His clinical picture including an extremely high ferritin (>60,000) and H-score over 90% raised concerns for hemophagocytic lymphohistiocytosis (HLH).

Considering patient’s outdoor construction occupation, season, and geographical location, broad-spectrum coverage was expanded to cover meningitis and tick-borne illnesses. Treatments included vancomycin, ceftriaxone, acyclovir, atovaquone and azithromycin for babesiosis, doxycycline for anaplasmosis and tick-borne etiologies. A bone marrow biopsy and lumbar puncture were performed. Due to continued rise in ferritin, persistent fevers, cytopenia, and hypertriglyceridemia (400), empiric treatment for HLH was initiated with etoposide and dexamethasone.

He showed significant clinical improvement. Infectious work up revealed positive blood Ehrlichia chaffeensis PCR, which was suspected to be the primary trigger for HLH. Notably, bone marrow biopsy indicated presence of histiocytes but did not show evidence of hemophagocytosis.

IMPACT/DISCUSSION: HLH is a rare but potentially fatal syndrome that is often challenging to diagnose particularly when associated with uncommon triggers like tick-borne illnesses. Current literature documents about 50 HLH cases secondary to Ehrlichiosis. Ehrlichia chaffeensis which primarily infects monocytes, a cell type implicated in HLH pathogenesis, can induce an excessive inflammatory response, mimicking a septic shock like picture. Most of these cases required initiation of HLH-94 protocol in addition to doxycycline. The rapid progression of the patient's symptoms from initial presentation to multi-organ failure and the eventual improvement with treatment of HLH and underlying infection emphasize the importance of early recognition and treatment.

CONCLUSION: It is important to recognize HLH in patients presenting with severe systemic inflammatory responses, especially when conventional treatments fail to show improvements. This case highlights the need for increased awareness of tick-borne diseases as potential triggers for HLH. Early identification of HLH is crucial for effective management and improved outcomes.

A CASE OF LARGE B-CELL LYMPHOMA WITH SVC SYNDROME THAT REQUIRED MECHANICAL VENTILATION AND ECMO.

Syed Muhammad Hussain Zaidi²; Mishouri Paul¹; Prodip Paul¹; Koushik Paul³. ¹Medicine, Geisinger Community Medical Center, Scranton, PA; ²Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ³Geisinger Health, Danville, PA. (Control ID #4062078)

CASE: A 25-year-old male with a past medical history of tobacco and alcohol abuse presented to the emergency room with complaints of shortness of breath, bilateral upper extremity, and neck swelling. He also had weight loss, dysphagia, and bluish discoloration on his chest. Lab works revealed hypercalcemia, hypokalemia, and elevated LFTs. A CT chest with IV contrast showed a large mediastinal mass measuring 22 X 12 X 20 cm with compression of the heart, airway, and vessels consistent with superior vena cava (SVC) syndrome. The mass encased the upper trachea and left hilum. Due to progressive respiratory failure secondary to SVC syndrome, he was mechanically ventilated. Bronchoscopy and endobronchial ultrasound (EBUS) showed tracheal, airway, and SVC compression. Biopsy from the mediastinal lymph node and mass was obtained. His scrotal ultrasound did not show a scrotal mass. CA-125, beta-hCG, and alpha-fetoprotein were normal. Due to compression to SVC and myocardial tissue evident on imaging and hemodynamic instability, he started requiring escalating vasopressor support; eventually it was decided to initiate extracorporeal membrane oxygenation (ECMO) for worsening hemodynamic instability and circulatory collapse and the patient was sent to a tertiary care center. The biopsy result was positive for Large B cell Lymphoma.

IMPACT/DISCUSSION: SVC obstruction usually is a complication of malignant tumors accounting for 78 to 93% of cases. Other etiologies include aortic aneurysm, or thrombosis secondary to indwelling central venous catheters or leads from defibrillators and pacemakers. Malignant tumors include lung and cardiac tumors, thymomas, hematologic malignant neoplasms, and metastatic cancers of the breast, testicle, and colon. In our patient, the mediastinal mass causing SVC syndrome was identified based on symptoms and CT scan. Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) may be the first diagnostic procedure in patients with suspected mediastinal lymphadenopathy. Our patient underwent bronchoscopy and EBUS with mediastinal lymph node sampling and the biopsy result was positive for B-cell lymphoma. In severe, life-threatening symptoms, such as cerebral and laryngeal edema, or hemodynamic instability, surgical intervention may be required for immediate treatment of symptoms. Our patient was transferred to a tertiary care center for extracorporeal membrane oxygenation due to hemodynamic instability and surgical intervention due to the severity of symptoms.

CONCLUSION: SVC syndrome as an initial presentation of B-cell lymphoma is relatively rare, and potentially a life-threatening condition. Clinicians should be mindful of the presentation. It is crucial to recognize and diagnose this condition in time so that appropriate treatment can be initiated in time.

A CASE OF LATE-STAGE AMYOTROPHIC LATERAL SCLEROSIS WITH AN INITIAL PRESENTATION OF DYSPHAGIA, SEVERE MALNOURISHMENT, AND RASH

Caroline Casper¹; Aditya Joshi²; Zach LeBaron¹; Brady Dennison¹; Mark MacElwee¹. ¹School of Medicine, Creighton University School of Medicine, Omaha, NE; ²Internal Medicine, Creighton University School of Medicine Phoenix Health Sciences Campus, Phoenix, AZ. (Control ID #4016307)

CASE: A 65-year-old female presented to the emergency department due to severe abdominal pain and a 12-month history of worsening dysphagia. She endorsed associated dysarthria and a 100-pound weight loss in the past year. The patient also reported skin sensitivity. On physical exam, she appeared severely cachectic with a BMI of 13 and had a well-demarcated erythematous rash on her face, chest, and neck. Autoimmune workup (ANA, anti-CCP, aldolase, anti-Jo-1, anti-SCL-70) was negative. Vitamin B12, folate, and TSH were within normal limits. RPR was nonreactive. A swallow study showed tracheal aspiration with thin and thick liquids. A brain MRI showed chronic microvascular disease, unchanged from one year prior.

Upon further neurological examination, brisk reflexes, and weakness in upper and lower distal extremities were noted. Atrophy of bilateral intrinsic hand muscles, and tongue fasciculations were seen. A clinical diagnosis of amyotrophic lateral sclerosis (ALS) was made.

The patient was started on enteral nutrition, and electrolytes and vitamins were replaced. Riluzole was not started due to the advanced disease progression. Over the course of her hospital stay, her rash began to improve. A foley catheter was placed due to the development of urinary retention. A jejunostomy tube was placed for nutrition. Palliative care was consulted regarding goals of care and the patient was discharged to a skilled nursing facility where she passed away after 3 weeks.

IMPACT/DISCUSSION: ALS is a progressive neurodegenerative disease that causes a combination of upper and lower motor neuron symptoms. The diverse clinical presentation is a diagnostic challenge, resulting in diagnoses late in the disease course. Common manifestations include asymmetric muscle weakness, weakness and atrophy in the thenar muscles, and bulbar symptoms. Recognizing bulbar dysfunction early in ALS is critical for the management of the disease course. Speech and swallowing dysfunction markedly decrease patients’ quality of life and lead to complications such as malnutrition, dehydration, and aspiration pneumonia. Once diagnosed, management ranges from regular monitoring of respiratory and swallowing status to interventions such as ventilation and gastrostomy tubes. Spasticity of bulbar muscles can be managed with pharmacotherapy.

Furthermore, our patient presented with a rash that we were unable to attribute to another pathology besides ALS. As the rash improved over the course of her hospitalization, this may be attributable to a vitamin deficiency. Additionally, skin sensitivity and hyperpigmentation have previously been associated with ALS. Clinicians should be aware that ALS can present with a wide variety of symptoms, including dermatological manifestations.

CONCLUSION: ALS should be included in the differential diagnosis of dysphagia and bulbar symptoms

Management of bulbar symptoms in ALS is crucial and associated with improved quality of life and mortality

A CASE OF LEFT OVARIAN VEIN THROMBOSIS FOLLOWING LUPRON USE IN A PATIENT WITH UNDERLYING UTERINE MYOMA

Joseph H. Than¹; Daniela Garcia Perez²; Gowtham Anche³; Taral Shah⁴. ¹Internal Medicine, New York City Health and Hospitals South Brooklyn Health, Brooklyn, NY; ²Touro College of Osteopathic Medicine Harlem Campus, New York, NY; ³Medical Student, Touro College of Osteopathic Medicine Harlem Campus, New York, NY; ⁴Hematology/ Oncology, New York City Health and Hospitals South Brooklyn Health, Brooklyn, NY. (Control ID #4064152)

CASE: Patient is a 51 years old Hispanic woman with a history of GERD, IBS, and uterine fibroids. She presented to the emergency department with worsening abdominal pain in the left lower quadrant (LLQ) and nausea for 2 days. Vitals in the emergency department (ED) were stable except for tachycardia upto 130 bpm. On physical examination, LLQ tenderness was noted. Labs were significant for leukocytosis of 15K with neutrophilic predominance. CT abdomen & pelvis revealed left ovarian vein thrombosis. Further history revealed that the patient had been on leuprolide for abnormal menstrual bleeding due to uterine fibroids for the past 4 months. Patient had no family history of hypercoagulable disorder. She was treated with anticoagulation with lovenox and antibiotics ie Zosyn. Hematology recommended hypercoagulability work up including testing for antiphospholipid syndrome - DRVVT, silica clotting time, cardiolipin and beta-2 glycoprotein antibodies, prothrombin gene and factor V Leiden mutation that were negative. Additionally, based on their recommendations, leuprolide was discontinued. Patient was started on enoxaparin and switched to apixaban for 3 months. Repeat CT abdomen and pelvis a month after starting treatment with apixaban showed no evidence of ovarian vein thrombosis.

IMPACT/DISCUSSION: The use of GnRH agonists causes a hypercoagulable state leading to increased risk of thromboembolic events. Initially after receiving GnRH agonists there may be an increase in estrogen levels due to increased FSH and LH release. High concentrations of estrogen have been shown to increase platelet counts, fibrinogen, and von Willebrand factor. This leads to greater activation of the coagulation cascade and increased risk of thromboembolic events. Moreover the patient had underlying uterine fibroids which can put mechanical pressure on the ovarian veins causing venous stasis and increase risk of thrombosis.

CONCLUSION: A case of ovarian vein thrombosis in association with the use of leuprolide in a patient with underlying uterine fibroids. The risk of elevated estrogen levels and mechanical pressure on the ovarian vein puts such patients at risk for thrombosis. Any patient with a history of uterine fibroids being treated with GnRH agonists presenting with acute onset abdominal pain, ovarian vein thrombosis should be in the differentials.

A CASE OF LIVER INJURY DUE TO SELECTIVE ANDROGEN RECEPTOR MODULATOR (SARM) USE

Aditya Joshi²; Emily R. Fraser²; Phillip Leff¹; Diego F. Kaune³; Talal Alomar⁴; Sabyasachi Roy¹. ¹Internal Medicine, Creighton University School of Medicine Phoenix Health Sciences Campus, Phoenix, AZ; ²Creighton University School of Medicine Phoenix Health Sciences Campus, Phoenix, AZ; ³Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD; ⁴Medicine, Creighton University, Omaha, NE. (Control ID #4064722)

CASE: A 47-year-old male with no significant past medical history presented to the emergency department due to worsening right upper quadrant abdominal pain. The patient also reported one episode of emesis, and pain with deep inspiration. He denied chest pain, back pain, flank pain, fever/chills, diarrhea, or difficulty urinating. He denied any alcohol or substance use, tattoos, prior blood transfusions, or family history of liver disease. His labs were significant for elevated ALT of 302 U/L, AST of 115 U/L, and total bilirubin of 3.4 mg/dL with an alkaline phosphatase of 42 IU/L. CT abdomen showed mild gallbladder distension and trace pericholecystic fluid. Right upper quadrant ultrasound identified gallbladder sludge without gallstones and a mild 7mm dilation of the common bile duct.

Surgery was consulted for possible cholecystitis. MRCP was negative for choledocholithiasis with mild pericholecystic fluid with no evidence of gallstones. A HIDA scan indicated hepatic metabolic dysfunction with an inability to conjugate or excrete isotope into the biliary tree. Furthermore, INR was normal and tests for acute/chronic and autoimmune hepatitis panels were all negative.

Upon further conversation, the patient admitted to daily use of a SARM as a muscle building supplement for the past few weeks.

Throughout his hospitalization, the patient's lab values worsened. His ALT and AST peaked at 523 U/L and 221 U/L respectively, and total bilirubin 7.8 mg/dL after 3 days. The patient developed slight jaundice along with darkening of urine and mildly elevated CK levels of 219 U/L. The patient was placed on IV antibiotics and fluids throughout his stay. He tolerated a normal diet with no nausea or vomiting and was discharged in 4 days upon clinical improvement and down trending of his liver enzymes.

IMPACT/DISCUSSION: In the past few years, SARMs use has increased among the fitness community as an alternative to anabolic steroids. While originally developed to treat conditions such as muscle wasting in chemotherapy and osteoporosis, no SARM has been approved by the FDA and limited safety information has been published. Despite this, SARMs are easily available to buy online. As SARMs use has increased in popularity, reports of adverse effects such hepatotoxicity, nephrotoxicity, rhabdomyolysis, and hormone dysregulation have emerged in the literature. Our patient presented with drug induced liver injury after SARMs use. Similar cases have presented with jaundice, elevated liver enzymes, and abdominal pain. While some may resolve without treatment, ursodeoxycholic acid, N-acetyl cysteine, and in serious cases liver transplant may be used for management. With the possibility of profound consequences from SARMs use, physicians need to be aware of symptoms, and further research is needed to better understand the safety of these drugs.

CONCLUSION: -The prevalance of SARMs is increasing and physicians must be aware of their use

-Hepatotoxicity is a common presentation of drug induced liver damage from SARMs

A CASE OF MISDIAGNOSED ADULT-ONSET STILL'S DISEASE

Asma Mohammadi, Julius Birnbaum. Rheumatology, UPMC Mercy, Pittsburgh, PA. (Control ID #4023363)

CASE: A 51-year-old male with no significant past medical history was evaluated for a 10-month history of persistent fevers peaking to 102 °F, myalgias predominantly in the thighs, sore throat, and swelling of the right wrist. Initial work-up showed ESR 106, elevated CRP, ferritin 530. He underwent extensive serological evaluation which showed ANA 1:40, negative anti-DNA antibodies, anti-MSA antibodies, elevated LDH, low albumin, elevated s-IL2 receptor, low IgG. His diagnostic studies included negative temporal artery biopsy, CTA chest, PET scan, with MRI thigh muscles showed edema-like changes; however negative muscle biopsy, and CT abdomen pelvis showed hepatomegaly. He had numerous visits to physicians in Japan and the USA with diagnosis ranging from Giant cell arteritis, Polymyositis, Hemochromatosis, to Vacuoles, E1 enzyme, X-linked, Auto-inflammatory, Somatic (VEXAS) Syndrome. He was eventually diagnosed with AOSD as per Yamaguchi criteria that included fevers of a quotidian pattern that responded to high-dose steroids, elevated ESR, CRP, and ferritin levels along with hepatomegaly. He was treated with IV steroids, IVIG, Imuran, and CellCept that led to resolution of the symptoms; however, when his prednisone dose was tapered, he experienced recurrence of his myalgia and fevers. This indicates that he had a polyphasic pattern that warranted immunotherapy.

IMPACT/DISCUSSION: Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder characterized by a high-spiking fever, arthralgia, rash, lymphadenopathy, and hepatosplenomegaly. Lab findings include elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and ferritin levels. Typically, the ferritin levels are higher than any other autoimmune, inflammatory, infectious or neoplastic diseases. There is no definitive diagnostic test to diagnose AOSD; however, the Yamaguchi and Fautrel classification criteria are used for diagnosis. Three phases of AOSD include: monophasic pattern that lasts few weeks to months and resolves within a year; polyphasic pattern is characterized by recurrent systemic flares with remissions between flares, and a chronic pattern has a persistently active disease lasting longer than 1 year. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, anakinra, methotrexate, and leflunomide.

CONCLUSION: The diagnosis of AOSD is quite challenging and other diagnoses like infection, tumor, connective tissue disease, and other diseases must be ruled out before diagnosing AOSD5. This case report highlights how the workup unduly chased the diagnosis of polymyalgia based on myalgias and MRI of muscles that is non-specific for diagnosis. The non-specific laboratory markers with elevated ESR, CRP, and ferritin levels could lead to misdiagnosis like hemochromatosis. One of the learning points from this case is that AOSD can be monophasic or polyphasic, however when there are relapses seen, it warrants immunosuppressive treatment.

A CASE OF MISTAKEN IDENTITY: EXTRA-NODAL NK/T CELL LYMPHOMA MASQUERADING AS REFRACTORY CELLULITIS

Natalie J. Reed¹; Nirja Sutaria¹; Zalak Shah¹; Caroline Horne². ¹Internal Medicine, Carolinas Medical Center, Charlotte, NC; ²Internal Medicine, Atrium Health, Charlotte, NC. (Control ID #4047731)

CASE: A 53-year-old Spanish speaking male presented with a weeklong history of nasal congestion and left sided facial swelling. CT was notable for left sided facial cellulitis and lymphadenopathy, adjacent periodontal disease, and paranasal sinus disease. He was given Augmentin and prednisone but had multiple re-presentations for worsening symptoms. Approximately 2.5 weeks later, he was evaluated by another physician who suspected medication non-compliance and changed his antibiotic regimen. He was seen shortly after by ENT with I&D completed. Despite these interventions, he was re-admitted for outpatient treatment failure one month after initial presentation. The patient was treated with IV daptomycin with repeat I&D performed. Left nasal mass pathology from this hospitalization showed degenerated mucoid material with acute inflammation. He was discharged with 4-6 weeks of IV antibiotics due to clinical stability, though on follow up appointments, he was noted to lack improvement and was readmitted.

During this readmission (9 weeks after symptom onset), alternative etiologies were explored. Repeat neck imaging showed extensive, enlarging lymphadenopathy and suspicious lung nodules, increasing concern for potential underlying malignancy. A PET scan revealed soft tissue thickening of the nose with numerous lymph nodes and pulmonary nodules, all of which were hypermetabolic. A punch biopsy was performed and showed extranodal NK/T cell lymphoma, nasal type, with EBV+ atypical cells. Subsequent lung biopsy confirmed metastatic disease.

He was treated with 4 cycles of modified SMILE chemotherapy regimen with complete metabolic remission 4 months after the initial PET scan. He continues to do well today with periodic surveillance.

IMPACT/DISCUSSION: This case highlights the need to continue to evaluate alternative diagnoses, especially in the setting of treatment failures. Though his initial presentation seemed most consistent with cellulitis, by the end of the case, other suspected etiologies included mucormycosis, leishmaniasis, and underlying malignancy. Challenges in this case including assessing medication adherence and providing care to patients with limited English proficiency, which likely led to diagnostic delays. Overall, this case is a reminder to revisit differentials with atypical courses, to practice culturally competent care, and to avoid anchoring bias.

CONCLUSION: Extranodal NK/T cell lymphoma is a rare lymphoma that should be considered in patients from endemic areas presenting with nasopharyngeal symptoms. This case highlighted a long clinical course of this rare condition further prolonged by social factors that commonly complicate admissions.

A CASE OF MULTIPLE SCLEROSIS MASKED BY HALDOPERIDOL-INDUCED EXTRAPYRAMIDAL SYMPTOMS

Harry Hurley¹; Hillary Weisleder²; Matthew Shaines³. ¹Hospital Medicine, Montefiore Medical Center, New York, NY; ²Internal Medicine, Montefiore Medical Center, Bronx, NY; ³Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4062126)

CASE: A 27-year-old man with schizoaffective disorder on haloperidol presented with 5 days of worsening left-sided low frequency high amplitude upper and lower extremity tremors. At baseline, he had bilateral upper extremity tremors at rest for the past 6 years. His tremors had been gradually increasing in severity to the point that he could no longer walk, which prompted his presentation to the emergency room. It was later found out that he had received an intramuscular haloperidol injection following discharge from a psychiatric ward one week prior in addition to his previously prescribed regimen. The primary team initially attributed these findings to extrapyramidal side effects (EPS) of haloperidol, with the understanding that unilateral EPS was unusual. The tremor was treated with benztropine and clonazepam, though neither led to notable improvement of symptoms. An MRI brain and subsequent spine imaging revealed extensive periventricular white matter abnormalities in the brain and spinal cord, and CSF analysis was positive for oligoclonal bands. The patient was diagnosed with multiple sclerosis (MS).

IMPACT/DISCUSSION: First generation antipsychotic agents have a range of side effects, including EPS. These can manifest as varied movement disorders including dystonia, akathisia, parkinsonism, and tardive dyskinesia. The prevalence of these effects is estimated to be approximately 50-75%. Acute symptoms can manifest in weeks, while chronic symptoms can occur within months–years. Tremors in EPS typically manifest as bilateral and low amplitude, and often present with rigidity and bradykinesia seen in parkinsonism. Pharmacotherapy to treat these side effects includes anticholinergic and antispasmodic agents. However, some patients will require an alternative second-generation antipsychotic. With treatment, some EPS symptoms improve within days while others remain permanent; only about 15% of patients achieve remission in tardive dyskinesia. With closer examination of this patient’s tremors despite high doses of several anticholinergic agents, the diagnosis of EPS symptoms was questioned—particularly due to the unilaterality and stark amplitudes of the movements. Further imaging was pursued which led to the alternative diagnosis of MS, which would have been easy to miss in this case. Like EPS symptoms, MS presentations are highly varied and often are missed until the neurological manifestations are more pronounced. MS usually occurs between 20-50 years of age, averaging in the late 20s-early 30s at diagnosis. The occurrence of 2 or more white matter lesions separated by space and time is diagnostic, and these can be detected clinically or with magnetic resonance imaging.

CONCLUSION: We present a unique case of multiple sclerosis that was confounded by a concurrent psychiatric disorder requiring a first-generation antipsychotic. Although EPS symptom presentation can be vast, if the symptoms do not fit with the diagnosis, clinicians should remain vigilant in investigating alternatives.

A CASE OF PNEUMOMEDIASTINUM IN A PATIENT WITH MYOSITIS AND INTERSTITIAL LUNG DISEASE

Adrian M. Alonso¹; Robert J. Hall¹; Katherine E. Ray¹; Anastasia Tishena². ¹Internal Medicine, University of Florida, Gainesville, FL; ²College of Medicine, University of Florida, Gainesville, FL. (Control ID #4059762)

CASE: A 27-year-old man with a recent diagnosis of anti-small ubiquitin-like modifier activating enzyme (SAE) dermatomyositis (DM) with associated interstitial lung disease (ILD) was admitted to the hospital for uncontrolled weakness and diffuse skin lesions. Due to the severity of his DM, his planned outpatient treatment consisted of IVIG and mycophenolate; however, his IVIG was not approved due to a lack of insurance. On arrival, vitals were notable for tachycardia. Inflammatory labs depicted a CK of 157 U/L (reference < 320 U/L), CRP of 8 mg/dL (reference < 5 mg/dL), and an ESR of 55 mm/hr (reference < 10 mm/hr). Chest X-ray showed a widened mediastinum. He was subsequently placed on 100% supplemental oxygen to aid with reabsorption of the pneumomediastinum. He had a history of esophageal ulcers; therefore, there was initial concern for an esophageal origin; however, a CT esophagography did not show oral contrast extravasation. His pneumomediastinum was thought to have occurred spontaneously, secondary to his ILD. He was started on IVIG for two days and a prednisone taper, with improvement in his weakness. Repeat imaging depicted a stable pneumomediastinum; he was discharged on no supplemental oxygen.

IMPACT/DISCUSSION: Dermatomyositis is an autoimmune disease with an elusive pathophysiology characterized by proximal muscle weakness, erythema around the eyelids, erythematous papules on the dorsal hand, and erythema on the chest. Interstitial lung disease is a known complication of myositis, usually associated with myositis-specific antibodies such as anti-SAE1 and anti-Jo-1. Anti-SAE1 is most commonly associated with cutaneous manifestations and occasionally with ILD, similar to this patient. Pneumomediastinum as a consequence of DM-associated ILD is a rare and seldom reported complication. In this patient, his spontaneous pneumomediastinum was likely secondary to the Macklin effect, which involves spontaneous rupture of the alveoli and accumulation of air along the sheath of pulmonary vessels or bronchi. Although rare, other cases of pneumomediastinum in DM patients have also attributed this complication to spontaneous subpleural cyst rupture due to damaged alveoli. Other theories suggest that steroids weaken the alveolar wall, predisposing these patients to alveolar rupture. Patients with pneumomediastinum typically present with dyspnea, chest pain, and voice hoarsness. Interestingly, however, this patient was entirely asymptomatic. Treatment is usually supportive with 100% oxygen and serial chest X-rays to assess disease progression.

CONCLUSION: Pneumomediastinum is usually a self-limiting process. However, it can cause significant morbidity if not appropriately addressed. This case presents another notable complication that can arise from DM-associated ILD. In a patient with new shortness of breath in uncontrolled DM, the internist needs to work up the causes of dyspnea with pneumomediastinum on the differential.

A CASE OF RECURRENT BRASH SYNDROME

Katlin Schmitz, Allison A. Reinhardt. Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4064182)

CASE: A 72-year-old male presented with weakness and hypotension after acute-onset non-bloody diarrhea. Comorbid conditions included hypertension (on metoprolol, lisinopril, and furosemide), stage II chronic kidney disease, and type 2 diabetes (on metformin and glimepiride). Initial workup was notable for hyperkalemia, acute kidney injury (AKI), and anion gap metabolic acidosis. An electrocardiogram demonstrated bradycardia and peaked T waves. Temporizing measures were given and patient was admitted to the intensive care unit (ICU). Of note, he had been admitted to the ICU one month prior for a similar constellation of symptoms.

In the ICU, patient received fluids and his home antihypertensives were held. His bradycardia resolved and his potassium normalized. He transferred to the floor after two days. On the floor, patient’s creatinine improved with further oral hydration and his diarrhea resolved. After three days, he was discharged to home in stable condition. He was advised to hold his glimepiride, lisinopril, and furosemide for a short time while his renal function recovered. Additionally, he was counseled to permanently avoid metoprolol (or other AV-nodal blocking medications) to reduce the risk of another episode of BRASH syndrome.

IMPACT/DISCUSSION: BRASH syndrome is a clinical pentad involving bradycardia, renal failure, atrio-ventricular (AV) nodal blockade, shock, and hyperkalemia. This is caused by the synergistic combination of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) and AV-nodal blocking medications with metabolic derangement leading to bradycardia and shock.

BRASH syndrome represents a constellation of symptoms that can be life-threatening and disproportionally impacts the elderly. In our case, the trigger was likely a pre-renal AKI precipitated by diarrhea. Metoprolol is renally excreted and accumulates with reduced glomerular filtration. Hyperkalemia is another sequela of an AKI. Hyperkalemia and AV-nodal blockade induce bradycardia. Bradycardia may lead to decreased cardiac output which worsens renal perfusion and exacerbates renal injury. This leads to more hyperkalemia and further enhances AV-nodal blockade. This vicious cycle can ultimately lead to multiorgan failure if left untreated.

Treatment for BRASH typically includes temporizing measures for the acute hyperkalemia and bradycardia while addressing the underlying acute kidney injury. AV-nodal agents should be held and physicians should consider stopping these agents permanently to reduce the risk of disease recurrence as seen in our patient.

CONCLUSION: Keep BRASH syndrome on the differential for patients, especially the elderly, who present with a constellation of symptoms including bradycardia, renal failure, hyperkalemia, or shock while on AV nodal blocking agents.

If patient is diagnosed with BRASH, hold AV-nodal blocking agents and consider discontinuing permanently.

A CASE OF REFRACTORY HYPOPHOSPHATEMIA IN X- LINKED HYPOPHOSPHATEMIA IN THE SETTING OF ALCOHOL ABUSE

Drushik Gangasani¹; Mayura R. Kesara². ¹Internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4064044)

CASE: 43-year-old male with a medical history significant for X-linked hypophosphatemia, necessitating multiple orthopedic surgeries, and currently managed with phosphorus supplementation, hypertension and alcohol abuse presented to the Emergency Department with complaints of generalized weakness and epigastric pain.

On presentation, the patient was afebrile and hemodynamically stable. Laboratory findings revealed hyponatremia (132 mmol/L), hypophosphatemia (0.7 mg/dL), and an elevated ethanol level (274 mg/dL). Additional laboratory results showed a normal Lipase and liver function levels within normal ranges. Vitamin D level was normal at 40 ng/mL. Abdominal ultrasound revealed hepatic steatosis.

The patient was admitted for the management of acute alcohol intoxication and electrolyte derangements. During the hospitalization, he was treated for alcohol abuse with Librium, folic acid, and thiamine. Despite multiple doses of intravenous and oral phosphorus repletion, there was initially no improvement in the hypophosphatemia. However, over the course of hospitalization, the patient's phosphorus levels eventually improved, leading to discharge with an increased phosphorus supplementation regimen and a referral to rehabilitation for alcohol abuse.

IMPACT/DISCUSSION: X-linked hypophosphatemia is an uncommon and progressive condition persisting throughout life, characterized by low phosphorus levels resulting from heightened fibroblast growth factor 23 (FGF23) activity. Elevated FGF23 leads to excessive phosphorus excretion in urine, a phenomenon referred to as phosphate wasting. This process contributes to a decrease in blood phosphorus levels, potentially causing skeletal issues such as weakened bones. XLH may manifest as bone irregularities, impairing mobility and giving rise to complications like bone fractures, hearing impairment, pain in bones and ligaments, as well as an elevated susceptibility to infections, including spontaneous dental abscesses.

CONCLUSION: X-linked hypophosphatemia, an inherited disorder, is typically managed through traditional approaches involving oral phosphate and Vitamin D analogs. Recently, alternative therapies such as Burosumab, a monoclonal antibody targeting FGF23, have emerged. Hypophosphatemia is commonly identified in individuals with alcohol dependence, due to various pathophysiological processes including inappropriate phosphaturia, heightened phosphorus uptake by cells, and gastrointestinal phosphate loss. In the context of this particular case, the concomitant alcohol abuse has contributed to as refractory hypophosphatemia.

A CASE OF SEVELAMER-INDUCED ISCHEMIC COLITIS

Tejal Desai, Ambili Ramachandran. Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4054471)

CASE: A 66-year-old male with end stage renal disease (ESRD), type 2 diabetes mellitus, adrenal insufficiency, and recurrent Clostridium difficile colitis presented with one day of hematochezia, loose stools, diffuse abdominal pain, and subjective fevers. A prior episode of rectal bleeding earlier that year resolved with antibiotic treatment for Escherichia coli. His most recent colonoscopy (CSP) from 2019 had found 3 tubulovillous adenomas.

Initial vital signs were stable and pertinent exam findings included abdominal tenderness in the lower quadrants and suprapubic region. Labs were notable for WBC 14.14 k/mcL, Hgb 10.2 g/dL, ESR 101 mm/h, CRP 82.7 mg/L. Computed topography of the abdomen/pelvis without contrast demonstrated proctocolitis, and he was started on Piperacillin-Tazobactam. His outpatient medications were continued. Gastroenterology (GI) was consulted, and the patient underwent CSP which showed a mucosal linear ulceration consistent with colonic ischemia and a distal rectal ulcer. Biopsy of the transverse colon showed multiple fragments of tubular adenoma and sevelamer resins. The rectosigmoid ulceration biopsy was consistent with ischemic type colitis with erosion.

GI recommended conservative management. The patient was started on midodrine to prevent hypotension that would worsen ischemia. Sevelamer was discontinued.

IMPACT/DISCUSSION: Sevelamer is a commonly prescribed phosphate binder to help manage hyperphosphatemia in ESRD. In this case we discuss a 66 year-old male with ESRD on sevelamer who developed ischemic colitis. Ischemic colitis is associated with various risk factors, including atherosclerosis, emboli, hypotension, and certain medications such as pseudoephedrine, sumatriptan, and estrogen containing medications. The pathogenesis by which sevelamer causes colitis remains unknown, and adverse gastrointestinal effects including bleeding gastrointestinal ulcers and necrosis were identified during post approval use of the medication by the FDA.

Sevelamer-induced ischemic colitis does not have a unique appearance on colonoscopy. On H&E staining, sevelamer resins appear as a characteristic two-toned pink and rusty yellow “fish-scale” pattern.

This patient and others with ESRD often present with multiple risk factors for ischemic colitis which may increase the likelihood of experiencing complications. Primary care providers and nephrologists should evaluate the risks and benefits of these medications for each patient. Moreover, patients should be counseled on the potential risks to be aware of the signs and symptoms of adverse gastrointestinal reactions.

CONCLUSION: Sevelamer induced ischemic colitis is a rare but serious side effect. Only 21 case reports have been published detailing this adverse reaction. It is important to note the use of this medication in patients with significant risk factors for ischemic colitis and when caring for patients with gastrointestinal bleeding secondary to ischemia.

A CASE OF SEVERE PULMONARY HYPERTENSION COMPENSATION

Sophie Silverstein²; Abigail Belasen¹; Christian Wong³; Sneha Nagesh Rao¹. ¹Internal Medicine, Albany Medical Center, Albany, NY; ²Albany Medical College, Albany, NY; ³Pulmonary/Critical Care Medicine, Albany Medical Center, Albany, NY. (Control ID #4062099)

CASE: A 56-year-old woman with a history of heart failure with preserved ejection fraction and recurrent miscarriages presented to the emergency department with pleuritic chest pain, dyspnea, and dizziness after a trans-Atlantic flight two days prior. Home medications included aspirin, clopidogrel, digoxin, furosemide, and spironolactone.

On exam, vital signs were stable. Lungs were clear to auscultation, there was a grade VI systolic murmur in the left 2nd intercostal space, and she had no lower extremity edema. Brain natriuretic peptide was 22 pg/mL and high sensitivity troponin 6.8 ng/L. CT pulmonary angiography showed severe enlargement of the main pulmonary artery at 7.5 cm and peripheral intraluminal filling defects suggesting chronic thromboembolic disease. Venous duplex ultrasound revealed bilateral lower extremity thrombi and a right nonocclusive internal jugular thrombus. She was initiated on enoxaparin.

Transthoracic echocardiography was concerning for severe pulmonary hypertension (PH). A V/Q scan was conducted as there was concern for chronic thromboembolic PH (CTEPH), revealing high probability for embolism in the left lower lobe. Right heart catheterization showed right atrial (RA) pressure of 6 mmHg, right ventricular (RV) systolic pressure 109, mean pulmonary arterial pressure (mPAP) 60, and pulmonary capillary wedge pressure 24. Given the discrepancy between RA and RV pressures, transesophageal echocardiogram was performed which revealed left- and right-to-left shunting with agitated saline contrast, indicating a patent foramen ovale (PFO). Her PFO was not corrected due to its value in alleviating high right-sided intracardiac pressure.

Discussion of treatment options included pulmonary endarterectomy, balloon thromboendarterectomy, and lifelong anticoagulation. Ultimately, surgery was deferred as the likelihood of reducing her extreme PH by alleviating her pulmonary clot burden was felt to be low. She was found to have antiphospholipid syndrome, and enoxaparin was transitioned to warfarin.

IMPACT/DISCUSSION: PH is defined by mPAP greater than 20 mmHg and has several etiologies. Patients with PH undergo extensive diagnostic evaluation to evaluate for underlying contributory factors, as this informs treatment. Evaluating for CTEPH is particularly important as it is potentially reversible with surgery.

Some patients, like this patient, may have multiple causes of PH. This patient likely had mixed pulmonary venous hypertension from left heart disease as well as CTEPH. In addition, recognizing her medical stability despite a severely high mPAP was critical to appreciating the value of her PFO to hemodynamic stability and survival.

CONCLUSION: It is important to obtain several imaging modalities for PH work-up to optimize diagnosis and treatment for unique patients presenting with multiple causative factors. It is also important to consider that stable patients with PH may not require correction of intracardiac shunts.

A CASE OF SHRINKING LUNG SYNDROME IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Adrian M. Alonso¹; Robert J. Hall¹; Oluyemisi O. Amoda²; Katherine E. Ray¹. ¹Internal Medicine, University of Florida, Gainesville, FL; ²Pulmonary and critical care, University of Florida, Gainesville, FL. (Control ID #4059827)

CASE: A 24-year-old woman with a past medical history of Systemic Lupus Erythematosus (SLE) presented to the pulmonary clinic with ongoing dyspnea and pleuritic pain. She recently underwent right heart catheterization and was diagnosed with group I pulmonary hypertension (PH) secondary to SLE after other causes of PH were excluded. She was initiated on PH treatment with macitentan and sildenafil.

Despite appropriate treatment for her PH, she continued to have worsening shortness of breath and pleuritis at outpatient follow-up. The patient had improved functional status and a six-minute walk test; thus, her symptoms were deemed less likely to be secondary to PH. Pulmonary function tests revealed severe intrinsic restrictive disease [FEV1 1.14L (42% predicted), FVC 1.2L (39% predicted), FEV1/FVC 0.88, TLC 2.19L (50% predicted), DLCO 9.18 ml/(min*mmHg) (47% predicted)]. CT chest did not show evidence of parenchymal lung disease. Her pleuritic chest pain and restrictive lung disease in the absence of parenchymal disease were suggestive of shrinking lung syndrome (SLS). Jointly with rheumatology, the decision was made to increase her immunosuppression.

IMPACT/DISCUSSION: There are a variety of causes of dyspnea in SLE, including interstitial lung disease, acute pneumonitis, pulmonary hypertension, and shrinking lung syndrome. The pathophysiology of SLS is still elusive due to the rarity of the disease, with a <1% prevalence. SLS is thought to result from pleural pain leading to reflex neuronal inhibition that prevents deep inspiration, which in turn causes a reduction in lung volumes. Patients with SLS typically present with dyspnea, pleurisy, and orthopnea. Imaging shows normal lung parenchyma and may show diaphragmatic elevation.

Uniquely in this patient, we observed pulmonary hypertension and shrinking lung syndrome, which are seldom reported together in SLE. While this patient had two possible diagnoses to explain her dyspnea, her symptoms were attributed to SLS as her PH was felt to be well controlled given the improvement in her functional status and six-minute walk test. Her clinical presentation with dyspnea, orthopnea, and pleuritic pain was felt to be consistent with SLS. This clinical diagnosis was further supported by restrictive PFTs and normal lung parenchyma. The mainstay of treatment for SLS is increasing immunosuppression, though there is limited literature on treatment efficacy. Many patients have improvement in symptoms and lung function after treatment; however, few regain complete recovery.

CONCLUSION: Shrinking lung syndrome is a rare complication of SLE. Given the range of pathologies that may cause shortness of breath in SLE, it is imperative that internists are mindful that SLS is a possible cause. Early detection of SLS by internists may lead to improved outcomes in this patient population.

A CASE OF SUBCUTANEOUS PANNICULITIS LIKE T CELL LYMPHOMA WITH SECONDARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

Umar Farooq¹; Ying Yin Zhou¹; Nicole Sadej²; Eric Dragos²; Mary Guan¹; Yamen Homsi¹. ¹Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY; ²New York University, New York, NY. (Control ID #4062265)

CASE: Our patient is a 46-year-old female with a PMH of HTN and OSA, presenting to the ED due to a 1-week history of worsening lower extremity pain and swelling. Symptoms had been intermittent for 2 years and had completely resolved for 10 months prior to relapse. The patient recently completed a course of Bactrim for suspected cellulitis without improvement. On presentation, the patient was afebrile and normotensive. Physical exam demonstrated tender, erythematous subcutaneous nodules on all extremities and lower back, with edema, and ulceration of the lower extremities. The diagnosis of subcutaneous panniculitis-like T-cell lymphoma (SPTCL) was made by skin biopsy, revealing the alpha-beta subtype. On day 3 of admission, she became acutely altered, tachycardic, and febrile with worsening bicytopenia. Further workup was notable for elevated inflammatory markers including a ferritin of 21,000, hepatomegaly, elevated transaminases and cytokines (IFN-gamma, ILs). She then underwent 2 bone marrow biopsies - the first inconclusive, and the second with evidence of hemophagocytosis, confirming susoected secondary hemophagocytic lymphohistiocytosis (HLH). The patient was started on treatment for HLH, with dexamethasone and etoposide. She demonstrated significant improvement in her inflammatory markers and her lower extremity symptoms 10 days post discharge.

IMPACT/DISCUSSION: SPTCL is a rare disease entity, often unrecognized and thus prone to diagnosis and treatment delays. Our patient’s symptoms occurred intermittently and persisted for 2 years, comparable to the average time to diagnosis of 18 months for SPTCL. Due to its rarity and its clinical features being very nonspecific, SPTCL is often mistaken for cellulitis and treated with antibiotics without improvement, as seen in our patient. Our patient’s course was complicated by signs of systemic inflammation, prompting concern for HLH – which is a potentially fatal state of immune hyperactivity that is characterized as a cytokine storm driven by acute T-cell activation; typically arising as either primary or secondary to malignancy, infection or autoimmune disease. An estimated 18% of cases of SPTCL can be complicated by HLH. Given that the alpha beta subtype is a more indolent form of SPTCL, the decision was made to treat her HLH, which was likely causing her clinical instability. She responded rapidly to HLH treatment with etoposide and dexamethasone, deferring the need to escalate to multi-agent chemotherapy for severe HLH. Her laboratory findings and lower-extremity symptoms improved rapidly, demonstrating the effectiveness of this treatment modality.

CONCLUSION: Early skin biopsy may limit the classic delay in recognition of SPTCL.

Patients with borderline HLH diagnostic criteria may need repeat bone marrow biopsies to confirm or rule out the disease.

In stable patients with mild symptoms and the indolent alpha beta SPTCL subtype, single agent therapy of etoposide plus dexamethasone can be highly effective in treating concomitant HLH.

A CASE OF TOXIC EPIDERMAL NECROLYSIS ASSOCIATED WITH ENFORTUMAB VEDOTIN

Juliana Bilowus, Yoshio T. Wagner, Nina Brahmbhatt, Dana Kabbani. Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4064936)

CASE: A 78-year-old male with a history significant for stage IV bladder cancer and type II diabetes mellitus previously treated with gemcitabine and radiation, presented to the emergency department with localized painful, pruritic, and sloughing rashes. He was recently started on enfortumab vedotin (Padcev) for relapsed urothelial carcinoma and developed pruritic rashes just two days after administration. The patient presented to the emergency department twelve days after initial therapy. Labs were significant for hyperglycemia, lactic acid of 3.8, and creatinine of 1.53 (baseline Cr 0.8). A review of systems was pertinent for weakness and shortness of breath. Physical exam was significant for an erythematous rash that occupied his oral cavity, arms, trunk, and groin with desquamation of the bilateral axilla; total body surface area (TBSA) affected was 5% axillary desquamation and 50% erythema. SCORTEN indicated a high risk of mortality (4). Due to concerns for Toxic Epidermal Necrosis (TEN), dermatology, burn surgery, and critical care were consulted. The patient was started on methylprednisolone 120 mg daily and admitted to the ICU. Further Interventions included intravenous immunoglobulin (IVIG), and frequent wound care. Despite aggressive management, the patient rapidly deteriorated; and per family wishes, was transitioned to hospice care.

IMPACT/DISCUSSION: Our patient presented with a drug rash in the setting of recent enfortumab vedotin therapy. Enfortumab vedotin is a human monoclonal antibody conjugated with a microtubule-disrupting agent and is aimed at Nectin-4, a transmembrane protein that is highly expressed in urothelial carcinoma. The patient was noted to have axillary desquamation. These factors raised suspicion for drug-induced TEN. Risk factors for mortality include age greater than 65, malignancy, TBSA, tachycardia, elevated BUN, decreased bicarbonate, and uncontrolled diabetes. The overall mortality of TEN at 1 year is approximately 34%. TEN secondary to enfortumab is a rare complication for a drug that is widely used and considered safe; physicians should be aware of the associated life-threatening cutaneous manifestations.

CONCLUSION: Enfortumab vedotin is known to cause SJS/TEN

Physicians should have high suspicion for the life-threatening cutaneous manifestations of this medication

A CASE OF VARICELLA ZOSTER VIRUS MENINGITIS TREATED WITH A HIGHER THAN RECOMMENDED DOSE OF ACYCLOVIR, RESULTING IN ACYCLOVIR ENCEPHALOPATHY

Kotaro Nemoto¹; Akihito Yoshida¹; Takaaki Kobayashi²; Megumi Matsuda¹; Takahiro Fukushima¹; Tadashi Eguchi¹. ¹General Internal medicine, Kameda Medical Center, Kamogawa, Chiba, Japan; ²Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #4057201)

CASE: A 73-year-old man on maintenance hemodialysis due to glomerulonephritis presented with visual hallucinations and altered mental status (AMS) for several hours. One day before the admission, he developed a skin rash on the top of his scalp with abnormal sensation. He was oriented to name and place but not time (Glasco coma scale E4V4M5). Physical examination revealed a positive Kernig sign and a blister on the parietal area of his head. Head MRI was unremarkable. Lumbar puncture showed an increased cerebrospinal fluid cell count (40/μL, 98% of which were monocytes) and protein (70 mg/dL), and CSF PCR (FilmArray) was positive for Varicella zoster virus (VZV). VZV meningitis was diagnosed, and acyclovir was mistakenly initiated at a higher than recommended dose of 625 mg (10 mg/kg). Later on the same day, his AMS acutely worsened (E1V1M4) with chorea-ballism-like involuntary movements in the extremities. The acyclovir dose was deemed excessive for a dialysis patient, leading to a clinical diagnosis of acyclovir encephalopathy. Acyclovir was discontinued, and his AMS slowly improved over the next 7 days with HD. Treatment was resumed with acyclovir 160 mg (2.5 mg/kg)/day, and he was successfully treated with 10 days of acyclovir with complete symptom resolution.

IMPACT/DISCUSSION: VZV has been identified as the causative pathogen in 8-13% of viral meningitis cases. Meningitis is considered an infrequent complication of VZV, occurring in only 0.5% of reported infections, primarily affecting immunocompromised individuals. Acyclovir and valacyclovir are the leading drugs for the treatment of Herpes zoster and VZV meningoencephalitis, but neurotoxicity should be noted as a side effect. Renal dysfunction and inappropriate dosing have been associated with its development. Acyclovir encephalopathy often appears within 0 to 2 days after acyclovir administration. Reported symptoms due to acyclovir encephalopathy include disorientation, tremors, agitation, hallucinations, delirium, seizures, etc. The electroencephalogram typically shows diffuse slow-wave activity rather than focal abnormalities. The radiological features are not well known. When suspected, acyclovir should be discontinued. Prior reports indicate neurologic symptoms improve within 48-72 hours after discontinuation, with complete recovery in 5 days.

CONCLUSION: Clinically differentiating between VZV meningitis and acyclovir encephalopathy is challenging but crucial, as the treatment for the two conditions is opposite. Drug-related encephalopathy should be suspected if a patient receiving acyclovir develops new neurological symptoms, particularly in the presence of renal dysfunction and/or excessive antiherpetic drug dosage.

A CASE OF VENTRICULAR BIGEMINY IN A 55-YEAR-OLD FEMALE PRESENTING WITH SUBACUTE CUTANEOUS LUPUS ERYTHEMATOSUS.

Nidhiben Patel¹; Farnaz Sadr²; Natalia Plotskaya³. ¹internal medicine, Capital Health, Trenton, NJ; ²Internal Medicine, Capital Health Medical Center - Hopewell, Pennington, NJ; ³Internal Medicine , Capital Health System Inc, Trenton, NJ. (Control ID #4064277)

CASE: A 55-year-old female with no medical history presented complaining of pruritic facial rash, palpitations and sensation of skipped heart beats that started 3 months ago. She denied any dizziness or chest pain at that time. Physical exam revealed facial malar rash and sinus bradycardia. Electrocardiography (ECG) showed heart rate (HR) of 58 beats per minute (bpm) and sinus rhythm, QTc interval of 430 ms. Serologic studies showed anti-double strand DNA antibodies (anti-dsDNA) < 1.0 IU/ml, antinuclear antibodies (ANA)1:160 titer, homogenous pattern. No hematologic abnormalities were found, no proteinuria was detected. Echocardiography demonstrated normal left ventricular function, severely dilated left atrium. Patient underwent 24-hour Holter monitoring (HM) which detected 3.7% premature ventricular contractions (PVCs) burden with periods of ventricular bigeminy with interpolated and multiform PVCs. Pharmacological stress test was negative for ischemia. Patient was not diagnosed with subacute cutaneous lupus erythematosus (SCLE) initially as her facial malar rash was not visualized during rheumatologic evaluation. She was re-evaluated in 8 months when erythematous facial rash associated with photosensitivity and arthralgias occurred. Patient was started on hydroxychloroquine and methotrexate. Sjogren’s, dermatomyositis, scleroderma serology was negative. Facial rash improved within 4 months after treatment initiation. Patient followed up with cardiologist and had electrophysiologic study which showed possible epicardial PVCs focus that was not amenable to endocardial ablation. Patient was continued on low dose of metoprolol succinate for PVCs suppression. She was not able to tolerate higher dose of beta-blocker due to symptomatic bradycardia. 24-hour HM was repeated and showed frequent unifocal PVCs, PVCs burden was 10.9% without significant pauses or atrioventricular blocks. Minimum HR was 33 bpm. Patient was recommended “back up” pacemaker implantation and epicardial mapping with possible ablation if she develops worsening symptoms and evidence of tachycardia-mediated cardiomyopathy.

IMPACT/DISCUSSION: Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by autoantibody production and systemic inflammation affecting multiple organs, including the heart. Cardiac involvement is a well-known complication of SLE and can manifest by cardiac conduction abnormalities and arrhythmias. SCLE usually presents with mild systemic symptoms such as arthritis and myalgias. Recent studies suggested that patients with SLE have heart rate variability due to dysautonomia. Detection of PVCs indicates higher risk of sudden cardiac death in these patients.

CONCLUSION: A high index of suspicion of SLE is critical when evaluating middle-aged female presenting with positive ANA and negative anti-dsDNA SCLE in the setting of sinus bradycardia. Clinicians should initiate simultaneous cardiac and immunologic work up. Close follow up is crucial to monitor PVCs burden in such cases.

A CASE PRESENTATION OF LARGE B CELL ORBITAL LYMPHOMA IN AN AFRICAN AMERICAN MALE

Emilia Ferreira, Maie Zagloul, Shanna Mogden. Hospital Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4043130)

CASE: A 44-year-old African American male with a history of Diffuse Large B-cell Lymphoma (DLBCL) of the right inguinal region treated with 6 cycles of cyclophosphamide, doxorubicin, vincristine, prednisone, and Rituxan (RCHOP) and intensity modulated radiation therapy (ISRT) presented to the Emergency Department with a 2- week history of progressively worsening left-sided facial numbness and 1-week of left eye swelling. An orbital CT scan showed abnormal ill-defined soft tissue enhancement throughout the left pterygopalatine fossa/retromaxillary space with involvement of the masticator space and extension into the left lateral extraconal space. Asymmetric left-sided proptosis was visualized along with involvement of the left infraorbital and vidian canals/nerves with intracranial extension along the left middle cranial fossa. The patient was subsequently transferred to ophthalmology services. MRI completed at the visit showed asymmetric enlargement of the left lacrimal gland and possible cellulitis or orbital lymphoma.

Patient was admitted to the hospital and given IV anti-microbial therapy consisting of amphotericin, cefepime, and vancomycin, for several days. Patient showed no signs of improvement and facial numbness increased. An orbitotomy for biopsy of left orbital mass revealed DLBCL germinal center B-cell type. Patient was discharged and a repeat PET/CT scan was conducted two weeks later to assess for central nervous system (CNS) involvement. PET revealed orbital-facial lymphoma demonstrating avid radiotracer uptake with cutaneous and subcutaneous metastases, Deauville 5. Lumbar puncture was performed with DLBCL population detected in the cerebrospinal fluid. Patient was admitted back to the hospital for chemotherapy treatment cycle of ifosfamide, carboplatin, and etoposide.

IMPACT/DISCUSSION: In this case, the discovery of DLBCL in the left orbit with CNS involvement following original diagnosis of the cancer in the right inguinal region brings attention to the complexities of this neoplasm. This unusual progression prompts critical questions on lymphoma metastasis and the efficacy of standard treatments like radiation and chemotherapy. DLBCL metastasis to the orbital region is rare. Yet, DLBCL histology confers the worst outcomes in orbital lymphoma – highlighting the need for thorough research on prognostic factors of ocular involvement (Chen et al., 2022). Studying the genes and molecules involved in cases like this is crucial for developing targeted treatments.

CONCLUSION: This case report highlights a rare presentation of DLBCL orbital and CNS involvement in an African American male following original diagnosis of DLBCL in the right inguinal region. This case emphasizes the importance of identifying prognostic factors and increasing clinician awareness of the variable DLBCL presentation for early treatment.

A CASE REPORT OF CO-EXISTENCE OF MICROSCOPIC POLYANGIITIS AND RHEUMATOID ARTHRITIS.

Claudia Villa Celi, Juan Sosa, Natalia Plotskaya, Knkush Hakobyan. Internal Medicine, Capital Health, Trenton, NJ. (Control ID #4054804)

CASE: A 58-year-old male with a past medical history of rheumatoid arthritis (RA), chronic bronchitis, tobacco use, and recurrent productive cough with hoarseness for three months presented to the hospital complaining of acute dyspnea. Six months ago, the patient was diagnosed with Legionella pneumonia and acute kidney injury. Physical examination was remarkable for bilateral coarse rales on lung auscultation. He was started on oxygen therapy via nonrebreather and required intubation due to worsening respiratory status. Laboratory findings showed hemoglobin of 6.4 g/dl, serum sodium of 133 mmol/l, serum potassium 2.8 mmol/l, BUN 27 mg/dl, creatinine (Cr) 2.03 mg/dl (baseline Cr was 1.2 mg/dl), ESR >150 mm/hr. Urinalysis showed erythrocytes >100/hpf and protein >500 mg/dl. CT scan of the chest was negative for pulmonary embolus but showed bilateral extensive patchy infiltrates. The patient was transfused with 1 unit of PRBC and started empirically on levofloxacin. Hemoglobin decreased below 6 g/dl after transfusion, and diffuse alveolar hemorrhage (DAH) was suspected. A bronchoscopy was performed, and it revealed erythema throughout the tracheobronchial tree, and blood on bronchial alveolar lavage suggested DAH. Methylprednisolone 500 mg daily was started. Subsequent laboratory testing showed negative legionella antigen. Rheumatoid factor (RF) was increased to 24.4 U/mL, pANCA titer was at 1:640, anti-MPO antibodies >8 HI, ANA titer was at 1:320, speckled pattern. Anti-dsDNA, cryoglobulin, cardiolipin, lupus anticoagulant, anti-glomerular basement membrane, and anti-cyclic citrullinated peptide (anti-CCP) antibodies were negative. The patient underwent a renal biopsy, which confirmed ANCA-associated vasculitis (AAV). The patient completed five days of methylprednisolone and started on rituximab with steroid tapering. He was extubated on day 7 of hospitalization. Respiratory symptoms improved, and Cr decreased to 1.56 mg/dl. The patient was discharged on a weekly rituximab infusion for four weeks.

IMPACT/DISCUSSION: Microscopic polyangiitis (MPA) is a type of AAV characterized by necrotizing small-vessel vasculitis. It can manifest as DAH and as rapidly progressive glomerulonephritis. RA is an inflammatory disease limited to joints, whereas MPA is characterized by multi-system involvement. RA pathogenesis involves immune dysregulation and activation of various cells, leading to the release of cytokines. Antibodies such as RF and anti-CCP can be detected up to 10 years before the clinical manifestation of RA. Recent studies revealed a predominance of MPA in AAV while coexisting with RA. The underlying mechanism remains unclear.

CONCLUSION: Our patient had recurrent respiratory symptoms and renal dysfunction before hospitalization. MPA-RA overlap syndrome is potentially treatable and should have a high index of suspicion in patients with preexisting RA. Timely initiation of immunosuppressive therapy at early stages is essential to prevent renal and pulmonary complications.

A CASE SERIES OF GASTRIC METASTASIS IN PATIENTS WITH A HISTORY OF RENAL CELL CARCINOMA

Jahnavi Ethakota, Bipneet Singh, Danesh kumar. Internal Medicine, Henry Ford Allegiance Health, Jackson, MI. (Control ID #4057046)

CASE:

Case 1

An 84-year-old male with a history of RCC (Clear cell type) with multiple metastases to bone and prostate, status post nephrectomy 5 years ago, presented with one episode of hematemesis, and dizziness. Admission lab work showed hemoglobin of 6.4. Endoscopic findings revealed a 7mm polypoid area with ulceration and active bleeding in the posterior wall of the stomach. This biopsy showed metastatic clear cell RCC, confirming the need for further consideration of gastric metastasis in RCC patients. Treatment involved blood transfusion and continuation of anticancer therapy (Cabozantinib).

Case 2

An 88-year-old male, with a history of RCC (Clear cell type) with multiple metastases to bone, bladder, and lung, status post nephrectomy 2 years ago, presented with acute dizziness and nausea. Hemoglobin on presentation was 6.3. Endoscopy showed five papules with central umbilicated versus ulcerated area with one having stigmata of recent bleeding. Biopsies from the largest nonbleeding lesion were taken and were diagnosed to be metastatic renal cell carcinoma. Despite treatment with multiple different regimens, the disease progressed and also had side effects, so the patient opted for hospice care

IMPACT/DISCUSSION: Renal cell carcinoma (RCC) typically metastasizes to the lungs and bones, making gastric metastasis a rare occurrence (0.2-0.7%). This case series presents two patients, with a history of RCC status post-nephrectomy, who presented with anemia. Endoscopy and biopsy confirmed metastatic gastric carcinoma, highlighting the importance of considering gastric metastasis in RCC patients. This series discusses their clinical presentation, diagnosis, and management. Gastric metastasis is infrequent, with breast, melanoma, lung, and esophageal cancers being common primary sites. RCC, the seventh most prevalent neoplasm, has an increasing incidence. Despite surgical resection, 20-50% of cases metastasize, though gastric involvement is rare (0.2%). Early detection is crucial for improved prognosis.

CONCLUSION: Gastric metastasis in RCC is rare, typically occurring late in the disease course. These cases presented earlier than average, indicating aggressive progression. Gastric metastasis in RCC patients, though uncommon, demands consideration. Early detection, even with atypical symptoms, allows for better management. The literature review revealed a median survival of 6 months post-gastric metastasis. The optimal treatment is undefined. Treatment options include embolization and epinephrine injection for bleeding and endoscopic resection or surgery. Surgical resection remains the best therapeutic option for solitary gastric metastasis, resulting in significant survival prolongation in eligible patients. The presented cases emphasize the need for continued research on early detection, optimal treatments, and prognostic factors in this subset of patients.

A CASE SERIES OF METASTATIC PROSTATE CANCER PRESENTING AS PERITONEAL CARCINOMATOSIS: A POTENTIAL PROGNOSTIC FEATURE

Tony Huynh¹; Peter Jiang²; Zhihong Zhang²; Lishi Sun². ¹Internal Medicine Residency, Washington State University, Pullman, WA; ²The Everett Clinic, Everett, WA. (Control ID #4057901)

CASE: We present an 88-year-old patient with history of prostate cancer (PC) diagnosed in 2006 but was lost to follow-up who presented with complaints of abdominal distention and pain. Subsequent workup revealed new peritoneal masses and ascites requiring multiple paracenteses. Peritoneal biopsy confirmed prostate carcinoma with neuroendocrine differentiation; he had no bone involvement on NM scan. He enrolled in hospice and passed 2 weeks after diagnosis.

Our second patient was a 72-year-old male with new omentum infiltration and ascites discovered during routine follow-up for elevated PSA. Omental mass biopsy confirmed prostate adenocarcinoma and imaging had no evidence for osseous metastasis. He had no other usual symptoms associated with PC. He was treated with abiraterone, prednisone, and leuprolide; and continues to do well 2 years after diagnosis.

The third patient was an 83-year-old male who presented with new abdominal bloating. His workup revealed prostatic adenocarcinoma involving the peritoneal serosal membrane with extensive osseous disease in the chest and abdomen. He started bicalutamide and degarelix three months ago and continues with treatment today.

IMPACT/DISCUSSION: Prostate cancer (PC) is among the most common malignancies that Internal Medicine clinicians encounter in practice. PC initially presenting as peritoneal carcinomatosis and ascites is exceedingly rare. We present three such cases from a single clinic in this case series: two without osseous involvement and one with bone metastasis. Thorough evaluation allowed for prompt determination of the disease in two of these cases.

Most PC are diagnosed in the localized stage and patients often asymptomatic. However, clinicans may associate PC with symptoms including: urinary difficulty, hematuria, or back pain. These cases offer rare initial chief complaints. Per our literature search, there was no current study that directly compares the prognosis of peritoneal carcinomatosis versus other metastatic sites. However, PC with either presentation is associated with worse outcomes. The mechanism for PC peritoneal metastases continues to be under investigation. Potential mechanisms may be iatrogenic seeding, hematogenous metastasis, or lymphatic spread. We hope that by presenting these atypical presentations of PC, we can add to the literature more information about mortality and treatment response. We hope these identifying factors can guide future patient care and treatment strategies in patients with prostate cancer.

CONCLUSION: When approaching common pathologies, clinicians should be mindful not to allow pre-conceived paradigms and schemas to interfere with a thorough workup. Despite the rare presentation of the patients' prostate cancer, prompt discovery allowed for the development of a medical plan. Peritoneal carcinomatosis secondary to prostate cancer is a known poor prognositc sign compared to non-visceral involved presentations and more research should be done to evaluate effective treatment strategies.

ACHY HEART: A CASE OF LUPUS MYOPERICARDITIS

Mashli Fleurestil^1,2. ¹Internal Medicine, University of Miami Health System, Miami, FL; ²Internal Medicine, Jackson Memorial Hospital, Miami, FL. (Control ID #4064249)

CASE: A 33-year-old woman presented with one-week of intermittent, right-sided stabbing chest pain that improved with upright repositioning. She also had viral upper respiratory infection symptoms of fever, sore throat, and malaise. Her medical history included systemic lupus erythematosus (SLE), occipital stroke, hyperlipidemia, and type 2 diabetes mellitus. On admission, vital signs were notable for tachycardia and hypertension. Physical exam revealed increased rate and regular rhythm with no rubs on cardiac auscultation. Laboratory results showed an elevated erythrocyte sedimentation rate of 23 mm/hr, C-reactive protein of 5.3 mg/dL, and high sensitivity troponin increase from 98 ng/L to 109 ng/L. The EKG showed sinus tachycardia, normal voltage, and no ST segment elevation.

Cardiology was consulted and recommended ischemic evaluation due to her multiple risk factors for atherosclerotic disease. A nuclear stress test revealed reversible anterior wall ischemia. Left heart catheterization showed no obstructive coronary disease. Persistent symptoms prompted additional investigation with a cardiac MRI, which was diagnostic for myocarditis. Lupus myopericarditis was diagnosed based on presentation and imaging findings. The chest pain resolved with one month of treatment with colchicine.

IMPACT/DISCUSSION: SLE is an autoimmune disorder where reduced self-antigen tolerance activates the innate and adaptive immune responses in excess (1,2). The condition disproportionately affects African American women when compared to age-matched counterparts (2). Skin lesions, arthralgias, and nephritis are the most common manifestations of SLE. Cytokine activation in SLE can also damage coronary arteries and all layers of cardiac muscle (3). Immune complex deposition and inflammation in cardiac tissue predispose patients to developing atherosclerotic plaques, pericardial disease, and cardiomyopathies (4). Immunotherapy with hydroxychloroquine and corticosteroids, and metabolic profile optimization can mitigate the increased risk.

Myopericarditis is a well documented complication of SLE affecting the pericardium and myocardium. Diagnostic criteria include confirmation of pericarditis with pleuritic chest pain, ST segment elevations or PR interval depressions on EKG, and/or pericardial effusion identification via imaging. Myocardial involvement is confirmed by increases cardiac enzymes, left ventricular systolic dysfunction on echocardiogram, or inflammation on cardiac MRI. Myopericarditis is typically self limiting, though guidelines recommended three month courses of NSAIDs and colchicine for symptomatic relief. If patients develop heart failure, initiating guideline-directed medical therapy is crucial to restoring cardiac function.

CONCLUSION: SLE increases the risk of cardiovascular disease, and proactive risk factor modification is critical.

Diagnosing lupus myopericarditis in patients with SLE requires the presence of pericardial disease, and biomarker or imaging evidence of myocardial involvement.

ACKEE FRUIT TOXICITY: A DIZZYING DIAGNOSIS

Afek Kodesh¹; Vicente Nehgme¹; Edwin C. Ho². ¹Internal Medicine, Montefiore Medical Center, New York, NY; ²Division of Cardiology, Montefiore Medical Center, New York, NY. (Control ID #4055556)

CASE: A 58-year-old male with six months of intermittent, nonspecific episodes of dizziness presents with one day of persistent dizziness.

At 2am on the day of admission, he was walking from his bed to the bathroom when he felt lightheaded with a prodrome of sweating. The episode persisted, unremitting, for the next several hours. He consumed tea and honey and drove to the ED. By the time he arrived at the ED, symptoms were moderately improved, but worsened again throughout the day.

He otherwise denied any auditory or neurological manifestations.

He was born in Jamaica and moved to the US 15 years prior. He consumes several Jamaican herbs and tropical fruits.

Complete physical examination was normal and his orthostatics were negative.

ECG, TTE, and MRI were all unremarkable.

Initial labs were normal. Recurrent POC glucose levels were initiated several hours after initial admission. Glucose levels decreased from 107 to 69 mg/dL even though he was intermittently consuming food.

On further history and questioning, he admitted to consuming large quantities of ackee fruit several hours prior to his current episode.

IMPACT/DISCUSSION: Dizziness is a common presentation to the ED. Generally, the greatest differentiator is whether it is continuous or episodic. When continuous, consideration of central etiologies and trauma or toxins is critical. Diagnosis of toxin-induced dizziness can be challenging, especially when initial history is unrevealing.

Ackee fruit is a native fruit of West Africa and the Caribbean islands, including Jamaica. It is banned in the United States by the FDA. Unripe fruit consumption can be toxic, due to the fruit’s contents of hypoglycin A and B. Hypoglycin A is the main toxin and is known to cause hypoglycemia due to gluconeogenesis inhibition. Although this patient’s blood glucose level was normal, this sample was taken closely after consumption of honey. Subsequent POC glucose levels demonstrated a moderate decline over the next 10 hours, even though the patient was not fasting. Spontaneous resolution of this unexplained hypoglycemia argues against other causes of hypoglycemia.

This syndrome is known as “Jamican vomiting sickness.¹” In addition to the symptoms described above, patients can present with vomiting or altered mental status. Confirmatory testing can be done with hypoglycin and its metabolite, methylene cyclopropyl acetic acid (MCPA), but will generally require special laboratory testing. Treatment is supportive with both IV fluids and dextrose. Without appropriate management, patients can develop coma and death due to the resultant electrolyte derangements.

1. Surmaitis, R. & Hamilton, R. J. Ackee Fruit Toxicity. (StatPearls Publishing).

CONCLUSION: -Consideration of culture on health can be crucial in diagnosis. It is important to incorporate culture-specific etiologies into differential diagnoses.

-Ackee fruit toxicity presents as delayed-onset hypoglycemia, which can manifest as dizziness. It can be fatal if not managed promptly.

A COMMON ABDOMINAL DIAGNOSIS FROM AN UNCOMMON SOURCE

Adriana R. Bracho²; Daniel Weinberg²; Taylor Broome¹. ¹Hospital Medicine, Duke University, Durham, NC; ²Internal Medicine, Duke University, Durham, NC. (Control ID #4064561)

CASE: A 72-year-old Caucasian female with a history of bilateral metastatic intraductal adenocarcinoma of the breast diagnosed two years prior, presented for 2 weeks of recurrent nausea and emesis. Her breast cancer had mixed histology (right breast and left axilla ER+/PR+/HER2- and right axilla ER+/PR+/HER2+) treated with neoadjuvant chemoradiation and bilateral mastectomy 2 years prior. She had continued letrozole and was considered in remission. On admission she was found to have a small bowel obstruction with retroperitoneal soft tissue thickening at the duodenojejunal junction on imaging.

Over a two-week period, the patient had multiple attempts at imaging and biopsy of the lesion. This includes small bowel enteroscopy, endoscopic ultrasound, and assessment by interventional radiology. Finally, the hepatobiliary surgery team performed a robot-assisted laparoscopy with successful biopsy of a duodenojejunal mass on the Ligament of Treitz and gastrojejunostomy for relief of obstruction. Frozen section pathology showed adenocarcinoma and immunohistochemistry was positive for markers consistent with metastatic adenocarcinoma of the breast, although now ER-/PR-/HER2- and PDL-. Notably, her breast cancer was not lobular carcinoma, which is more likely to metastasize to the GI tract. Six days after surgery she was discharged home, and after following up with her oncologist she began treatment with capecitabine.

IMPACT/DISCUSSION: Small bowel obstruction is a common diagnosis, accounting for 14% of acute abdominal pain admissions and 12-16% of surgical admissions in the United States. Most small bowel obstructions in the US are caused by adhesions from previous abdominal surgeries, hernias, and. malignancy. Malignancy is the cause of about 5% of all small bowel obstructions in the US, most commonly due to peritoneal carcinomatosis. Neoplasms around the bowel itself are quite rare. However, when they do occur, breast cancer accounts for nearly 50% of these obstructions. This case illustrates a rare example of primary intraductal adenocarcinoma of the breast with metastasis to the small bowel causing obstruction. The patient’s care required careful coordination between eight teams spanning five specialties. The biopsy required three separate attempts over the course of two weeks. However, due to persistence of all team members and the support of consulting teams the final procedure was ultimately successful, and the patient is now receiving treatment.

CONCLUSION: This case highlights the importance of performing biopsy of sites of obstruction in patients with a history of breast cancer, even those in remission.

Medical and surgical specialties do not work in a vacuum. To achieve optimal patient outcomes, consistent coordination from various specialties is required.

ACTIVATED VITAMIN D PROTOCOL FOR RAPID RESOLUTION OF SEVERE HYPOCALCEMIA PRECIPITATED BY RANKL INHIBITION IN METASTATIC PROSTATE CANCER WITH UNRECOGNIZED SEVERE VITAMIN D DEFICIENCY

Zygy Roe-Zurz¹; Aman Rajpal². ¹Internal medicine, Alameda Health System, Oakland, CA; ²Medicine/Endocrinology, Alameda Health System, Oakland, CA. (Control ID #4064804)

CASE: 72 y/o man with HIV on ART (CD4 887, undetectable VL), prostate cancer with metastasis to the bones with recent infusion of denosumab presented to ED with sudden onset severe abdominal pain associated with vomiting. His vital signs were normal and physical exam was significant for diffuse abdominal tenderness. Serological studies revealed a corrected calcium of 4.9 mg/dl with an ionized calcium of 2.6 mg/dl (his serum calcium was 8.3 mg/dl prior to Denosumab infusion) with a normal kidney function. The initial EKG showed a QTc of 520. On further testing he was found to have elevated parathyroid hormone of 485 pg/ml along with 25-OH vitamin D of < 3.4 ng/ml. His initial management included 2 grams of intravenous (IV) calcium gluconate and a single dose of 50,000 units oral ergocalciferol. His abdominal pain and EKG changes resolved as his serum calcium improved to 6.9 the following day however he was unable to maintain this level and fell below 6 mg/dl again. He continued to receive intermittent IV calcium gluconate along with oral calcium supplementation with continued fluctuation in serum calcium levels. Given the seesawing serum calcium levels, endocrine was consulted and he was started on oral calcitriol 0.25 mcg twice daily (day 5 of admission). Over next 24 hours, his calcium levels began to stabilize into an upward trend without requiring any further IV calcium supplementation. He was stably discharged with a calcium level of 7.9 mg/dl after 10 days of hospitalization.

IMPACT/DISCUSSION: Denosumab is often used in men with advanced prostate cancer to prevent skeletal-related events. Severe hypocalcemia from denosumab treatment is a rare (1%) but a recognized complication. Based on a prior retrospective study, the need for IV calcium repletion in these patients may last greater than 2 weeks, thereby prolonging the duration of hospitalization. Calcitriol has previously been deployed in severe cases of hypocalcemia from hypoparathyroidism, we however propose its early use in hypocalcemic crises induced by Denosumab. Calcitriol may act to significantly catalyze sustainable eucalcemia by reducing the need for IV calcium repletion. Also identifying the risk factors (severe vitamin D deficiency, active osteoblastic metastases, chronic kidney disease and hypomagnesemia) for developing hypocalcemia is key in preventing these complications.

CONCLUSION: RANKL inhibition can lead to life-threatening hypocalcemia requiring prolonged hospitalization for IV calcium administration. We propose early co-administration of oral calcitriol, along with transitioning to enteric repletion of elemental calcium, which may significantly lead to a crucial hospital-stay reduction. Also modifiable risk factors, such as severe vitamin D deficiency should be treated prior to Denosumab infusion to prevent this complication.

A CURIOUS CASE OF MACROGLOSSIA

Chelsea S. Pan, Puneet B. Kumar, Sheila N. Kapyur. Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4016220)

CASE: A 55-year-old female with history of hypertension, chronic kidney disease requiring hemodialysis, and presumed seronegative rheumatoid arthritis presented with subacute whole-body pain, odynophagia, and dysarthria in the setting of painful lip lesions and tongue swelling. Physical exam was notable for reduced range of motion of all extremities secondary to edema, multiple friable oral mucosal lesions with raised, scalloped edges, and an enlarged, firm tongue with teeth indentations. Imaging revealed diffuse osseous lytic lesions and labs demonstrated elevated kappa-lambda ratio and monoclonal free kappa light chain on immunofixation consistent with a new diagnosis of multiple myeloma.

Differential diagnoses for her oral ulcers and macroglossia included infection, malignancy, and vitamin deficiency. Appearance was atypical for herpes simplex virus and subsequent swab was negative. Biopsy of the mucosal lesions showed reactive hyperplasia. Vitamin deficiency workup was notable for severely low levels of vitamin C, folate, and thiamine. While the oral ulcers improved with vitamin repletion over one week, the patient’s macroglossia remained. There was growing suspicion for amyloidosis as the cause of macroglossia in the setting of newly diagnosed multiple myeloma. The patient underwent abdominal fat pad biopsy, which returned negative, followed by biopsy of the tongue itself confirming light chain amyloid deposition. She was started on induction therapy consisting of cyclophosphamide, bortezomib, dexamethasone, and daratumumab, and referred to an in-network oncologist for ongoing therapy and consideration of autologous hematopoietic cell transplantation.

IMPACT/DISCUSSION: Amyloidosis results from abnormal protein deposition, with the most common being the light chain form (AL), often associated with multiple myeloma. The clinical presentation depends on the organs involved and can include waxy skin, enlarged muscles, neuropathy, heart failure, or nephrotic syndrome. This case highlights macroglossia as the primary presentation of systemic AL amyloidosis. Alternatively, localized amyloidosis of the tongue, which often manifests as nodules, papules, or ulcers, is very rare. The patient’s friable oral ulcers and macroglossia were initially thought to be a manifestation of multiple vitamin deficiencies reflecting anchoring bias. While her ulcers improved with vitamin supplementation, her macroglossia did not, which prompted further workup for amyloidosis.

CONCLUSION: Given its variable presentation, amyloidosis remains an elusive diagnosis, but should remain on the differential in the setting of risk factors including multiple myeloma, chronic hemodialysis, inflammatory diseases, or notable family history. In particular, macroglossia should be recognized as a potential presenting symptom for amyloidosis, warranting further workup with tissue biopsy and testing for systemic amyloidosis.

A CURIOUS CASE OF RECURRENT CEREBROVASCULAR ACCIDENTS AND HYPERTENSIVE EMERGENCY INCITED BY UNDIAGNOSED NEPHROTIC SYNDROME

Saima Hafiz¹; Sadia A. Tanami²; Dhyanesh Patel⁴; Imtiaz A. Khan³; Tarek Naguib³. ¹Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²Internal Medicine, Texas Tech University System, Lubbock, TX; ³Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX; ⁴Internal Medicine, Texas Tech University Health Scienves Center, Amarillo TX, Amarillo, TX. (Control ID #4060792)

CASE: A 37-year-old gentleman with a medical history of three cerebrovascular accidents, resistant hypertension, and Class III obesity presented to the intensive care unit with left-sided weakness, left facial droop, and difficulty ambulating for approximately five hours before presentation. On examination, he was agitated, confused, tachycardic, tachypneic, dyspneic, right upper and lower extremity decreased muscle power, deep tendon reflexes +1 with blood pressure of 265/170 mm Hg. His laboratory works showed normocytic anemia, creatinine 2.2 mg/dL, eGFR 45 mL/min/1.73m2, and serum creatinine kinase of 37 U/L. Urinalysis showed +3 protein, +1 blood, 0-5 WBCs, 0-5 RBCs, and. MRI of the brain showed a small acute infarction within the right thalamus. Secondary causes of hypertension were evaluated. Duplex ultrasound of renal arteries showed no hemodynamically significant stenosis of renal arteries. Renal ultrasound showed increased echogenicity of the kidneys. Chest x-ray showed bilateral infiltrates. Hepatitis panel negative. His ANA and ANCA panels were non-significant. During the hospitalization, his creatinine did not improve with resuscitation measures, and proteinuria persisted. Three 24-hour urine protein tests done over one week showed nephrotic range proteinuria, with the last one showing 3.3 g/24 hours. Finally, the patient's kidney biopsy showed focal segmental glomerulosclerosis (FSGS). The patient's weakness and ambulation gradually improved, and he was discharged with a recommendation to follow up with a nephrologist.

IMPACT/DISCUSSION: Patients with obesity and resistant hypertension are commonplace in the internal medicine practice. Recurrent cerebrovascular accidents in a patient in an obese patient with resistant hypertension should intrigue us to evaluate kidney function with the metabolic panel as well as urinalysis. Urinalysis findings can be pivotal in guiding further investigations, such as a 24-hour urine protein study and ultimately a kidney biopsy, as in the case of your patient, leading to the diagnosis of FSGS. The correlation between the patient's FSGS, resistant hypertension, and recurrent CVAs can indeed provide a comprehensive understanding of the interplay between these conditions. Addressing the underlying kidney disease becomes pivotal in managing and potentially preventing further complications.

CONCLUSION: With our case, we would like to highlight the importance of timely evaluation of proteinuria detected in urinalysis during episodes of hypertensive emergencies or cerebrovascular accidents is crucial. Addressing urinalysis findings through further investigation could lead to the early detection of underlying kidney diseases such as nephrotic syndrome. Recognizing and managing nephrotic syndrome at an early stage can significantly impact the patient's prognosis and quality of life, as well as potentially mitigate the risk of complications.

ACUTE COLONIC PSEUDO-OBSTRUCTION "OGILVIE SYNDROME": A RARE CAUSE OF FUNCTIONAL BOWEL OBSTRUCTION- A CASE REPORT

Mohamed Sleem¹; Saima Hafiz²; Jairah Shaikh³; Ali Yusuf¹; Bharat khandheria¹. ¹Internal Medicine, Texas Tech University Health Science Center/Amarillo, Amarillo, TX; ²Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ³Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX. (Control ID #4064920)

CASE: Introduction

Acute colonic pseudo-obstruction (ACPO) also know as Ogilvie Syndrome is a distinct form of colonic dilatation without evidence of underlying mechanical or anatomical causes. Commonly observed in older adults with comorbidities like electrolyte imbalances, immobility, or polypharmacy, it can also occur post-trauma or surgery in otherwise healthy individuals. Patients typically exhibit gradually worsening abdominal distension, discomfort, nausea, and vomiting, with some experiencing bowel movements or diarrhea due to increased water secretions. Supportive care with close observation is the primary treatment. Invasive procedures or surgery are reserved for refractory cases. This case underscores the importance of recognizing ACPO as a potential cause of functional bowel obstruction and outlines suggested management plans.

Case Report

A 62-year-old male with a history of obesity and umbilical hernia presented to the ER with two days of intermittent abdominal pain, starting epigastrically and migrating to the lower abdomen. The patient also reported abdominal distention, nausea, and vomiting. On examination, obesity, significantly distended abdomen, tympany to percussion, and generalized tenderness were noted. The patient denied opioid use or recent surgeries. Laboratory results at presentation were largely normal, showing a sodium level of 135 mEq/L, potassium of 3.5 mEq/L, calcium of 8.7 mg/dL, and low phosphorus of 2.2 mg/dL. CT abdomen and pelvis revealed severe distention of the colon, especially the ascending colon (measuring 11 cm). Colonoscopy showed moderately distended and redundant colon, and a decompression tube was placed. Treatment involved bowel rest, electrolyte replacement, ambulation, and decompression tube placement, leading to significant improvement.

IMPACT/DISCUSSION: ACPO is an uncommon cause of unexplained functional colonic obstruction, advocating a conservative approach. A thorough assessment, including laboratory tests (e.g., leukocytosis and elevated lactate for bowel ischemia, liver function tests, lipase, and thyroid function evaluation), is crucial. Imaging, such as plain radiography and CT scan with oral and IV contrast, aids in diagnosis. CT scans typically reveal isolated dilatation of the cecum and ascending colon, with a gradual transition at the splenic flexure. Treatment focuses on bowel decompression, with options including observation, neostigmine if appropriate, and endoscopic colonic decompression. Discontinuing medications impacting colonic motility and encouraging ambulation are vital. Close monitoring and follow-up imaging assess cecal dilatation and potential complications. Surgical intervention may be needed if conservative measures fail or complications arise.

CONCLUSION: ACPO is a potential cause of functional bowel obstruction. Thorough and timely approach with conservative management including decompression and supportive care is important and minimizes the need for invasive procedures in uncomplicated cases.

ACUTE ILIOFEMORAL VENOUS THROMBOSIS IN A YOUNG MALE, WITH AN UNEXPECTED UNDERLYING ETIOLOGY; THINKING ZEBRAS IS ESSENTIAL AT TIMES.

Alina Sehar¹; Ali Hachem². ¹Internal Medicine, The University of Alabama at Birmingham, Birmingham, AL; ²oncology, The Cancer Center of Huntsville, Huntsville, AL. (Control ID #4046357)

CASE: A 26-year-old male with no medical history, presented to the hospital with complaints of right lower extremity pain and swelling starting 1 week ago. Vitals signs were normal. A physical exam revealed tenderness and swelling in right leg disproportionate to his left leg. US duplex showed extensive DVT in the right lower extremity common femoral vein, saphenofemoral Junction, and proximal femoral vein. CTA showed acute DVT in the right external iliac, right internal iliac, and right common femoral veins and infra-renal IVCA with numerous surrounding collateral vessels. He was started on a heparin drip. IR was consulted and he underwent a thrombectomy, resulting in the improvement of swelling and pain in his leg. He was discharged home on apixaban. He presented to the hospital 8 days later with similar complaints, including right inguinal pain. The patient was found to have extensive thrombus in the greater saphenous vein and nonocclusive thrombus in the common femoral vein. IR and Oncology were consulted, and he underwent a repeat thrombectomy, with symptom improvement. Hypercoagulable workup was negative. The patient was discharged on Lovenox every 12 hours.

IMPACT/DISCUSSION: Inferior vena cava agenesis (IVCA) is a rare anomaly, with an estimated prevalence of 0.005-1% in the general population. There are various subtypes of IVCA, amongst which infra-renal IVCA is the most uncommon and least discussed in the literature. We present a rare case of extensive and recurrent DVT found in a young man with otherwise no risk factors, who was found to have infra renal IVCA. IVCA is a rare risk factor for DVT due to poor venous drainage despite extensive collaterals. Ultrasound duplex is an initial test of choice for DVT, but IVCA can be diagnostically challenging. Hence, CT angiography and venography can provide a detailed description of the IVC. Optimal management for DVT associated with IVCA is unexplored and difficult. Per conventional wisdom, patients should be on anticoagulants for chronic periods. In incidentally found IVCA, no treatment is indicated. Patients with acute DVT are treated with oral anticoagulants (AC), but the duration of AC has not been defined. Catheter-directed thrombolysis/thrombectomy provides rapid symptom relief, offers long-lasting results, and thus should be considered. Invasive surgical interventions like IVC prostheses are also reported. Early identification of IVCA prompts timely intervention and risk reduction for complications.

CONCLUSION: While IVC agenesis is rare, it carries a risk for the development of thrombotic sequelae and bears consideration when evaluating young patients with unexplained deep vein thrombosis, especially if extensive.

ACUTE MANAGEMENT OF EUGLYCEMIC DIABETIC KETOACIDOSIS DUE TO SGLT2I USE IN A PATIENT WITH ADVANCED HFREF

Zoe C. Burger¹; Pegah Khaloo¹; Sukrit Narula¹; Jeremy Liu¹; Andrew Schwartz²; Abhay J. Dhond^1,2. ¹Department of Internal Medicine, Yale University, New Haven, CT; ²Yale School of Medicine, New Haven, CT. (Control ID #4027016)

CASE: A 79-year-old male with a past medical history of T2DM, CKD3b, and HFrEF (EF 15-20%) presented to the emergency department with hematochezia. The patient denied any nausea, vomiting, abdominal pain or dyspnea but endorsed decreased oral intake for the past two days. Vital signs in the ED were within normal limits. His hemoglobin was found to be 6.4 g/dL and he was admitted and transfused pRBCs. Admission labs were notable for bicarbonate of 17 mEq/L, normal anion gap, and glucose of 181 mg/dL. The patient had been taking dapagliflozin prescribed for heart failure for two years and sitagliptin for T2DM.

The following morning, his physical exam was significant for an increased respiratory rate and signs of hypovolemia. His morning basic metabolic panel was notable for a decreased bicarbonate to 12 mEq/L, elevated anion gap to 20 and glucose of 83 mg/dL. At this time his morning dose of dapagliflozin was held and a beta-hydroxybutyrate was sent which returned elevated at 4.77 mg/dL. A diagnosis of EDKA was made and he was carefully resuscitated with a fluid bolus and D5 ½ NS continuous fluids and IV insulin. That evening his anion gap closed and he was transitioned to subcutaneous insulin. Dapagliflozin was discontinued on discharge.

IMPACT/DISCUSSION: EDKA is an uncommon clinical syndrome characterized by euglycemia (blood glucose <250 mg/dL) with significant metabolic acidosis (arterial pH <7.3, serum bicarbonate <18 mEq/L) and ketonemia. DKA is a life-threatening complication of diabetes, however only 2.6-3.2% of DKA admissions are euglycemic which often results in delayed or missed diagnosis. In the case of our patient, his EDKA was likely triggered by poor oral intake and gastrointestinal bleeding in the setting of his SGLT-2 inhibitor (SGLT2i) use.

While there have been other reported cases of EDKA in the setting of dapagliflozin use, to our knowledge, this is one of very few cases reported in a patient with advanced HFrEF. As an important component of DKA treatment is early and aggressive fluid resuscitation, we needed to be especially mindful of the amount and rate at which we provided fluids to our patient with severely reduced ejection fraction to avoid acute pulmonary edema. Another challenge that we encountered was the lack of guidelines for the management of EDKA. Lastly, we discontinued dapagliflozin at discharge, however further investigation is needed to determine if restarting an SGLT2i is worth the risk given the mortality benefits of its use in the treatment of HFrEF.

CONCLUSION: With the expanding use of SGLT2i to treat diabetes, heart failure and chronic kidney disease, we expect to see an increasing incidence of EDKA. Early diagnosis and treatment of this condition is important as it is currently underdiagnosed, undertreated and underreported. In patients with advanced HFrEF, special consideration must be given to fluid resuscitation during treatment. Formal guidelines should be developed to assist providers in the diagnosis and inpatient treatment of EDKA.

ACUTE RENAL FAILURE AND LIVER FAILURE IN A PATIENT ON IMMUNE CHECK POINT INHIBITOR

Yuming Shi¹; Masood P. Syed²; Shannon Huggins-Puhalla²; Neha B. Etherington¹. ¹Medicine, UPMC, Pittsburgh, PA; ²Hematology/Oncology, UPMC, Pittsburgh, PA. (Control ID #4040565)

CASE: A 61-year-old woman with left breast stage IIb invasive ductal carcinoma s/p 12 cycles of neoadjuvant carboplatin/paclitaxel/pembrolizumab and 1 cycle of doxorubicin/cyclophosphamide/pembrolizumab presented with neutropenic fever, diarrhea, and generalized weakness 9 days after receiving therapy. She was pan-cultured and treated empirically with cefepime/vancomycin on admission, and a single dose of voriconazole on hospital day 8. No infectious source was identified. On day 9, patient became anuric. Cr increased from 1.6mg/dL on day 8 to 10.2mg/dL on day 13 when hemodialysis was initiated. Concurrently, she developed acute liver injury. Liver tests were normal on admission. On day 9, AST 1043U/L; ALT 443U/L, ALP 165U/L, and total bilirubin 0.9mg/dL. On day 11, values were AST 3346U/L, ALT 1139U/L, ALP 384U/L, INR 1.8. Pertinent tests were not suggestive of viral hepatitis, autoimmune hepatitis, or shock liver. On day 12, IV methylprednisolone 1mg/kg BID was initiated for presumed immune mediated hepatitis (IMH). On day 13, labs improved to AST 1231U/L, ALT 1019U/L. Bilirubin peaked at 7.4mg/dL on day 18. Steroid taper was started on day 21, when AST and ALT both improved to <5x upper limit of normal. The patient regained urine production on day 23 though remained on dialysis at discharge.

IMPACT/DISCUSSION: We describe a case of acute kidney failure and liver failure in the setting of 15 weeks of immunotherapy. The initial differential was broad and included infectious, autoimmune, toxic, and drug induced etiologies. While voriconazole has been linked to acute liver failure, this typically occurs as a dose-dependent toxicity and would be uncommon to occur after a single dose in a patient with normal baseline liver function. Hence, immune mediated adverse effects were considered. Immune mediated kidney failure and liver failure have been independently described with anti-PD1 agents, though immune mediated adverse effects typically affect a single system at a time. This patient’s acute kidney failure could have been attributed to a secondary cause (i.e. acute tubular necrosis from sustained pre-renal azotemia), however there was no strong alternative explanation for patient’s acute liver failure. IMH with anti-PD1 therapy is the third most frequent adverse event (5-10%), with high grade hepatotoxicity occurring in 1-2% of cases. This is typically observed 8-12 weeks after initiation of treatment, though have been reported at up to 21 months after. In this case, liver biopsy was not pursued as our patient improved significantly after initiation of IV steroids, which supported our presumptive diagnosis.

CONCLUSION: - Immune mediated adverse effects can first appear months after initiation of immunotherapy and should be considered as a potential cause for acute liver failure in patients receiving immunotherapy

- IMH may be treated with IV steroids which can be tapered when AST and ALT both reach less than 3-5 times upper limit of normal

ACUTE SARCOIDOSIS WITH LOFGREN SYNDROME MISTAKEN FOR CELLULITIS

Abida Babu³; Lauren Strang¹; Nikesh R. Kapadia². ¹Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL; ²Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL; ³hematology oncology, University of South Florida, Tampa, FL. (Control ID #4041512)

CASE: A 60-year-old-female with hypertension, prediabetes and venous insufficiency presented to the hospital with right ankle erythema, tenderness and bilateral lower extremity swelling for 1 month. Outpatient treatment included multiple courses of antibiotics for presumed cellulitis without improvement. She reported bilateral ankle pain, fevers, myalgias, malaise, foamy urine and 10 lb weight loss in 1 month. She had no dyspnea or cough. She denied tobacco, alcohol or drug use, recent travel or significant family history.

On admission, she was afebrile and mildly hypertensive. On physical examination, the patient had right ankle pain, confluent erythema from the ankle to the dorsum of her foot, and bilateral shin tenderness with non-pitting lower extremity edema. Significant labs included mild hypercalcemia, elevated CRP and ESR, and negative ANA, HIV, Hepatitis B and C, RPR, QuantiFERON, Urine GC, and parvovirus B19. Urinalysis showed microscopic hematuria and proteinuria. Chest Xray showed hilar fullness. CT chest, abdomen and pelvis revealed nonspecific hilar and mediastinal adenopathy, prominent nonspecific periaortic and inguinal lymph nodes, and signs of prior granulomatous disease process. We diagnosed the patient with acute sarcoidosis/Lofgren syndrome, started a steroid taper and short course of NSAIDs, and referred to Rheumatology, Nephrology and Pulmonology for further evaluation.

IMPACT/DISCUSSION: Lofgren syndrome is characterized by bilateral hilar adenopathy, fever, erythema nodosum, and periarticular ankle inflammation. This patient had a nearly classic presentation in terms of symptoms, imaging, and labs. We raise a teaching point that her atypical presentation of erythema nodosum as confluent redness rather than typical discrete circular lesions may have delayed the diagnosis. This case will add to the literature an example where atypical skin manifestations did not exclude a diagnosis of Lofgren syndrome.

This case may alter clinical practice by highlighting the need for self-awareness of failures in clinical reasoning. Anchoring contributed to delay in diagnosis with the assumption that her symptoms were due to infection, as she had multiple risk factors and had been treated for infection in both primary care and ED settings. However, thorough independent history-taking combined with expanded labs and imaging obtained inpatient pointed toward an autoimmune condition.

CONCLUSION: Consider autoimmune etiology for systemic symptoms in a patient that has not improved clinically despite treatment for infection.

It is each clinician’s duty to perform thorough and independent evaluation and assessment to avoid anchoring bias.

ACUTE TOXIC ENCEPHALOPATHY IN A HOSPITALIZED PATIENT WITH ESRD SECONDARY TO CEFEPIME-INDUCED NEUROTOXICITY

Anam K. Shaikh²; George E. Mina²; Maham Ahmad²; Omar Elkattawy¹; Nicolas Lepore¹; Diana Finkel³; Manasa S. Ayyala¹. ¹Internal Medicine, New Jersey Medical School Department of Medicine, Newark, NJ; ²Rutgers New Jersey Medical School, Newark, NJ; ³Infectious Disease, Rutgers New Jersey Medical School, Newark, NJ. (Control ID #4025805)

CASE: A 62-year-old woman with end stage renal disease on hemodialysis presented with 1-day history of right upper extremity pain and swelling at the site of her arteriovenous fistula (AVF), and 2-day history of subjective fever and chills. Her vital signs were notable for a Tmax of 100.1°F, blood pressure of 154/98, heart rate of 121 and respiratory rate of 20. Physical exam was notable for right upper extremity edema with blanching erythema and palpable thrill of her AVF. Labs were significant for leukocytosis. Venous duplex ultrasound was negative for deep venous thrombosis, however CT scan showed cellulitis of the anteromedial arm. She was started on 1000mg vancomycin and 1000mg cefepime, both renally dosed. Over the next 5 days, the patient reported improvement in symptoms. On day 6, the patient developed myoclonus of the left upper extremity, facial twitching, aphasia and an inability to follow commands. Prior to this change, the patient had no tremors or myoclonus, was alert and oriented to name, time and place, and was able to communicate without difficulty. An emergent CT head and CT angiogram were done with normal results. Cefepime-induced neurotoxicity was suspected, and the drug was immediately discontinued. She was placed on video electroencephalogram (EEG) monitoring and started on sodium valproate for symptomatic treatment of myoclonus. EEG was notable for state dependent runs of periodic generalized delta sharps (SI-GPDs) and triphasic waves, often seen with underlying metabolic encephalopathies, without evidence of seizures. On day 8, the patient demonstrated significant improvement; she was able to track objects, communicate with two-word responses and follow commands. Myoclonus of the left upper extremity was markedly reduced, and her facial twitching resolved completely. The patient’s neurological status returned to baseline on day 9.

IMPACT/DISCUSSION: This case highlights the clinical presentation of cefepime-induced neurotoxicity. Given that cefepime is renally excreted, it is important that patients with renal impairment are appropriately dosed to reduce the risk of toxicity. Cefepime-induced neurotoxicity can manifest with encephalopathy, myoclonus, or seizures. Given widespread use of cefepime for treatment of infections, it is important that physicians are aware of this adverse effect. Literature on cefepime-induced neurotoxicity is limited and its true incidence may be underreported as it may be underrecognized. While most patients have at least partial recovery, it is unclear whether the cessation of cefepime improves outcomes or if patients’ symptoms resolve regardless of cessation. Further research on manifestations, and dosing in patients with renal dysfunction is crucial to avoid adverse patient outcomes.

CONCLUSION: Patients with renal impairment are at an increased risk of cefepime-induced neurotoxicity.

Acute encephalopathy developed after 6 doses of cefepime.

Immediate discontinuation of cefepime resulted in return to baseline within 3 days.

A DEADLY SCENE: A CASE OF MITRAL VALVE PROLAPSE AND SUDDEN CARDIAC DEATH

Swagata Patnaik, Matthew Siano, Richa Chhaya. Internal Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #4063933)

CASE: Mitral Valve prolapse (MVP) is defined as a superior displacement and thickening of one or both mitral valve leaflets above the plane of the mitral annulus. MVP can have varying presentations, from an incidental diagnosis to endocarditis, arrhythmia and in rare cases, sudden cardiac death (SCD).

A 55-year-old female with a history of MVP presents to the hospital after cardiac arrest. While watching a Broadway play with her husband, she suddenly became unresponsive without a pulse. CPR was started and she achieved ROSC after being defibrillated twice for presumed ventricular tachycardia or fibrillation. Patient had a known history of MVP since age 20. Her most recent transthoracic echocardiogram (TTE), two months prior to presentation, did not demonstrate significant MR. On arrival to the hospital, she was loaded with clopidogrel, aspirin and initiated on heparin drip. She was in normal sinus rhythm with occasional premature ventricular contractions (PVC) on telemetry. Initial blood work was notable for troponin peak at 237, brain natriuretic peptide 136, and mild transaminitis. TTE showed ejection fraction 50-55%, bi-leaflet mitral valve prolapse and severe mitral regurgitation (MR). Subsequent PET/MRI revealed late gadolinium enhancement of the posteromedial papillary muscle. The patient underwent an open-heart MV and tricuspid valve repair and received a single chamber ICD for secondary prevention.

IMPACT/DISCUSSION: Arrhythmias in MVP are found more commonly in young females, although the reasoning remains unknown. Non-sustained ventricular tachycardia (NSVT) or pleomorphic VT may be seen but are also common in those without malignant MVP. Several features increased this patient’s risk of SCD, with most only being discovered following her cardiac arrest. Bi-leaflet MVP, as seen here, may increase risk of SCD, though there is insufficient data to conclude this is a risk factor in isolation. Severity of concomitant MR may be a predictor of ventricular arrhythmia. Although our patient had newly severe MR, she had longstanding MVP which may be a risk factor. One theory on the mechanism driving SCD is the idea of a combination of substrate and trigger. The traction of the prolapsed MV along the papillary muscles results in mechanical stretching which creates an area of fibrosis. This area serves as a substrate for triggered PVCs as well as a re-entry pathway for sustained tachyarrhythmias. Such a theory suggests that younger patients may benefit from earlier surgery as they have less time to develop an area of fibrosis. However, other data shows that MVP associated with mitral annular disjunction (MAD) and severe myxomatous disease may relate to SCD independent of severity of MR.

CONCLUSION: This case highlights the challenges in risk stratification of MVP-related SCD. Currently, research is underway to create tools that can identify candidates who would benefit from primary prevention therapy.

A DELAYED DIAGNOSIS OF MYASTHENIA GRAVIS IN A PATIENT WITH SCHIZOPHRENIA

Vi Nguyen¹; Francis Perkins^1,2; Adnan Husein³; Sarah W. Takimoto¹. ¹Internal Medicine, University of California Los Angeles, Los Angeles, CA; ²Anesthesia, University of California Los Angeles, Los Angeles, CA; ³Neurology, University of California Los Angeles, Los Angeles, CA. (Control ID #4056256)

CASE: A 66-year-old woman with schizophrenia on longstanding antipsychotic medications and a history of bulimia was sent to the emergency room by her primary care provider with progressive dysphagia, dysphonia, and weight loss over ten months. The patient had previously denied fatigability or ocular symptoms, though clinic exams had noted right-sided ptosis. Outpatient workup included normal basic labs, neurology referral, and unremarkable MRI brain and MRA head and neck. Differential diagnoses included extrapyramidal effects of her antipsychotic agents or a movement disorder.

On admission, her exam was remarkable for significant sinus tachycardia, tachypnea, hypophonia, right-sided ptosis, right cranial six palsy, and tremor of the head and upper extremities. CT neck was unremarkable. CTA chest showed a left lower lobe consolidation consistent with aspiration pneumonia for which she received antibiotics. Neurology and ophthalmology were consulted. Their exams found bilateral extraocular weakness with upward gaze sustained for 22 seconds (normal >60 seconds). Her negative inspiratory force was -20 cm H2O (normal <-60 cm H2O).

The patient was clinically diagnosed with myasthenia gravis crisis for which she was transferred to the intensive care unit and treated with pyridostigmine, pulse dose steroids, mycophenolate, immune globulins, and later plasmapheresis and monoclonal antibodies. Her acetylcholine blocking, modulating, and binding receptor antibodies later returned positive. After a month-long hospitalization, she was discharged home.

IMPACT/DISCUSSION: Initial symptoms in myasthenia gravis are most commonly ocular, with dysphagia and dysarthria as the most prominent early symptoms in 20% of patients. As in this case, drug-related extrapyramidal symptoms (e.g., dysphagia, Parkinsonism) may overlap or confound myasthenia gravis symptoms.

When any ocular, bulbar and/or respiratory weakness are observed, internists should have a high index of suspicion for myasthenia gravis. Patients may not notice fatigability but can be objectively assessed with sustained upward gaze, counting aloud, or other repetitive motor activities. Respiratory fatigue can be assessed with neck flexion/extension and negative inspiratory force. This case highlights the vulnerability of patients with schizophrenia and the importance of timely recognition of disease to avoid respiratory crisis.

CONCLUSION: Ocular, bulbar and/or respiratory weakness, either in isolation or alongside other symptoms, should raise suspicion for myasthenia gravis. In patients who do not endorse the classic fatigability of myasthenia gravis, exam maneuvers may be provocative. Co-existing psychiatric diagnoses and antipsychotic medication side effects may obscure concurrent neurologic diagnoses such as myasthenia gravis.

ADENOCARCINOMA OF THE COLON DISGUISED AS A PERICOLONIC ABSCESS – A DECEPTIVE DIAGNOSTIC DILEMMA

Ashish Guragain, Sreekartthik Athiyaman, Urusha Poudel, Clint Vaz. Internal Medicine, NYMC/St. Mary's General hospital & St. Clare Health, Parsippany, NJ. (Control ID #4065113)

CASE:

A 69-year-old male presented to the hospital with severe abdominal pain, and bright red stools. He had a history of four prior episodes of bright red blood per rectum before this hospitalization but was not able to schedule a screening colonoscopy in time.

Initial evaluation with CT scan of abdomen revealed a 7cm air collection along the anterior aspect of the sigmoid colon and was indicative of a multifocal tiny abscess throughout the peritoneum. Patient was admitted with the impression of sepsis secondary to pelvic abscess and sigmoid colitis. Patient’s symptoms worsened and led to emergent exploratory laparotomy with colostomy. Small bowel and sigmoid bowel resection were performed due to contaminated fluid, patchy areas of ischemia, and pericolonic abscess formation. The patient was subsequently managed in the ICU and managed with extensive antibiotic therapy, ventilator and pressor support. Pathology identified a 1 cm polypoid adenocarcinoma infiltrating the submucosa with negative resection margins, isolated pericolonic lymph nodes, and diverticulosis.

After a few days of continued ICU management, the patient eventually recovered and was discharged with instructions to follow up with oncology for continuity of care.

IMPACT/DISCUSSION:

Majority of colorectal carcinomas are detected prior to the emergence of clinical symptoms like GI bleeding, abdominal pain, altered bowel habits, weight loss, or iron-deficiency anemia. However, in the elderly population, around 25% of CRC cases manifest as emergencies, with bowel obstruction being the predominant presentation in over 80% of instances. Uncommon manifestations include perforation (10-15%), abscess formation (0.3-0.4%), hemorrhage, and fistulization with the urinary bladder or female genital organs, listed in descending order of frequency.

Patients presenting with unusual abdominal wall abscesses should undergo further assessment using imaging techniques. Abdominal computed tomography (CT) plays a crucial role in diagnosis and surgical planning, while computed tomographic colonography is a comprehensive preoperative tool for patients with suspected lesions or colorectal cancer. When faced with such scenarios, an early diagnosis, effective drainage, and decisive management play a pivotal role in minimizing both morbidity and mortality rates. This is especially critical when dealing with patients with comorbidities, as the timely elimination of the sepsis source can be a life-saving intervention.

CONCLUSION: In conclusion, highlighting the essential requirement for increased vigilance, this report illustrates the vital importance of embracing a thorough approach when confronted with atypical presentations of colon carcinoma. Additionally, it accentuates the crucial role of implementing prompt and targeted interventions in the early stages when symptoms persist despite initial therapeutics.

ADULT-ONSET STILL’S DISEASE IN A PATIENT WITH LEFT KNEE EFFUSION AND HYPERFERRITINEMIA

Grace E. Pazienza, Alexandria Lucas. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4063976)

CASE: 63-year-old male with PMH of HTN and CAD presented with a 2-day history of left knee pain limiting ambulation, which was preceded by a sore throat, rash, and fever. He denied weight loss, recent trauma, LAD, ulcers, penile lesions/discharge, travel, sick contacts, or insect bites. He denied family history of autoimmune disease. Physical exam was notable for a non-toxic appearance, normal oropharynx, edematous L knee (+1 effusion) with erythema rash, L CMC tenderness, and limited L knee ROM due to pain. A left knee x-ray showed only mild arthritic changes. There was concern for septic arthritis, therefore vancomycin and ceftriaxone were initiated. The synovial fluid analysis showed WBC 12,198, RBC 21,352 and TNC 12,198, with 94% neutrophils. Septic arthritis was ruled out given the negative blood and synovial cultures as well as otherwise negative infectious workup (group A Strep/ASO titer, HIV, hepatitis, mono, parvovirus, STIs). Other initial labs: leukocytosis of 18.5 with a left shift, ferritin 7716.3, ESR >130, CRP 205.9, microcytic anemia, and elevated liver enzymes. Although the patient’s knee pain improved, he continued to have daily fevers (Tmax 103.1F) and hyperferritinemia ( >40,000).

Differential included gout, autoimmune disease, malignancy, thyroid disease, and Still's disease. Crystalline arthropathy and autoimmune workup was negative, including ANA and RF. Malignancy workup was negative. Thyroid labs were insignificant. Adult-onset Still’s disease (AOSD) was confirmed, as Yamaguchi classification criteria was met. He was discharged on low-dose prednisone. Biologics are now being considered due to continued disease.

IMPACT/DISCUSSION: AOSD is a rare systemic autoinflammatory disorder characterized by polyarthritis/arthralgia, rash, fevers and systemic illness. The diagnostic tool of choice is the Yamaguchi classification criteria (96% sensitivity, 92% specificity). Diagnosis requires meeting 5 or more criteria including 2 major criteria. The major criteria include a fever >39 C for >7 days, arthralgias/arthritis for ≧2 weeks, rash, and leukocytosis ≧10,000 with ≧80% neutrophils. Minor criteria include sore throat, lymphadenopathy, hepatosplenomegaly, elevated LFTs, and negative RF/ANA. Ferritin is not included in diagnostic criteria, but levels >1000ng/mL are seen in 70% of cases. Mild disease is treated with NSAIDs or low-dose corticosteroids. Moderate disease is treated with prednisone 0.5-1mg/kg and occasionally biologics or DMARDs. Life-threatening disease is treated with pulse dose steroids and early biologic use. It is important to consider macrophage activation syndrome (MAS) as a potentially fatal complication of AOSD and is correlated with ferritin levels >10,000. Therefore, it is important to keep AOSD on the differential in patients with hyperferritinemia and polyarthritis as if not treated appropriately/promptly, it can be fatal.

CONCLUSION: Yamaguchi criteria can be used to diagnose AOSD.

Treatment regimen depends on severity of disease.

A DYSPHAGIC DIAGNOSTIC DILEMMA

Alice Kennedy¹; Jenna Port¹; Laura K. Snydman². ¹Internal Medicine, Tufts Medical Center, Boston, MA; ²Internal Medicine, Tufts Medical Center, Boston, MA. (Control ID #4064398)

CASE: A 38-year-old woman with history of spastic quadriplegic cerebral palsy (CP) managed with an intrathecal baclofen pump presented to the emergency department due to reduced oral intake, weight-loss, and increased salivation. Symptoms were noted by her mother and communicated through a virtual Spanish interpreter. The patient’s symptoms had worsened over several months despite medications introduced by her primary care provider, baclofen dosing adjustments, and an inpatient work-up elsewhere. Further history was difficult to elicit due to the patient’s limited ability to mouth words and the mother’s emotional distress.

Initial labs demonstrated hypokalemia (2.9) and an elevated anion gap (16), prompting admission. When given oral potassium repletion, the patient gestured to indicate chest pain and became tachycardic to the 150s, concerning for esophagitis. However, she failed to respond to IV proton pump inhibitors, H2 blockers, and a scopolamine patch. Interrogation of her baclofen pump demonstrated proper functioning. Nevertheless, a neurologically driven motility problem was considered likely given her CP. Unfortunately, a barium swallow could not be performed because the patient could not stand, as is needed to position patients for the test at our institution. Due to refractory symptoms, she ultimately underwent an upper endoscopy with biopsies that showed Grade A Esophagitis with intraepithelial eosinophil infiltration up to 90/HPF. She was diagnosed with EoE, and therapy was initiated with oral budesonide.

IMPACT/DISCUSSION: EoE is a disease with rising prevalence. Most cases are in young men with an average age 34 years. Typical presenting symptoms include dysphagia, food impaction, and chest pain with meals that does not respond to antacids. This case highlights the essential role of a patient’s subjective experience in informing appropriate testing for esophagitis. Perhaps more directed yes/no questions through an interpreter could have better elucidated our patient’s symptoms and shortened time to diagnosis. In retrospect, the absence of spasticity affecting other muscle groups indicated that a neurological cause was unlikely. Her work-up was also complicated by a desired test being inaccessible because of her pre-existing health condition. This underscores how disabled patients face inequities in diagnosis due to limitations of our healthcare infrastructure. Fortunately, in this case, diagnosis of EoE was made by histology.

CONCLUSION: Physicians should have a high index of suspicion for EoE when patients fail to respond to usual therapies for esophagitis.

Specific efforts to bridge communication barriers and advocacy for systemic solutions to inequities disabled patients face accessing healthcare infrastructure are needed.

A FATAL CASE OF RAPIDLY PROGRESSIVE MYOSITIS

Adrian M. Alonso¹; Oluyemisi O. Amoda^2,1; Robert J. Hall¹; Katherine E. Ray¹. ¹Internal Medicine, University of Florida, Gainesville, FL; ²Pulmonary and critical care, University of Florida, Gainesville, FL. (Control ID #4059685)

CASE: A 57-year-old man was admitted to the hospital with two weeks of progressive upper and lower extremity muscle weakness, weight loss, dyspnea on exertion, and dysphagia. Before this presentation, he could mobilize independently; however, at the time of admission, he could not stand without assistance. Vitals on arrival were normal. Labs were significant for a CK level of 2,632 U/L (reference < 320 U/L), LDH of 1,096 IU/L (reference 135-225 IU/L), and mildly elevated liver enzymes.

Muscle strength was 3/5 in his extremities. Bilateral MRI of the thighs was significant for diffuse muscular edema, consistent with myositis. Because of his rapid symptom progression, there was concern for a severe form of inflammatory myositis. He was started on IV methylprednisolone and intravenous immunoglobulin. At this time, his myositis panel returned positive for anti-signal recognition peptide (SRP) antibody. Subsequent EMG testing revealed severe axonal sensorimotor peripheral neuropathy with myopathic units. After a week of treatment, the patient continued to have weakness and difficulty breathing. The patient was severely debilitated with significant muscle wasting and became more somnolent. He had sudden onset diarrhea associated with tachycardia. CT abdomen revealed pneumatosis intestinalis. Due to his poor overall health, surgery was not performed, and the family elected for comfort care.

IMPACT/DISCUSSION: The diagnosis of myositis is based on a clinical history of progressive weakness, dysphagia, and imaging showing muscle edema. EMG studies and muscle biopsies are frequently also performed to confirm the diagnosis. This patient's clinical presentation was indicative of severe myopathy. He had progressive dysphagia, as well as loss of deep inspiration, leading to reduced vital capacity. He ultimately passed away from an inability to breathe and pneumatosis intestinalis. Pneumatosis has been associated with certain types of myositis, most notably dermatomyositis and polymyositis. Other cases have reported swift development of myositis-associated interstitial lung disease; however, this case is unique as the patient had no evidence of rapidly progressive acute parenchymal lung disease. Myositis typically does not lead to fatal cases. This patient also had a positive anti-SRP antibody, which has been associated with severe forms of necrotizing myositis, resistant to treatment.

CONCLUSION: This case highlights the importance of myositis recognition in patients with rapid-onset weakness. Weakness is a common concern for patients presenting to the hospital. Therefore, the general internist needs to identify symptoms that may suggest myositis, such as the distribution of weakness, dysphagia, and dyspnea. Early treatment is typically associated with improved outcomes. Subsequent treatments with IVIG or starting rituximab may have enhanced the patient's clinical condition; however, he ultimately expired from bowel ischemia and generalized weakness.

AFTERNOON SERUM CORTISOL AND ACTH LEVELS: A METHOD TO DIFFERENTIATE CUSHING DISEASE AND METABOLIC SYNDROME

Saima Hafiz¹; Tanzina Afroze¹; Letisha Mirembe²; Dhyanesh Patel³; Harold Werner¹. ¹Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX; ²Medicine, Texas Tech University System, Lubbock, TX; ³Internal Medicine, Texas Tech University Health Scienves Center, Amarillo TX, Amarillo, TX. (Control ID #4016248)

CASE: An 18-year-old male with no significant past medical history was admitted to the behavioral health facility for major depressive disorder with suicidal ideation. The patient had morbid obesity with a BMI of 40.4. His body habitus was unique compared to his other family members; he had a prominent dorsocervical fat pad, central obesity, and no abdominal striae. Pediatric growth curves were unavailable. However, since 5th grade, he gained much more weight than his peers but less height. His bloodwork was normal except for hemoglobin A1c of 6%, indicating pre-diabetes, and he was started on metformin 250 mg twice daily. Also, he had a persistently high blood pressure of 150s/90s mmHg. A serendipitous cortisol level at 1400 hours (well after the cortisol peak) was markedly elevated at 21.9 mcg/dL (1.8-13.6 mcg/dL, pm reference range); thus we recognized that the diurnal rhythm of cortisol was very abnormally high, an important sign of Cushing syndrome. Also, his afternoon ACTH diurnal rhythm was abnormally elevated at 66.7 pg/mL, (6-50 pg/mL, am cortisol). The abnormal diurnal rhythms and very high cortisol in the presence of elevated ACTH were highly suggestive of hypercortisolism secondary to Cushing disease. Patient circumstances have prevented pituitary imaging at this time, and it will be available soon.

IMPACT/DISCUSSION: Our patient’s morbid obesity along with new onset hypertension and prediabetes is consistent with either Cushing syndrome or metabolic syndrome. His history of stunted growth, central obesity, and new onset of psychiatric issues suggested the clinical diagnosis of Cushing syndrome rather than metabolic syndrome. The fact that he did not have any abnormal abdominal striae, is not unusual for a young person with Cushing syndrome. His very high afternoon cortisol and inappropriately elevated ACTH, indicated diurnal rhythm is absent with both hormones. This indicated the negative feedback suppression of ACTH with high cortisol was lost. Thus, all of his clinical and laboratory findings helped to diagnose hypercortisolism due to Cushing syndrome and very likely Cushing disease.

CONCLUSION: In our internal medicine resident clinic, morbid obesity and metabolic syndrome are common. Most have primary obesity, but we always are alert to find a secondary cause of the morbid obesity. A common problem in office diagnosis is to distinguish the rare patient with Cushing syndrome from the numerous patients with metabolic syndrome. Our findings in this patient suggest the possibility of using an afternoon cortisol level to differentiate a rare but treatable Cushing syndrome patient from the many with metabolic syndrome. In a patient with Cushing syndrome, the diurnal rhythm of cortisol and ACTH secretion is lost. Thus, abnormally high both afternoon cortisol as well as ACTH levels can be a valuable tool to quickly diagnose Cushing syndrome and its etiology Cushing disease from patients with metabolic syndrome.

A FULL BLAST CASE OF MALIGNANT SPINAL CORD COMPRESSION - AN UNFAMILIAR PRESENTATION OF A FAMILIAR DISEASE

Samia Nadeem¹; Yamna Jadoon¹; Prarthna Bhardwaj². ¹Internal Medicine, University of Massachusetts Chan Medical School - Baystate Regional Campus, Springfield, MA; ²Hematology and Oncology, University of Massachusetts Chan Medical School - Baystate Regional Campus, Springfield, MA. (Control ID #4063927)

CASE: A 65-year-old female with history of chronic back pain on long term opioid therapy, presented to the hospital with progressively worsening acute on chronic lower back pain and bilateral lower extremity weakness for 6 weeks leading to inability to walk unassisted, and bowel and bladder incontinence for 2 weeks. She also had perianal numbness and tingling in her hands. Magnetic resonance imaging showed multiple osseous lesions throughout the thoracic and cervical spines, multiple compression fractures and a circumferential epidural enhancing mass at T12 causing moderate spinal canal stenosis and early cord compression. The patient’s presentation and work up were suggestive of metastatic disease. Imaging of the chest, abdomen and pelvis did not show any evidence of primary cancer. Intravenous dexamethasone and palliative radiotherapy were started for management of spinal cord compression, with subsequent improvement of back pain and lower extremity weakness. A review of her complete blood counts showed a pattern of chronic leukocytosis and thrombocytosis, raising concern for myeloproliferative neoplasia. Immunoglobulin testing and serum protein electrophoresis were negative for myeloma. Biopsy of the T12 lesion revealed a malignant neoplasm likely of hematopoietic origin. Bone marrow biopsy was obtained for further classification, which eventually confirmed CML blast crisis characterized by BCR-ABL positivity and clusters of undifferentiated blast cells effacing 80–90% of the marrow. Cytogenetics showed a complex karyotype with translocation (9;22) and trisomy 19 supporting CML with cytogenetic progression. The patient died two days later without an apparent cause on post-mortem examination.

IMPACT/DISCUSSION: This case portrays an unusual presentation of CML blast crisis. Our patient presented with typical symptoms of cord compression including low back pain, lower extremity weakness, perianal numbness, and bowel and bladder incontinence. She was ultimately diagnosed with CML, which is a myeloproliferative neoplasm consisting of 3 clinical stages over its lifetime, as disease burden increases and mutations accumulate. There is a chronic phase that can last years, followed by an accelerated phase lasting approximately 4 – 6 months, culminating in blast crisis which typically lasts for a few months. CML blast crisis usually presents with fever, splenomegaly and bone pain, of which our patient only had bone pain.

CONCLUSION: Malignant spinal cord compression is mostly caused by solid tumors but hematological malignancies, particularly multiple myeloma and non-Hodgkin's lymphoma, are often implicated. Acute and chronic leukemia contribute to less than 3% of cases of tumor related compressive myeolopathy. CML is typically an indolent disease with 50% of cases diagnosed in asymptomatic patients. Symptoms of CML are usually related to splenomegaly and anemia, corresponding to the chronic phase. It is important to recognize that CML can have atypical presentations when it progresses.

AGAINST MEDICAL ADVICE DISCHARGE FORMS – UNPROVEN BENEFITS AND PROVEN HARMS

David Sterken. Hospital Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4064058)

CASE: A 25-year-old man with major depressive disorder and polysubstance use disorder presented after a suicide-attempt via forearm laceration. His lacerations were repaired, and he was admitted to the hospital medicine service for management of alcohol withdrawal.

Prior to being deemed medically ready for discharge, he told his nurse that he wanted to leave the hospital. The unit charge nurse had him sign our institution’s “Against Medical Advice” (AMA) discharge form and then told him that he may leave the hospital. His medical provider was subsequently notified, but since he was currently unhoused and did not have a working telephone, there was no way to contact him to discuss outpatient planning such as medication reconciliation, suture removal, follow-up appointments, etc.

IMPACT/DISCUSSION: It is common practice in the US to have patients sign an “AMA discharge form” when discharging them before medically advised, wherein they confirm that they understand the potential consequences of discharging and attest that they will not hold institution responsible for those consequences. Purported benefits to the institution include protection from legal liability and avoidance of Medicare readmission penalties, and proponents claim these forms help ensure patients are properly informed of the potential consequences of their decision.

All of the above can be accomplished with an informed consent discussion and appropriate documentation in the discharge summary, however; there is no convincing evidence of any added clinical or legal benefits from AMA discharge forms.

In contrast, there is growing evidence that AMA discharge forms stigmatize patients, interfere with informed consent, distract from safe discharge planning, reduce access to care, and disproportionately affect marginalized groups. In the case presented above, for example, nursing staff had been acculturated to view this form as the most important part of an AMA discharge, which precluded completion of crucial patient safety tasks. Providers, too, can falsely believe they no longer have an obligation to provide discharge prescriptions or other care because they are absolved from potential blame.

Furthermore, many AMA forms are not legally enforceable because they 1) lack the legal concept of “consideration” by both parties, and 2) contain “exculpatory language” which is invalid in multiple states. They have the appearance of contract, however, and thus may mislead patients to incorrectly believe they have relinquished their right to legal recourse. Patients may also be under duress (e.g., experiencing substance withdrawal) or feel coerced to sign, may be leaving due to mistreatment by staff, and may not know their right to leave the hospital is not contingent on this form.

CONCLUSION: Traditional AMA discharge forms have unproven benefits, proven harms, and should be either eliminated or drastically overhauled in favor of more patient-centered practices. Evidence-based alternative forms which accomplish these goals do exist.

A HAIRY SITUATION: A UNIQUE CASE OF HAIRY CELL LEUKEMIA PRESENTING AS A BONY LESION

Joshua Dein, Sara Chitlik, Carol Burke. Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4060024)

CASE: A 49-year-old male with a history of right biceps tendonitis, atrial fibrillation (not on anticoagulants), and chronic thrombocytopenia was referred to an orthopedist for 3 months of worsening right arm pain. An MRI of the right shoulder and arm revealed a 2 x 3 cm lesion in the right humeral head and blood work showed a WBC count of 3.2k and platelets of 41k. Given the bony lesion and CBC abnormalities, he was directly admitted to the hospital. Upon admission, he had no constitutional symptoms, was not on any medications, and had no alcohol or illicit drug use. He reported that his thrombocytopenia had been present for at least two years. He denied easy bruising or recent bleeding. His vital signs were stable and physical exam was remarkable only for mild weakness on right forearm flexion. His admission CBC was notable for a WBC count of 2.92k, ANC of 700, and platelets of 49k. Blood work from 2022 revealed WBC count of 3.67k, ANC of 1200, and platelets of 60k, with a normal CBC back in 2019. Hematology was consulted and peripheral flow cytometry was sent and revealed 2% kappa-restricted B cells consistent with hairy cell leukemia (HCL). He underwent a bone marrow biopsy and a biopsy of the humeral head lesion, which showed 40% marrow involvement by HCL and humeral marrow space with confluent involvement by HCL, respectively. Staging CT showed splenomegaly. He was discharged with plans to initiate cladribine.

IMPACT/DISCUSSION: HCL is a mature B-cell disorder that comprises 2% of adult leukemias. It has a higher incidence in middle-aged men and commonly presents with generalized fatigue, hypersplenism, and cytologic abnormalities due to bone marrow infiltration. This patient’s presentation was unique in that his HCL was discovered inadvertently after evaluation of worsening tendonitis with subsequent MRI showing humeral head lesion. Although rare, lytic bone lesions have been described in association with HCL in the literature, most often affecting the proximal femur and occasionally associated with other paraproteinemias like multiple myeloma. Clinicians should be aware of the more uncommon lytic lesions which can manifest as part of HCL, as musculoskeletal symptoms may lead to its ultimate diagnosis. Chronic, even mild cytologic abnormalities, such as the leukopenia and thrombocytopenia seen in this patient, should raise the level of suspicion for underlying HCL. This allows for prompt diagnosis and timely treatment. In the presence of symptoms, like the arm pain in conjunction with a bony lesion in this case, treatment with chemotherapy is warranted.

CONCLUSION: -Underlying myelodysplastic conditions, including HCL, should be considered in the differential of both acute and chronic hematologic abnormalities.

-The clinician should recognize the association of HCL with osteolytic bone lesions.

AIR-RAISING CONFUSION: PNEUMOMEDIASTINUM MASQUERADING AS INFERIOR STEMI

Lillian Abdelmalek¹; Roshni V. Khatiwala²; Sandhya Venugopal². ¹Internal Medicine, UC Davis Health, Sacramento, CA; ²University of California Davis Division of Cardiovascular Medicine, Sacramento, CA. (Control ID #4061685)

CASE: A 61-year-old man was brought to the emergency room with chest pain after a motor vehicle collision where he crashed into a tree at freeway speed. Blood pressure was 68/46 mmHg, heart rate 104 bpm, respiratory rate 26, and oxygen saturation 100% on a non-rebreather mask. Initial electrocardiogram (EKG) showed a bifascicular block (BFB) with a right bundle branch block (RBBB) and left posterior fascicular block (LPFB), with no prior for comparison. Serial troponin T were elevated but flat in the 70s. EKG 8 hours later showed BFB resolution. Imaging was remarkable for bilateral hemopneumothorax for which bilateral chest tubes were placed. On admission day two, he underwent right-sided thoracotomy and video-assisted thoracic surgery (VATS). On postoperative day one, he developed acute severe hypotension and tachycardia with focal ST-segment elevation in inferior leads II, III, and aVF on EKG. He was taken for emergent cardiac catheterization, which showed no coronary artery disease. Left ventriculography was significant for pneumomediastinum (PMD).

IMPACT/DISCUSSION: PMD is the presence of gas or air in the mediastinum and can be primary (spontaneous) or secondary. PMD is associated with various EKG abnormalities including electrical alternans, T-wave inversions, low voltage QRS, and R-wave progression loss. Proposed mechanisms for these findings include cardiac displacement or rotation, heart insulation by mediastinal air, and enlargement of the right ventricle. Rarely have ST-segment changes associated with PMD been described in the literature previously, as in our case above. Secondary PMD can result from traumatic chest or abdominal injuries, in addition to iatrogenic mediastinal structure manipulation across a variety of procedures including thoracic and abdominal surgery, endoscopic procedures, cardiac catheterizations, and endotracheal intubation. The PMD in this case was likely trauma-induced with possible exacerbation during the right-sided thoracotomy. PMD was likely the cause of his focal ST elevations, mimicking an inferior wall ST-segment elevation myocardial infarction (STEMI). This case highlights a rare association in an uncommon pathologic state, and early identification is vital.

CONCLUSION: PMD is rare and despite the previously associated EKG changes, ST-segment abnormalities are uncommon. Thus far, only a few cases exist in the literature. Although rare, it is imperative for clinicians to recognize that PMD may mimic a STEMI.

A MASKED APPEARANCE OF RICHTER’S SYNDROME

Zaraq Khan¹; Muhammad Yafaa Naveed Chaudhary¹; Margaret Beliveau². ¹Internal Medicine, Indiana University Southwest Indiana Internal Medicine Residency, Evansville, IN; ²Mediicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #4064792)

CASE: A 54-year-old female presented with worsening jaundice and nausea. She was otherwise asymptomatic, remaining this way until discharge. Her past medical history (PMH) was only remarkable for chronic lymphocytic leukaemia (CLL) in remission. She denied tobacco, alcohol, or recreational drug use. Initial labs were significant for severe acute liver injury (ALF) with raised liver enzymes (ALT 1960, AST 1412, ALP 371 and bilirubin 20.2), but were otherwise unremarkable including a normal CBC. A hepatic panel showed no evidence of auto-immune, viral, metabolic, or toxic aetiology. CT abdomen and pelvis showed evidence of enlarged lymph nodes above and below the diaphragm including left supraclavicular, mediastinal and celiac. However, no palpable lymphadenopathy was noted on examination at this time. A potential relapse of CLL was considered, but it was thought of as being in its early stages and unrelated as a likely cause of ALF. Following admission, the patient’s transaminitis continued to worsen. A liver biopsy was completed with pathology noting dense lymphocytic inflammation in periportal areas and parenchyma with interface hepatitis and ballooning degeneration. Evidence of portal infiltration with small, atypical lymphocytes that were CD20, CD23 and CD5 positive was also noted. These findings were in keeping with active CLL/small lymphocytic lymphoma (CLL/SLL), then making hepatic infiltration from hematologic malignancy the leading diagnosis. A week into the patient’s admission, she began to display worsening lymphocytosis with palpable lymphadenopathy. Biopsy of an enlarged left inguinal lymph node revealed features suggestive of high-grade transformation of CLL to diffuse large B cell lymphoma (DLBCL), finally confirming a diagnosis of Richter’s transformation. The patient was started on steroids with symptom improvement. Upon discharge, she received outpatient follow-up by hematology/oncology for management.

IMPACT/DISCUSSION: Richter’s syndrome is an uncommon complication of CLL/SLL. Patients usually present with B symptoms, including fever, night sweats, and weight loss. Rarely does it initially present as organ dysfunction alone. As discussed by Kreiniz et al., whilst acute liver failure is a recognized complication of CLL/SLL, very few cases have been linked to Richter’s syndrome. Our case adds to the literature by displaying an atypical presentation of the latter, as this patient’s chief complaint remained jaundice throughout with no evidence of any B symptoms. This demonstrates the importance of maintaining clinical suspicion for Richter’s syndrome when presented with a case of organ dysfunction in a patient with a PMH of CLL.

CONCLUSION: Hepatic injury secondary to Richter’s transformation can be difficult to diagnose in a patient without the typical associated symptoms. Liver involvement being rare makes it more difficult. In a case with significantly elevated liver enzymes and PMH of CLL, it should be acknowledged as a potential diagnosis.

AMBIGUOUS DIAGNOSIS IN A PATIENT WITH JAUNDICE, TRANSAMINITIS, AND WEIGHT LOSS

Gina Ma¹; Saman S. Ahmadian³; Zachary Zins¹; Xiaomei Meng². ¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Hospital Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ³Pathology, The Ohio State University, Columbus, OH. (Control ID #4064095)

CASE: A 45 y/o male with a history of sarcoidosis, recurrent pancreatitis from alcohol use, and prior cocaine use presented with significant weight loss, transaminitis, and worsening jaundice. He was diagnosed with pulmonary and liver sarcoidosis in 2021 after presenting with a chronic dry cough, mild transaminitis and mild elevated bilirubin. Liver biopsy and bronchoscopy confirmed non caseating granulomas, and he followed in clinic for surveillance without active treatment. On presentation, he had 26% weight loss over 2 years, worsening transaminitis, and bilirubin levels up to 8mg/dl. CT imaging showed gallbladder wall thickening with multiple intraabdominal nodules. PET revealed hypermetabolic and diffuse lymphadenopathy, hypermetabolic splenic lesions, and hypermetabolic bilateral airspace opacities. ERCP showed a main bile duct stricture requiring stent placement and an irregularity in the main bile duct and left main hepatic duct. EUS revealed enlarged lymph nodes in the perihilar area, with both cytology and lymph node FNA pathology showing inflammatory debris without malignant cells. He progressively became weaker and cachectic, eventually aspirating and developing ARDS with hypoxic respiratory failure. Repeat MRCP showed a suspected tumor at the gallbladder fundus, though another ERCP with biopsy could not be performed due to his clinical status. His respiratory condition continued to worsen and he eventually passed away. Autopsy results showed invasive cholangiocarcinoma involving the gallbladder, liver, and possibly pancreas, mixed with active liver sarcoidosis. Lung findings included remote granulomas with signs of ARDS.

IMPACT/DISCUSSION: This report describes how liver sarcoidosis can mimic malignancy due to similar findings of weight loss, diffuse lymphadenopathy, splenic and liver lesions, elevated liver enzymes, and hypermetabolic regions on PET scan. However, markedly increased elevations in labs and significant weight loss of 26% as seen in this patient should prompt more aggressive malignancy workup earlier on. By delaying invasive biopsy procedures in favor of more conservative imaging, his diagnosis was not apparent until after death when his autopsy ultimately confirmed concurrent active sarcoidosis with concurrent cholangiocarcinoma. By the time he was being considered for another biopsy due to equivocal findings from his lymph node FNA and the presence of a gallbladder mass, his clinical status had deteriorated to the point where he could no longer undergo the biopsy. Our patient presented with worsening hyperbilirubinemia with failure to thrive, raising concerns of active hepatic sarcoidosis versus malignancy, which should have prompted earlier attempts to obtain a more conclusive biopsy result.

CONCLUSION: Liver sarcoidosis can mimic cholangiocarcinoma. Early biopsies are crucial when warning signs are present before further clinical deterioration occurs.

AMIODARONE INDUCED SCLERODERMA RENAL CRISIS

Salman S. Qureshi, Mansi Sheth, Kate Radvansky. Internal Medicine, Jefferson Enterprise, Philadelphia, PA. (Control ID #4064937)

CASE: Our patient is a 54 year old female with a past medical history of scleroderma on active immunosuppressive therapy, pulmonary fibrosis, pulmonary hypertension and chronic opioid use due to chronic constipation who presented due to syncope, weakness and hypoxia that did not improve despite recent ER evaluations and treatments. Initial workup was notable for elevated troponins, patient was admitted to the hospital for further evaluation and treatment. She was seen by Cardiology who on admission did not recommend any acute interventions initially but was patient converted into atrial fibrillation w/ rapid ventricular response requiring Diltiazem infusion. Electrophysiology was consulted and started her on a DOAC and recommended cardioversion, which was done but unsuccessful in maintaining sinus rhythm. With this, amiodarone was started and after induction doses patient showed signed of hypertensive emergency then abruptly began to show signs of cardiogenic shock, including bradycardia, hypotension and bi-ventricular systolic failure seen on bedside echocardiogram. Patient was upgraded to ICU for inotropic and pressor support. Bloodwork results were notable for concerns of acute renal failure, with significant elevation in creatinine and blood urea nitrogen (BUN). Review of chart noted that she became anuric over the initial 24 hour period of treatment as well. Patient was taken off amiodarone with immediate improvement in cardiac and urine output. However, she remained in uncontrolled atrial fibrillation during the rest of her hospital course and was discharged to hospice on oral beta-blocker for palliation.

IMPACT/DISCUSSION: Use of amiodarone for atrial fibrillation is a common tool used and has been studied to be safe and effective in most patient. Our patient with known scleroderma with progressive systemic complications including pulmonary fibrosis and pulmonary hypertension prior to this hospital course puts our patient at high-risk for complications from any medication intervention. Use of amiodarone immediately caused our patient to rapidly progress into acute renal failure and immediate discontinuation showed rapid improvement.

CONCLUSION: In conclusion, the use of amiodarone should be closely monitored in scleroderma patients. Individuals who have systemic impacts from scleroderma, including systemic sclerosis and cardiomyopathy, prior to initiation of amiodarone are at higher risk for complications once therapy has started, including acute renal failure.

AM I THE ONE IN HUNDRED: A CASE OF FALSE POSITIVE HIV TEST

Mohamadanas Oudih¹; Katherine McPherson¹; Min Ju Kim¹; Muhammad A. Khan¹; Joseph Hong². ¹Internal Medicine, Montefiore Wakefield Campus, Bronx, NY; ²Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4030888)

CASE: We present a case of a 41-year-old female with a family history of hereditary spherocytosis who presented to the general medical floor with recurrent fever, frontal headaches and myalgias for five days. Her myalgias developed into bilateral lower back pain and she continued to have recurrent fevers with a maximum temperature of 103 F despite supportive treatments. Her complete blood count on admission was significant for pancytopenia. The patient reported recent travel to Arizona three months before admission and two visits to Las Vegas in the past few months. She denied rashes, hiking, camping, outdoor activities, and sick contact. She reported that she is in a monogamous relationship. During the hospitalization, the patient was found to have preliminarily positive HIV Ab/Ag on two separate assays, with negative confirmatory testing. To further confirm the validity of the HIV Ag/Ab testing, HIV viral load and CD4 count were assessed. Viral load was negative and CD4 count was 398 cells/uL. With a thorough infectious work-up for pancytopenia, the patient was found to have positive EBV IgM and Parvovirus B19 IgM, which we suspect caused the false-positive HIV Ab/Ag test. However, the premature result of a positive HIV Ag/Ab test was emotionally traumatizing and had a negative psychosocial impact on the patient and her family. Psychiatry and social work services for post-test counseling were offered until we confirmed the results.

IMPACT/DISCUSSION: HIV Ab/Ag assay sensitivity and specificity are 99.94% and 98.78%, respectively. False positive results are relatively rare, with a false positive rate of 1.22%, representing a reliable screening test.^[1,2] In our case, the HIV Ab/Ag assay was positive twice. However, when confirmatory tests with HIV-1/HIV-2 antibody differentiation and HIV viral load were done, both were negative. Multiple case reports have shown possible false positive HIV Ab/Ag testing in malignancy and cross-reactivity with antibodies to pathogens such as EBV, SARS-CoV-2 and hepatitis C.^[3,4,5] As the diagnosis of HIV can have a negative psychosocial impact on patients and their family members, it is essential to consider false-positive results in the differential for patients who otherwise lack risk factors for HIV transmission. Also, it is necessary to provide appropriate pre-test counseling in those situations.

CONCLUSION: Although a false positive HIV Ab/Ag test is rare, patients who are at low risk for acquiring HIV should be tested for other clinically appropriate infectious causes.

EBV virus represents one of the most common causes of false positive HIV Ab/Ag test.

HIV pre-test and post-test counseling should always be offered, and psychosocial support must be provided to patients with positive results.

AN 87-YEAR-OLD WITH RESOLUTION OF CARDIOGENIC SHOCK AFTER COMPLEX PERCUTANEOUS INTERVENTION

Ruxandra Ionescu¹; Madeline Sharp¹; Krishna Tummalapalli². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Cardiology, UPMC Shadyside, Pittsburgh, PA. (Control ID #4062610)

CASE: An 87-year-old female with hypertension, atrial fibrillation, breast cancer, and dementia presented to the emergency room with sudden-onset chest pain and dyspnea. She was found to have an anterior ST-elevation myocardial infarction (STEMI) with new anteroseptal wall motion abnormalities and reduced ejection fraction (25-30%) on echocardiogram. Providers were hesitant to intervene due to the patient’s age, prognosis, and goals of care. After discussion, her longstanding Do-Not-Resuscitate code status was reversed for a cardiac catheterization. She was found to have 90% disease of her left main coronary artery and 80% disease of her left anterior descending artery with an extremely low cardiac index (1.2 L/min/m2). An intra-aortic balloon pump was placed prior to transfer to a larger hospital where complex percutaneous intervention (PCI) could be performed. She was trialed on milrinone without significant improvement. Providers were again reluctant to pursue aggressive care, but after discussion with family she was intubated and underwent successful PCI. She was soon extubated, her balloon pump and inotropic support were withdrawn, and she was transferred out of intensive care. Ten days after initial presentation she was discharged to a nursing facility.

IMPACT/DISCUSSION: This case supports literature demonstrating that elderly patients derive mortality benefit from early revascularization in STEMI and cardiogenic shock. Clinicians may harbor ageism bias when considering interventions such as PCI for elderly patients. Patient age should be considered in conjunction with functional status, procedural risk, and patient values. The Journal of the American College of Cardiology has published that many risk-stratification tools predicting mortality are not validated in patients over 75 years old. Some older patients may prioritize survival time, and for others quality of life is more important. Due to the limitations of conventional risk-stratification tools, they should be used only as part of a broader shared decision-making process when considering interventions in elderly patients.

CONCLUSION: Recognizing ageism bias is crucial in facilitating effective shared decision-making with elderly patients considering complex procedures. Risk stratification tools for PCI are not well-validated in patients over age 75. Elderly patients derive mortality benefit from PCI in STEMI and cardiogenic shock.

AN ALTERNATIVE MULTIDRUG REGIMEN FOR MULTIBACILLARY HANSEN’S DISEASE

Nazar Akhverdyan¹; Zachary Cantor². ¹School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4060750)

CASE: A previously healthy 30-year-old male who recently immigrated to the United States from South America presented with eight months of nodular skin lesions on his face and extremities, nasal obstruction, epistaxis, and facial numbness. Exam was notable for numerous erythematous papules and nodules on the bilateral earlobes, face, extensor surfaces of the forearms, and lower extremities. Additionally, there was left facial hypoesthesia, edema of the external nose, hyposensate anterior nasal cavities, and an ulcerated papule on the dorsal aspect of his right hand. Laboratory studies, including complete blood count, basic metabolic panel, liver enzymes, inflammatory markers, blood cultures, HIV, TB Quantiferon Gold, and viral hepatitis panel were within normal limits. Biopsies of the nasal mucosa and right dorsal hand showed a dense dermal infiltrate of vacuolated histiocytes with numerous organisms on Fite stain compatible with Mycobacterium lepromatosis. The patient was started on a once monthly regimen of rifampin, moxifloxacin, and minocycline (RMM) for an anticipated 12-24 months. On follow-up, there was improvement of his cutaneous lesions without signs of reversal reaction or erythema nodosum leprosum.

IMPACT/DISCUSSION: Leprosy (Hansen’s disease), caused by the acid-fast bacilli Mycobacterium leprae and Mycobacterium lepromatosis, frequently effects the skin and peripheral nerves. Clinical manifestations arise due to the host’s cellular immune response and include hypopigmented or erythematous cutaneous lesions, peripheral nerve enlargement, and sensory loss. Despite public health efforts to eliminate the disease, nearly 200,000 new cases are reported annually to the World Health Organization, primarily from Africa and Southeast Asia. According to the National Hansen’s Disease Program, 159 new cases were reported in the United States in 2020. Treatment of multibacillary leprosy consists of 12-24 months of multidrug therapy with dapsone, rifampin, and clofazimine. However, this regimen is associated with high pill burden and side effects that limit adherence, such as skin discoloration, hemolytic anemia in G6PD deficiency, agranulocytosis, and hepatotoxicity. A recently published case series of 10 patients with multibacillary or pure neural leprosy treated with RMM for 12-24 months demonstrated rapid clinical response, minimal side effect profile, and improved adherence. We report a case of multibacillary leprosy with mucosal involvement treated successfully with RMM.

CONCLUSION: Prompt diagnosis and treatment is crucial to reduce disease transmission and sequelae, which includes nerve function impairment, ocular injury, and stigmatizing physical deformities. This case report adds to the growing repertoire of literature supporting the use of RMM. Further studies are needed to assess the efficacy of this regimen and monitor rates of relapse and delayed immunologic reactions, which may occur 5-10 years after completion of treatment.

AN ATTACK FROM WITHIN: A RARE CASE OF IMMUNOTHERAPY INDUCED MYOSITIS

Amira Eftaiha¹; Erica Roman²; Bradley Sackfield²; Huthaifah Aburumman¹; Kanishka Chakraborty². ¹internal medicine, East Tennessee State University, Johnson City, TN; ²oncology, East Tennessee State University, Johnson City, TN. (Control ID #4060126)

CASE: An 85-year-old male with history of metastatic renal cell carcinoma presents with bilateral lower extremity weakness and left-sided ptosis after recent initiation of immunotherapy with Nivolumab and Ipilimumab. His labs showed creatine kinase (CK) level of 1,569 U/L, aldolase 44.1 U/L, AST 230 U/L, ALT 139 U/L, as well as evidence of acute kidney injury with creatinine of 2.78mg/dL. His inflammatory markers were elevated. Endocrine panel showed elevated TSH at 6.02 ulU/ml, free T4 of 1.4ng/dL, and normal cortisol level. He was started on aggressive fluid hydration with interval improvement of creatinine and CK levels. He was started on prednisone 1 mg/kg followed by IVIG 1gm/kg for suspected immune-checkpoint inhibitor related myositis with interval resolution of weakness after completing two doses of immunoglobulin. The patient had persistent ptosis, which raised suspicion for concurrent immune checkpoint inhibitor induced myasthenia gravis. Brain imaging showed no evidence of acute intracranial process. Further workup showed: negative Acetylcholine Receptor Binding Antibody test (AChR), negative Voltage-gated calcium channel antibodies, and negative extended myositis panel. A pyridostigmine trial was started with near resolution of his ptosis. The patient was discharged on prednisone and pyridostigmine. Given this patient’s grade 3 toxicity from immune checkpoint inhibitors, he will require transition to a different line of therapy.

IMPACT/DISCUSSION: Immune checkpoint inhibitor (ICI) induced myositis is a rare but serious side effect that can lead to severe complications like rhabdomyolysis, myocarditis, as well as respiratory compromise. It accounts for 0.38-0.6% of immune-related adverse events (irAEs). Combination ICI therapy has been associated with higher frequency and mortality risk of myositis. Diagnosis requires a high index of suspicion and to rule out other causes like cancer progression, autoimmune diseases, endocrinopathies, neuromuscular disorders, and paraneoplastic syndromes. Concurrent myocarditis can develop in up to 40% of patients; therefore, cardiac enzymes should be part of the initial workup. Immune checkpoint inhibitors can also induce myasthenia gravis. In most cases Acetylcholine Receptor Binding Antibody will be positive, but a negative antibody test does not exclude the diagnosis. Treatment of myositis depends on the severity of symptoms; the main treatment is steroids. IVIG and plasmapheresis have also been used, but further studies are needed to determine their efficacy.

CONCLUSION: The incidence of immune-related adverse events will continue to grow as immunotherapy has been widely implemented for cancer treatment. Further studies are needed to describe these adverse events as well as guidelines in management. Timely identification of immunotherapy-induced myositis is crucial and requires immediate management due to its high risk of fatality.

AN ATYPICAL PRESENTATION OF ADULT-ONSET STILL’S DISEASE COMPLICATED BY HLH

Frank S. Aguilar¹; Paul Gallina¹; Serena L. Roth². ¹Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Department of General Internal Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4064960)

CASE: A 50-year-old male landscaper presented with 2 weeks of fevers, chills, sore throat, fatigue and generalized weakness after a recent COVID-19 infection. The patient was febrile but hemodynamically stable with an unremarkable physical exam. Initial labs were notable for leukopenia, neutropenia, thrombocytopenia, and transaminitis. Imaging studies only showed bilateral pulmonary opacities. Although the initial infectious workup was negative, atypical, tick-borne, & zoonotic infections were considered. Despite weeks of empiric broad-spectrum antibiotics, persistent quotidian fevers & hyperferritinemia (25,945 ng/mL) were concerning for HLH. Bone marrow biopsy was negative for hemophagocytosis or malignancy. Karius testing, serologies, & cultures were negative for any infectious causes. Persistent symptoms, lab abnormalities, & borderline hypotension were suggestive of cytokine storm requiring immunosuppression with anakinra. The patient’s ferritin levels began to downtrend & further workup showed elevated sCD25, IL-6 and IL-10. Soon after the patient developed arthralgias and synovitis prompting escalation of immunosuppression, which improved the patient’s overall condition. The development of arthralgias with no other clear etiology was most consistent with AOSD complicated by secondary HLH.

IMPACT/DISCUSSION: HLH is an aggressive systemic inflammatory disorder with multiorgan involvement, making timely diagnosis critical. The HLH-2004 diagnostic criteria requires meeting at least 5 of the 8 criteria; this patient only met 4. The HScore, a clinical tool, predicted a 5-9% risk of secondary (reactive) HLH in this case. However, if there is clinical suspicion of HLH sCD25 levels should be measured to help guide therapy since they most correlate with disease activity. The patient’s improvement with immunosuppression led to the conclusion this was most likely secondary HLH.

Establishing the etiology of HLH due to AOSD was challenging. The Yamaguchi criteria used to diagnose AOSD requires that at least 5 of the 8 diagnostic criteria be met, with at least 2 being major criteria. Initially only 1 major criteria (fever) and 2 minor criteria (sore throat & transaminitis) were met. AOSD requires exclusion of infection, malignancy, or other rheumatologic diseases prior to diagnosis. Eventually with the development of arthralgias the diagnosis of AOSD was made despite not meeting the Yamaguchi criteria. This case highlights the pitfalls associated with rigid application of diagnostic criteria and the need to maintain a high degree of suspicion for life-threatening conditions in the face of diagnostic uncertainty.

CONCLUSION: Diagnostic criteria may not include atypical presentations and should not replace clinical judgement – especially in life-threatening conditions.

AN ATYPICAL PRESENTATION OF AN ATYPICAL DISORDER: AKI SECONDARY TO ATYPICAL HEMOLYTIC UREMIC SYNDROME (AHUS)

Spencer Gibson¹; Melissa Thomas³; Faustine Luo⁴; Farah Shah²; Minh-Ha Tran¹. ¹Internal Medicine, University of California Irvine, Irvine, CA; ²Hematology/Oncology, UCI Health, Orange, CA; ³Internal Medicine, UCI Medical Center, Orange, CA; ⁴internal medicine, UCI Medical Center, Orange, CA. (Control ID #4063669)

CASE: Ms. A is a 20 year old female with recent pregnancy and uncomplicated delivery who was transferred to our medical center secondary to hemorrhagic shock after cholecystectomy at OSH was complicated by perihepatic hematoma. Upon arrival, the patient was found to be significantly anemic, hypotensive, oliguric, and hypervolemic. Her BUN and creatinine were significantly elevated from baseline. She was subsequently admitted to the ICU for close hemodynamic monitoring and further respiratory support. Repeat abdominal imaging demonstrated persistence of the perihepatic hematoma that was stable in nature. Her hypotension and hypoxemia responded well to fluid and oxygen support; however, her renal function continued to worsen, and she eventually required intermittent dialysis. Her anemia also persisted despite multiple transfusions and hematology was consulted after hemolysis labs demonstrated elevated LDH and reticulocyte count with low haptoglobin. Notably, her platelets were only mildly low at this time and throughout her hospital course. Given her recent pregnancy, a wide differential was considered, and renal biopsy was obtained which demonstrated thrombotic microangiopathy consistent with the leading differential of aHUS. She was treated with Eculizumab with improvement in hematologic markers and renal function by discharge.

IMPACT/DISCUSSION: Hemolytic Uremic Syndrome (HUS) is a type of thrombotic microangiopathy characterized by hemolytic anemia due to endothelial damage, thrombocytopenia and subsequent end organ damage. HUS is most associated with Shiga-toxin producing E. Coli infections; however, atypical HUS (aHUS) is generally associated with genetic or acquired dysfunction of complement activation. Atypical HUS can be associated with triggers such as infection, pregnancy, surgery or other inflammatory conditions that result in the activation of the complement system. These clinical scenarios can also result in temporary complement dysregulation which can overlap with genetically induced aHUS making the diagnosis challenging. In this case, hemorrhagic shock secondary to her perihepatic hematoma and recent surgery could have triggered the complement system dysregulation. However, genetic testing revealed a heterozygous missense variation in exon 25 of ADAMTS13 gene which is associated with TTP, ADAMTS13 deficiency and HUS. This suggests patients with genetic predisposition to these TMAs may be at increased risk for development of aHUS in the setting of clinical scenarios such as pregnancy and surgery which can cause complement deregulation.

CONCLUSION: Atypical HUS is an uncommon but important etiology of AKI. It should be included in the differential in patients who otherwise do not have clear reason for rapidly progressing AKI, especially in patients who may have had a recent trigger for uncontrolled complement activity such as infection, pregnancy, autoimmune diseases or surgery.

AN ATYPICAL PRESENTATION OF FOOT GANGRENE IN A PATIENT LIVING WITH HIV

Jaime J. Rueda¹; Corina Lopez¹; Zahra Markatia²; Naomi Sequeira³. ¹Internal Medicine, Baylor College of Medicine Margaret M and Albert B Alkek Department of Medicine, Houston, TX; ²Ophthalmology, Baylor College of Medicine, Houston, TX; ³Baylor College of Medicine, Houston, TX. (Control ID #4065042)

CASE: 36-year-old male with HIV, Kaposi Sarcoma (KS), and a prior left below knee amputation (BKA) presented to the emergency room (ER) with right foot gangrene. In February 2022, he had a left BKA for foot gangrene. Pathology showed inflammation, edema, necrosis, and chronic osteomyelitis of the middle toe. In May 2022, during a postoperative visit, his right foot started developing similar wounds and swelling as to those observed on the left foot prior to the amputation. He was given Bactrim for 7 days and then was lost to follow up. In April 2023, a wound on the bottom of his right foot underwent an incision and drainage. Culture grew E. Faecalis and E. Coli. He was again given Bactrim and with wound care there was modest improvement in the appearance of the foot. In July 2023, he reported to the ER with increased erythema, drainage, and worsening foot pain. His right foot was edematous, with tender papules, erosions, and necrosis. There were also purple papules along the border of the necrotic part of the foot. His right medial thigh had a small group of purple macules. His laboratory data showed a CD4 count of 257, HIV viral load of 1,010, WBC count of 5.7, ESR/CRP of 21/<0.2, and an A1c of 5.2%. An MRI of the foot showed bone loss and fragmentation in digits 2-5 with subtle marrow edema, soft tissue ulceration, and myositis. General surgery recommended amputation, but the patient opted for medical management. ID suggested debridement with biopsy and broad intravenous antibiotic coverage. Dermatology, upon discussing with ID deferred biopsy, because KS was thought to be unlikely since the CD4 count was elevated. The patient decided to proceed with an amputation. The pathology report revealed extensive multifocal KS with positive Human Herpesvirus 8 (HHV-8) immunohistochemical staining.

IMPACT/DISCUSSION: This case illustrates the potential for KS to present as a gangrenous foot in a patient with HIV and having relative immune restoration and viral suppression. HHV-8, the virus that leads to KS, can induce chronic inflammation, resulting in abnormal vascular proliferation, compromising blood flow, mimicking a gangrenous foot. Studies are showing KS occurring at higher CD4 levels. Systemic chemotherapy with anthracyclines is indicated for cases of widespread, symptomatic, rapidly progressive disease, or visceral manifestations. Case reports note reversal of necrotizing leg gangrene from KS with pegylated liposomal doxorubicin and debridement. Recognizing KS when it presents as a gangrenous foot in patients with a restored immune system is critical to preventing unnecessary amputations of affected limbs.

CONCLUSION: KS can have an atypical presentation with the potential to manifest as gangrene. KS can occur in individuals with low viral loads and normal to high CD4 levels, challenging conventional associations with immunocompromised states. Pegylated liposomal doxorubicin may be a promising treatment for achieving limb salvage therapy in cases of KS presenting as gangrene.

AN ATYPICAL PRESENTATION OF LEMIERRE’S SYNDROME AND A THERAPEUTIC DILEMMA

Sanjana Murthy²; Jenna J. Port¹; Alice Kennedy¹; Laura K. Snydman³. ¹Internal Medicine, Tufts Medical Center, Boston, MA; ²Tufts University School of Medicine, Boston, MA; ³Internal Medicine, Tufts Medical Center, Boston, MA. (Control ID #4065072)

CASE: A 26-year-old woman with no past medical history presented to the ED with one week of malaise, fever, sore throat, cough, and tested positive for coronavirus. Initial vitals were significant for sinus tachycardia (140-150s) and a 2LPM oxygen requirement, prompting admission. Physical exam was negative for pharyngeal or tonsillar erythema, exudate, LAD, or neck tenderness. Blood cultures quickly grew GNR which later speciated to fusobacterium. CT head/neck obtained for source identification showed nonocclusive thrombosis in the lingual/facial vein branches with extension into the left internal jugular vein (IJV). CT chest demonstrated new multifocal opacities compared to normal CXR two days prior, concerning for septic emboli. These findings were all consistent with Lemierre's syndrome. She was treated with ceftriaxone and metronidazole, and the decision was made to defer anticoagulation (AC). However, her fevers persisted despite antibiotic treatment, prompting repeat CT which demonstrated mildly increased thrombus and new findings of necrotizing pneumonia with multiple small intrapulmonary abscesses. Due to this progression despite 9 days of an appropriate antibiotic regimen, and after discussion with vascular surgery, ID, and ENT, the patient was started on a heparin GTT. Patient defervesced the day after anticoagulation was initiated. She was discharged home on IV antibiotics and therapeutic AC.

IMPACT/DISCUSSION: Lemierre’s syndrome is defined by septic thrombophlebitis of the IJV that begins as a localized oropharyngeal infection. Our patient presented with a sore throat which could have been explained by her RVP being positive for coronavirus, and her physical exam was notable for no other evidence of Lemierre’s (i.e. oropharyngeal erythema, abscess, tender neck). A CT soft tissue neck was ordered solely based on blood culture growth and patient report of sore throat. Additionally, while immediate antibiotic therapy is clearly indicated in Lemierre’s, there are no guidelines for the role of anticoagulation. One study demonstrated that most patients recover well without therapeutic AC, and that adverse events are rare in patients treated with AC. Another study recommends AC in patients with extensive internal jugular vein thrombosis or poor clinical response despite antibiotic therapy. In our young and healthy patient, with low bleeding risk, who was found to have increasing clot burden despite antibiotic treatment, starting anticoagulation led to clinical improvement.

CONCLUSION: 1. CT face/neck to evaluate for Lemierre’s should be considered for presentations of unknown etiology of gram negative bacteremia in an otherwise young and healthy adult.

2. In patients with low has relatively low bleeding risk, consider early anticoagulation for Lemierre’s due to high morbidity if antibiotics alone are unsuccessful in treating septic thrombophlebitis.

3. Recognize the importance of multidisciplinary involvement, particularly when evidence to guide management is scarce

AN ATYPICAL PRESENTATION OF MADELUNG'S DISEASE IN A 58-YEAR-OLD MALE WITH ALCOHOL USE DISORDER

Benjamin Bryant¹; Aishwarya Nugooru²; Michelle Sweet³. ¹Hospital Medicine, Rush University Medical Center, Chicago, IL; ²Department of Internal Medicine, Rush University Rush Medical College, Chicago, IL; ³Internal medicine, Rush University Medical Center, Chicago, IL. (Control ID #4065366)

CASE: We present a patient who is a 58-year-old male, with a past medical history significant for Alcohol Use Disorder, Hypertension, Type II Diabetes Mellitus, and Chronic Obstructive Pulmonary Disorder. He presented with swelling of her bilateral arms, legs, and abdomen which was associated with burning pain, weakness, and fatigue for 5 days prior to admission. The patient also had a 50-pound weight gain in a 3-week period with no changes in diet or exercise changes. Physical exam was notable for diffuse soft tissue swelling in upper/lower proximal extremities, bilateral chest, and back. Imaging with Doppler ultrasonography of upper and lower extremities, Chest X-ray, and CT chest without contrast were unremarkable. Patient underwent laboratory testing which was negative and unrevealing. After consultation with Rheumatology and Dermatology, further evaluation pointed to the direction of Madelung’s disease (benign symmetric lipomatosis) given the patient’s past medical history of alcohol use disorder and findings from workup. A fat pad biopsy was subsequently undergone, which did not reveal any pathologic findings, which was further evidence to support the diagnosis of benign symmetric lipomatosis. As the patient’s pain from the swelling increased during admission, the plastic surgery team was consulted for a potential resection. However, after evaluation, the surgical team recommended no acute surgical interventions at the time and the patient was instructed to have an outpatient follow-up in two months. Patient was discharged in stable condition to a skilled nursing facility for further rehabilitation and strengthening.

IMPACT/DISCUSSION: Madelung’s Disease, also known as benign symmetric lipomatosis, is a rare metabolic disorder that often presented with onset of symmetric fatty deposition in face, neck and shoulder girdle. [1] The disease is commonly seen in patients with a history of alcohol abuse as well as metabolic disturbances including glucose intolerance such as diabetes. [2] This case highlights the importance of considering rare etiologies and conditions like Madelung's disease in patients with unexplained weight gain, especially if they have a history of alcohol use disorder. The case contributes to the current medical literature by raising further awareness on the link between Madelung’s disease and alcohol use disorder, to help providers be able to recognize this rare condition in their diagnostic process should they encounter a patient with a similar presentation

CONCLUSION: -It is important to be aware about broad atypical presentations, such as sudden unexplained weight gain in patients with alcohol use disorder, which should prompt a work-up for rare conditions like Madelung's disease if other common etiologies can be ruled out.

-Collaboration with interdisciplinary teams along with thorough clinical evaluation and imaging plays a pivotal role in confirming the diagnosis of Madelung's disease and determining the most appropriate and effective management strategies.

A NEEDLE’S BETRAYAL: UNEXPECTED PARALYSIS FOLLOWING STEROID INJECTION IN A PATIENT WITH UNDIAGNOSED GRAVES’ DISEASE

Maria G. Parra Riveros, Juana Martinez, Krishna Suhagia, Maryam Hajiabbasi, Robert Thompson. Elmhurst Hospital Center Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY. (Control ID #4064144)

CASE: A 35-year-old healthy East Asian man presented with acute onset symmetric bilateral lower extremity weakness. Notably, the evening prior to presentation, the patient received a paraspinal injection of dexamethasone to treat radicular left arm pain and had a pasta dinner with two bottles of beer. On examination, the patient was afebrile, with a heart rate of 88 beats/min, a respiratory rate of 16 breaths/min, and a blood pressure of 151/69 mmHg. He had bilateral hip flexor weakness (2/5 strength) and decreased patellar reflexes. Laboratory testing revealed potassium 2.2 mmol/L (reference range 3.5 – 5.1 mmol/L), TSH <0.01 uIU/mL (reference range 0.27 – 4.20 uIU/mL), T3 201.1 ng/dL (reference range 80 – 200 ng/dL), free T4 2.80 ng/dL (reference range 0.93 – 1.70 ng/dL). He was treated with 120 mEq of potassium chloride resulting in a follow-up potassium level of 5.6 mEq. Neurologic examination returned to baseline within hours, including full strength in both extremities. The diagnosis of thyrotoxic periodic paralysis (TPP) in the context of a steroid injection with a high-carbohydrate meal was made based on clinical presentation and laboratory findings. Graves’ disease was confirmed with positive thyroid-stimulating hormone receptor and thyroid-stimulating immunoglobulin antibodies. Treatment with methimazole was started, and the patient was advised to avoid TPP triggers like steroid injections, high-carbohydrate meals, and alcohol consumption.

IMPACT/DISCUSSION: TPP is a rare and life-threatening complication of hyperthyroidism, that primarily affects young East Asian men between 20 and 40 years old. It presents as an acute onset of weakness and hypokalemia, often in patients with undiagnosed thyrotoxicosis. The pathogenesis of TPP involves increased sodium-potassium (Na-K) adenosine triphosphatase (ATPase) activity, leading to potassium influx into cells with a preserved total body potassium level. Activation of the pump can occur via insulin, adrenergic stimulation, or thyroid hormones. Triggers include high-carbohydrate meals, stress, strenuous exercise, alcohol, cold temperatures, and corticosteroids. Steroids elevate Na-K ATPase expression in skeletal muscle and increase insulin secretion, triggering TPP onset. Rare steroid-related TPP cases, all with co-precipitating factors, have been reported. Treatment consists of judicious potassium repletion to prevent rebound hyperkalemia. Propranolol has demonstrated efficacy in refractory cases. The definitive treatment is to achieve a euthyroid state and to treat the underlying cause of hyperthyroidism.

CONCLUSION: TTP should be considered in patients with acute lower limb paralysis, especially in young men of East Asian descent. In our case, a high-carbohydrate meal and alcohol intake were co-precipitating factors. Early recognition and prompt therapy involving antithyroid drugs, potassium treatment with frequent serum level measurements to prevent hyperkalemia, and beta-blockade are highly effective.

AN ELDERLY MALE PATIENT PRESENTED WITH URTICARIAL LESIONS: AN UNCOMMON CASE

Imtiaz A. Khan¹; Tanzina Afroz¹; Obaidah Adi¹; Nicole Davey². ¹Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX; ²Rheumatology, Allergy A.R.T.S, Amarillo, TX. (Control ID #4064822)

CASE: A 61-year-old male having complaints of very painful rashes and swelling on the skin over his forearms, elbows, shin, knees, and thighs for one week, preceded by a sore throat, presented to the ER. He was treated with antibiotics previously with no improvement. He reported having chills, poor appetite, and recent weight loss. He has been suffering from recurrent oral ulcers since his teenage, with a recent increase in frequency. The patient has HTN, DM, hyperlipidemia, fatty liver, and asthma controlled with medications. His personal or family history was negative for autoimmune or coagulation disorder. According to the Lab study, the patient’s autoimmune panel tests were negative, complements were normal, and CRP, lactic acid, ESR were elevated. Urticarial vasculitis was diagnosed according to clinical presentation and lab data. The patient was managed with IV solumedrol followed by oral prednisone.

IMPACT/DISCUSSION: Recognition of urticarial vasculitis in an aged male patient is challenging as it is a disease almost exclusive to the female sex, with a peak incidence in the fourth decade of life. Though the prognosis is not severe, if overlooked, systemic involvement may lead to organ failure. Urticarial vasculitis is a rare condition caused by inflammatory insults of small vessels of the skin. Skin manifestations can occur anywhere on the body. The lesions are longer lasting than typical urticaria and may present with tenderness, burning sensation, and pruritus. Other findings include angioedema, dermographism, annular erythema, and livedo reticularis. It commonly involves musculoskeletal, renal, pulmonary, and ophthalmologic systems. The disease may be normocomplementemia or hypocomplementemia with extensive vasculitis and systemic manifestations. Skin biopsy shows leukocytoclastic vasculitis; several cases are reported with inconclusive findings. Urticarial vasculitis starts idiopathic or is triggered by infections (e.g., EBV, COVID, hepatitis, Lyme disease) or medications (e.g., Infliximab, fluoxetine, enalapril). The disease has an association with various autoimmune diseases, e.g., SLE, RA, IBD, and rarely with malignancy. The specific antigen has not been identified yet; the assumption is that immune complex deposition in the vessel wall activates the classical complement pathway, leading to mast cell degranulation and urticaria. Neutrophil proteolytic enzymes cause further tissue damage. In hypocomplementemia, autoantibody C1q precipitin targeted to collagen-like region of C1q has been implicated. Some studies hypothesized the role of IL-1 or genetic mutation in DNASE1L3. Treatment options include antihistamines, NSAIDs, glucocorticoids, dapsone, and colchicine. Here, glucocorticoid administration resolved the symptoms.

CONCLUSION: Prompt diagnosis and management prevent our patient’s prognosis from getting worse. After resolving the initial symptoms, the patient was followed up by a rheumatology clinic.

A NEW RASH AND A LONG-UNATTENDED DIAGNOSIS

Lauren Heery^1,2. ¹Medicine, New York University Grossman School of Medicine, New York, NY; ²Medicine, NYU Langone Hospital Brooklyn, Brooklyn, NY. (Control ID #4064756)

CASE: The patient is a 75-year-old woman with hypertension, hyperlipidemia, and with 30 pack-year smoking history who presented to the emergency department after two weeks of a rash on both legs and one day of abdominal pain, nausea, diarrhea, and vomiting. The rash was not itchy or painful, and she denied new exposures to topical agents, irritants, and recent travel. She also noted brown vaginal discharge and endorsed weight loss. She denied having fevers, chills, night sweats, fatigue, anorexia, and cardiopulmonary symptoms.

Exam was notable for purpuric rash bilaterally from mid-thigh level extending to the feet. Initial laboratory evaluation was notable for: white blood cell count 14.9, 90% neutrophils, C-reactive protein 35.83, erythrocyte sedimentation rate 51. CT abdomen pelvis showed a mass in the distal rectum with associated anovaginal fistula, extension into the right ischioanal fossa, and right inguinal lymph node.

Additional history revealed that the patient started experiencing a mass-like sensation in vagina, anal pruritus, and brown vaginal discharge two years prior, but reported she was unable to seek care as she was caring for multiple sick family members. She saw a primary care provider one year prior, had never received a colonoscopy, and her last cervical cancer screening and mammography were three years prior.

Her rash was biopsy-confirmed to be leukocytoclastic vasculitis (LCV). Rheumatologic, infectious, and medication evaluation revealed no inciting causes. A biopsy of the anal mass confirmed invasive squamous cell carcinoma. At time of discharge, the patient established care and received pelvic radiation, Mitomycin-C and capecitabine, and loop sigmoid colostomy.

IMPACT/DISCUSSION: This case highlights an unusual presentation of palpable purpura pathognomonic of LCV in the setting of malignancy. LCV is an uncommon paraneoplastic syndrome, and its pathogenesis is not well understood. This patient’s case was also notable in demonstrating unusual access to care barriers. While she confided she did not like going to see doctors, she also said she did not have time due to her caregiving responsibilities of other family members. Few studies address healthcare access in full-time caregivers. This patient’s case reiterates the need to normalize discussion of urogenital, sexual, and defecation-related symptoms with all patients.

CONCLUSION: Palpable purpura has a broad differential and can be associated with malignant etiologies and significant chronic diseases.

Patients’ personal barriers to seeking healthcare vary and should be assessed to ensure they can continue accessing care.

Providers should create a stigma-free environment for patients to discuss intimate and sensitive concerns in medical encounters.

AN EXPENSIVE TATTOO: ASCENDING COLITIS SECONDARY TO COLONOSCOPIC INK INFILTRATION

Todd Yeates, Dmitriy Scherbak, Matthew Yurkewicz, Jacob Keeling, Alexandra Moran, Zachary Adams. Internal Medicine, Sky Ridge Medical Center, Lone Tree, CO. (Control ID #4065025)

CASE: A 65-year-old female with history of recent colonoscopic polypectomy and tattooing presented to the emergency department with chief complaint of abdominal pain. She underwent the polypectomy from the ascending colon two weeks prior during regular colon cancer screening. Pathology resulted as colonic adenocarcinoma. Repeat colonoscopy was performed for the purpose of tattooing for subsequent surgical resection. One hour following the procedure, she developed abrupt-onset abdominal pain in the right lower quadrant. The pain was described as “sharp” and easily localizable. She denied nausea and vomiting. Physical exam revealed exquisite tenderness of the right lower quadrant with voluntary guarding but without rigidity or rebound tenderness. CT imaging showed pericolonic fat stranding along the mid-ascending colon without evidence of perforation. It also incidentally showed a hepatic lesion concerning for metastasis. The site of inflammation was also the site of the polypectomy and tattooing. She met Systemic Inflammatory Response Syndrome (SIRS) criteria with tachycardia and leukocytosis and probable source of ascending colitis. She also had an elevated lactate, which led to a diagnosis of severe sepsis. Intravenous Ceftriaxone and Metronidazole were started and gastroenterology consultation was obtained. The abdominal pain was deemed to be due to local infiltration of the tattoo ink rather than the polypectomy because the polypectomy was two weeks prior. Her abdominal pain gradually improved throughout her stay. Her leukocytosis resolved on hospital, day 2 and she was ultimately discharged on hospital day 3 to another facility with positron emission tomography (PET) capabilities for completion of her oncologic workup. She underwent uncomplicated right hemicolectomy two weeks later.

IMPACT/DISCUSSION: This case is an example of a rare complication of pre-operative localization technique that is considered safe. Knowledge of this complication and its treatment with antibiotics may change clinical practice of some physicians. An important learning point was foregoing repeat endoscopy, as the inflamed segment of colon would later be removed. Adequate bowel preparation and avoiding transmural injection of ink can help prevent this complication.

CONCLUSION: 1. Pre-operative localization of colon lesions is performed endoscopically with India Ink Carbon Black dye, an immunologically active substance.

2. Although rare, there have been reports of immunologic reactions to the ink such as inflammation and fat necrosis

AN INCONSPICUOUS TOXICITY OF GLUCOSE: NON-KETOTIC HYPERGLYCEMIC CHOREA

Tasfia Tasnim¹; Natalia Orihuela¹; Jeffrey Weiss²; Matthew Shaines². ¹Internal Medicine, Montefiore Medical Center, New York, NY; ²Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4027525)

CASE: 69 year old female with long standing uncontrolled T2DM and recent discontinuation of medications presents with 1 week of progressively worsening, debilitating, involuntary left sided chorea. The symptom began as a minor twitch in her forearm which intensified to include the entire left side. The patient denied any focal neurological symptoms but reported increasing thirst and urination. CT head was negative for any acute bleed and MRI brain was negative for any acute infarct. She was found to have an elevated blood sugar of 600 mg/dL, normal anion gap and bicarbonate. Heavy metal panel was also negative. After multidisciplinary team discussion, movements were attributed to non-ketotic hyperglycemic chorea, a manifestation of glucose toxicity. The patient was placed on a strict glucose control with basal bolus insulin, which improved her movements after a few days of variability. Low dose quetiapine was started for symptomatic relief during sleep.

IMPACT/DISCUSSION: Non-ketotic hyperglycemic chorea (NKH) is a rare neurological manifestation of uncontrolled T2DM, marked by unilateral, involuntary, irregular, and wide-amplitude movements. While the exact pathophysiology is unknown, it is theorized that micro hemorrhages or ischemia in contralateral basal ganglia may lead to unilateral symptoms¹. Other theories propose a metabolic phenomenon, where depletion of GABA and acetylcholine levels in NKH lead to functional disorders in the basal ganglia causing choreiform symptoms². For many NKH patients, MRI of Brain demonstrates high intensity signals in the basal ganglia in TW1 images¹. The patient’s Brain MRI did not show any signal intensity making the diagnosis challenging.

The mainstay treatment of NKH is glucose control to correct the underlying metabolic disequilibrium. While correction of glucose may occur rapidly, the symptoms may last months to a year with risk of recurrence. The role of antipsychotic medications and VMAT-2 inhibitors for symptomatic control is not well studied. In a small meta-analysis study of 72 articles with a total of 176 patients who presented with NKH chorea symptoms, the efficacy of symptom control with glucose-control-only versus glucose control with anti-chorea medications did not show any significant difference³. Given the small size, the results should not decide clinical management. Our patient was treated with a small dose of clonazepam however her chorea worsened. Whether this was secondary to the benzodiazepine or just a variability of the disease process, it is difficult to assess. Clonazepam was discontinued and she was trialed on a low dose quetiapine for symptomatic relief. To truly assess the efficacy of antipsychotics on NKH chorea, a multicenter double blind study is optimal. Unfortunately, given the rarity of this disease, this may be challenging.

CONCLUSION: Chorea is a debilitating neurological sign of glucose toxicity. It is essential to appreciate the rare manifestation to encourage patients to maintain strict diabetes control.

AN INDICATION FOR SKIPPING LEG DAY: AN UNEXPECTED CASE OF DIABETIC MYONECROSIS

Nurcan Ilksoy¹; Kain Kim¹; Michael S. DeBakey². ¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Internal Medicine, Emory University, Atlanta, GA. (Control ID #4064351)

CASE: Case

A 60-year-old female with no past medical history presented to the ED with 6 days of worsening right thigh swelling and pain after hitting her thigh on a car door. She had recently been on a 3-day road trip with infrequent stops or fluid intake. She denied a history of DVT. Her physical exam showed significant swelling and tenderness to the anteromedial right thigh with palpable distal pulses and no warmth, redness, discoloration, or tightness. Right lower extremity strength was 3/5, with limited range of motion due to pain. On admission, she was hemodynamically stable and afebrile. Pertinent labs revealed a white cell count of 10x10⁹/L, a blood glucose of 345 mg/dL, and a CPK of 691 units/L. A urinalysis was notable for >50 red blood cells and 1+ hemoglobin. Further workup revealed a hemoglobin A1C of 14.0 without a history of diabetes. CT demonstrated a tiny non-occlusive filling defect of the proximal right external iliac artery. She was started on therapeutic enoxaparin, IV fluids, and insulin. Her CPK and symptoms improved.

On day 4, however, she reported increased swelling and pain after exercising in an attempt at DVT prophylaxis. A repeat CT of her femur was ordered to rule out hematoma in the setting of anticoagulation, and demonstrated hypoattenuation and enlargement of the vastus lateralis with loss of fasciculation, confirming DMN diagnosis. She was discharged to recuperative care with follow-up at a diabetes clinic.

IMPACT/DISCUSSION: DMN is a rare complication of poorly controlled diabetes, presenting as acute muscle pain and swelling in the absence of fever or trauma. Most have coexisting diabetes complications (nephropathy in 75% and retinopathy in 47%), which were absent in our patient. Also notable is the acute history of trauma, which significantly skewed initial suspicions toward an unconventional path to diagnosis.

Though exact pathogenesis is unclear, vasculopathic changes associated with long-standing diabetes may play a role in DMN. Normal to mildly elevated CPK levels or leukocytosis can be seen. Clinical and radiologic concordance is diagnostic. Although an MRI is usually preferred, a CT was diagnostic here, as we were ruling out hematoma.

Her initial presentation without fever, leukocytosis, or tachycardia lessened suspicion of an infection or abscess. Though the history of prolonged immobilization suggested DVT, the thrombus insufficiently explained her symptoms. The inciting trauma event was also suggestive of a hematoma or rhabdomyolysis, but the CPK level was too low for the latter, and urinalysis suggested true hematuria rather than myoglobinuria. Notably, physiotherapy is avoided in treatment, as it has been shown to worsen healing. Our patient’s acute decompensation after exercising supports these findings.

CONCLUSION: For patients without established diabetes, a high index of suspicion for DMN is necessary as to avoid exacerbation by exercise or unnecessary antibiotic/anticoagulant use, as it typically resolves with conservative management

AN INFLAMMATION EXACERBATION: A CASE OF ADULT ONSET STILLS DISEASE

Emma Hanlon, Aditya Mohanty. Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4063490)

CASE: A 42-year-old female with seronegative rheumatoid arthritis was referred from outpatient infectious disease clinic to the emergency room for fevers, chills, headache, epistaxis and lab abnormalities. Two weeks prior to presentation she developed fevers and a transient pink rash on her extremities. Lab abnormalities that prompted admission included pancytopenia, transaminitis, elevated CRP, and ferritin of 26,589. Broad infectious work-up was negative. CT imaging showed mild splenomegaly. Bone marrow biopsy showed no morphologic evidence of leukemia or lymphoma. Rheumatologic work up was also negative. Her IL-2 levels were elevated and H score yielded >99% probability for hemophagocytic syndrome. She was ultimately diagnosed with hemophagocytic lymphohistiocytosis (HLH)/macrophage activation syndrome (MAS) secondary to Adult Onset Stills Disease (AOSD) and started on methylprednisolone and anakinra, later started on dexamethasone and etoposide with improvement in symptoms and inflammatory markers.

IMPACT/DISCUSSION: HLH is a condition of overactivation of the immune system associated with cytokine storm and mortality can be as high as 88% in adults.¹ Triggers include infection (most common), malignancy, rheumatologic conditions, or transplant. The HLH-2004 criteria and H Score were important developments in HLH diagnostic approach, with 91% and 96% sensitivity respectively.^2,3,4 Cases of HLH that are due to rheumatologic etiology are referred to as MAS.

AOSD is a condition of aberrant inflammatory response due to an unknown second hit trigger, and MAS is reported in up to 15% of these patients.⁵ Mortality associated with MAS driven by AOSD ranges from 10-41%.⁵ AOSD is a clinical diagnosis, and a common framework is the Yamaguchi criteria.⁶ Treatment for HLH and AOSD hinges on the interruption of the cycle of inflammation. The HLH-94 protocol, developed by the Histiocyte Society in 1994, uses dexamethasone, etoposide, cyclosporine and possible intrathecal methotrexate if neurologic symptoms.⁷ Given the high mortality associated with HLH/MAS driven by AOSD, it is important to consider as a diagnosis when work-up for infection or malignancy is unrevealing. Additionally, since the clinical manifestations of HLH/MAS are very common yet non-specific findings, it is important for generalists to be familiar with these diagnostic approaches and distinguish them from other common pathologies.

CONCLUSION: 1. HLH/MAS involves high mortality but can be treated if diagnosed appropriately.

2. HLH/MAS presents with common yet non-specific findings, and it is important for generalists to distinguish them from other common pathologies.

A NON-CIRRHOTIC, “CIRRHOTIC”: THE IMPORTANCE OF REDUCING ANCHORING BIAS

Roshnee Raithatha¹; Michael Kriss²; Lynne Rosenberg¹. ¹Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4062775)

CASE: A 45-year-old female with a reported history of cirrhosis, chronic pancreatitis, fibromyalgia, recent intracerebral hemorrhage (ICH), and polysubstance use disorder presented with altered mental status after discharge from a prolonged hospitalization for ICH. Family reports she had not taken her lactulose since discharge. On presentation, she appeared jaundiced, with scleral icterus, asterixis, psychomotor slowing, and confusion on exam.

Laboratory data was notable for indirect hyperbilirubinemia and hyperammonemia with elevated lipase, liver function tests, and coagulation factors. Urine toxicology screen was positive for opioids, which she had been prescribed for chronic pancreatitis. Given her history of missed lactulose doses in conjunction with her physical exam findings and laboratory data, grade 2 hepatic encephalopathy (HE) was the leading diagnosis. The patient was treated with lactulose with significant improvement in her mental status. Right upper quadrant ultrasound completed morning after admission showed no evidence of cirrhosis but did show reversal of left portal vein flow. Patient and family were unable to provide collateral information regarding initial cirrhosis diagnosis but reported that she had been diagnosed years ago presumed secondary to her history of alcohol use.

Computed tomography (CT) of the abdomen showed non-cirrhotic liver morphology with portal hypertension, a large retroperitoneal portosystemic shunt, mild splenomegaly, and periesophageal varices. In addition, there were signs of chronic pancreatitis with a chronic splenic vein thrombus and gastric varices. Without evidence of true cirrhosis on imaging, the patient’s HE was thought to be secondary to splenic vein thrombus causing a large portosystemic shunt.

IMPACT/DISCUSSION: Anchoring bias, during which people rely heavily on the first piece of information they are given on a topic, was likely present throughout her care as we continued to treat her for presumed cirrhosis-related HE. While we were not present for her initial diagnosis, a history of alcohol use disorder may have led to a false cirrhosis diagnosis.

The patient’s splenic vein thrombus, likely from her chronic pancreatitis, lead to the development of a large portosystemic shunt, thus allowing ammonia to bypass metabolism in the liver and cross the blood-brain barrier leading to her symptoms of HE. On literature review, a study from 2006 studied 10 patients with biopsy confirmed non-cirrhotic livers with portal vein thromboses, and found that these patients had subclinical neurological abnormalities consistent with minimal HE. It seems that our patient had a more severe presentation of HE as compared to the patients in the study, which may be associated with the size of the shunt in question.

CONCLUSION: Patients with portosystemic shunts can present with symptoms of hepatic encephalopathy without underlying liver disease. Patients with a history of substance use disorder are more likely to experience bias in the healthcare system.

A NOT-SO-COMMON COMPLICATION OF COMMON VARIABLE IMMUNODEFICIENCY

Lauren Hilt, Nisar Asmi. Internal Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4043195)

CASE: A 39-year-old male with a history of common variable immunodeficiency (CVID), Crohn’s disease, and nodular regenerative hyperplasia presented with a three-month history of fevers, night sweats, and non-productive cough. He was admitted for a workup of fever of unknown origin. Initial CBC revealed WBC 4, Hb 15.1, and PLT 141. Following admission, he developed pancytopenia that worsened to WBC 0.4, Hgb 9.3, and PLT 85. An extensive infectious workup was negative. Hematology workup revealed a decreased haptoglobin, increased LDH, and an elevated reticulocyte count. Peripheral blood smear showed tear drop cells and rare bite cells. Peripheral flow cytometry was negative for lymphoproliferative malignancies and bone marrow biopsy revealed a normocellular bone marrow with trilineage hematopoiesis. A PET scan revealed extensive diffuse heterogeneous uptake in the entire body's cutaneous and subcutaneous soft tissues. Multiple skin biopsies were negative for malignancy. He received additional doses of IVIG to his home regimen during hospitalization with improvements in blood counts (WBC 1.4, Hgb 11.1, and PLT 120). His symptoms stabilized and was discharged to outpatient follow up.

IMPACT/DISCUSSION: Common variable immunodeficiency is aptly named considering its variable clinical presentations and manifestations. Clinical manifestations of CVID include recurrent infections, chronic lung disease, autoimmune disorders, gastrointestinal disease, and an increased risk of lymphoma. Hematological disorders, such as immune thrombocytopenia (ITP) or autoimmune hemolytic anemia, are the most common autoimmune CVID manifestations while autoimmune pancytopenia remains rare. The patient’s symptoms and pancytopenia could possibly have an infectious, neoplastic, or autoimmune etiology and workup required a multidisciplinary collaboration to establish a diagnosis. Infectious and lymphoproliferative mechanisms were unlikely due to unrevealing workups. Laboratory evidence of peripheral RBC destruction, trilineage hematopoiesis within the bone marrow, and stabilization with IVIG infusions indicated an immunological phenomenon. Identification of autoantibodies was deferred due to the numerous extrinsic antibodies circulating in the blood from the chronic replacement IVIG infusions.

CONCLUSION: Autoimmune pancytopenia is a rare hematological manifestation of CVID (0.4% of a CVID cohort) while ITP (7.4%) or hemolytic anemia (4.5%) is considerably more common. Studies have reported that patients with CVID and autoimmune cytopenia are more likely to be associated with non-infectious complications. Further investigation into autoimmune cytopenia as a possible prognostic indicator for non-infectious complications of CVID is needed. This case highlights the importance of a multidisciplinary approach to assess the etiology of fever, abnormal imaging, and cytopenia in patients with CVID and encourages close monitoring of the various non-infectious complications to prevent further morbidity or mortality.

ANTERIOR MEDIASTINAL SYNOVIAL SARCOMA: A CASE REPORT OF UNUSUAL PRESENTATION AND DIAGNOSTIC CHALLENGES

Nikita R. Chintapally¹; Ritika Gadodia¹; Enrico Bautista²; Narayanan Sadagopan¹; Zhonghua Liu¹; Sosipatros Boikos^1,2. ¹Internal Medicine, MedStar Washington Hospital Center, Washington, DC; ²Georgetown University, Washington, DC. (Control ID #4042228)

CASE: The patient is a 37-year-old obese, non-smoking female with no significant past medical history. She presented with progressive dyspnea on exertion one month after being newly diagnosed with heart failure. She had experienced similar symptoms, leading to the discovery of a pericardial effusion causing tamponade. During this hospitalization, an echocardiogram revealed a recurrence of the pericardial effusion and evidence of diastolic compression of the right ventricle. A chest CT revealed an anterior mediastinal mass (8.4 cm x 7.6 cm x 6.7 cm) encircling the ascending aorta, causing moderate narrowing, and laterally displacing the superior vena cava. The differential diagnoses at this point included lymphoma, teratoma, thymoma, and thyroid malignancy. Initial pathology obtained from a biopsy via video-assisted thoracic surgery pericardial window was non diagnostic for malignancy and showed thymic tissue. Flow cytometry from pericardial fluid was unrevealing. Despite negative results the suspicion for malignancy persisted, prompting further investigation.The decision was made to pursue a repeat biopsy before considering surgical resection, primarily due to the lack of a definitive diagnosis, the need for sternotomy, and the patient's BMI of 60. A robotic anterior mediastinal mass biopsy was then performed, revealing a biphasic tumor with monotonous spindle cells, epithelioid cells, vascular proliferation, and rare poorly formed glandular structures. Immunostaining and fluorescence in situ hybridization for SS18-SSX fusion protein were positive, confirming the diagnosis of synovial sarcoma.

IMPACT/DISCUSSION: This patient's case deviated from the typical slow growth pattern and location of synovial sarcomas. Within a 9-month period, the tumor rapidly grew from undetectable to 14.8 cm in diameter. Diagnostic challenges included an initial nondiagnostic biopsy and technical difficulties in obtaining subsequent biopsies. Complicating the management of these cases, anterior mediastinal masses may impinge upon critical structures such as the heart and superior vena cava. This pressure can cause symptoms of heart failure, increase central venous pressure, and, as observed in our patient, directly compress the heart by mass effect and induce tamponade physiology secondary to recurrent pericardial effusion. Despite multimodal treatment options, the prognosis for patients with mediastinal synovial sarcomas remains poor, with a median overall survival of 36 months and a 5-year overall survival rate of 35.7%, compared to a 5-year overall survival rate of 50–80% for extremity primaries.

CONCLUSION: Despite the rarity of mediastinal synovial sarcomas, clinicians should remain aware of this condition due to the critical implications they have on patient prognosis, therapeutic decision-making, and overall management.

ANTI-MI2 AND DERMATOMYOSITIS: SHINING LIGHT ON A MYOSITIS-SPECIFIC ANTIBODY

Anthony Ribarich, Jeffrey Wagner. Hospital Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4062227)

CASE: A 26-year-old man presented to the emergency room after one month of progressive proximal arm and leg weakness. He had associated dysphagia and unintentional 9-kg weight loss. He had no medical or surgical history, took no medications, had no allergies, and did not use any recreational substances.

On evaluation, he was afebrile and normotensive. He had facial erythema with periorbital swelling, blanchable erythema of the chest, and bilateral red lesions with associated joint swelling and tenderness over the metacarpophalangeal joints. There was weakness limited by pain when testing grip strength. Labs demonstrated elevated aspartate transaminase, a creatinine kinase of 15,600 U/L, and serum aldolase of 96 U/L. He was started on empiric prednisone in addition to intravenous fluids which resulted in a downtrend in creatinine kinase and improved strength testing. Autoimmune workup noted positive antinuclear antibodies in a fine speckled pattern with titer 1:320 and myositis antibody panel was positive for anti-Mi-2. A biopsy was obtained as a gold-standard test. Pre-procedure MRI of the left femur showed scattered myositis and T2-enhancement most prominent in the proximal to mid quadriceps and abductor compartments. Left thigh muscle biopsy showed acute necrotic, inflammatory myopathy in the perifascicular regions including perifascicular atrophy.

Given findings of an idiopathic inflammatory myositis (IIM) with cutaneous manifestations of Gottron papules (red lesions of metacarpophalangeal joints) and Shawl sign (blanchable erythema of the chest) that were anti-Mi-2 positive, he was diagnosed with dermatomyositis (DM). He was continued on high-dose prednisone and discharged with outpatient follow-up.

IMPACT/DISCUSSION: Numerous myositis-specific antibodies (MSAs) exist that aid in the diagnosis, classification, prognostication, and treatment decisions of IIM. Mi2 is a helicase of the nucleosome remodeling deacetylase multi-protein complex with histone deacetylase and demethylase activities. Anti-Mi2 was the first MSA characterized in 1976 with a positive and negative likelihood ratio of 2.0 and 0.98 for the diagnosis of DM and is associated with a milder disease course. UV radiation upregulates the expression of Mi2 in keratinocytes, which is geographically associated with areas of high UV intensity having an increased prevalence of DM in patients who are anti-Mi2 positive, namely in the African American and European populations. It has no known association with the development of interstitial lung disease with an unclear association with malignancy-related DM.

CONCLUSION: Anti-Mi-2 is a marker of IIM associated with UV radiation exposure that is most suggestive of dermatomyositis. The clinical course for patients who test positive is likely to be steroid-responsive without known associations for the development of interstitial lung disease or malignancy compared to other MSAs.

ANTI-RO, ANTI-LA AND LYMPHOMA, OH MY! A PEEK INSIDE DLBCL IN THE EYE

Julia Constable, Milna Rufin, sara stream. Medicine, New York University, New York, NY. (Control ID #4063815)

CASE: A 66 year-old female with type 2 diabetes, hypertension, hyperlipidemia, and stroke, presented to a neurologist with daily headaches, 22 pound weight loss, and right sided temporal headaches with vision loss for 2 months. The physician suspected giant cell arteritis and treated empirically with prednisone. Initial labs showed high titer antinuclear antibody (ANA), anti-Ro and anti-La antibodies. The patient denied dry eyes and mouth.

The patient was referred to the hospital for hyperglycemia, where her exam was notable for a right-sided temporal visual field deficit and axillary and inguinal lymphadenopathy. CT chest revealed multiple subsegmental pulmonary emboli and bilateral axillary adenopathy. Labs were notable for elevated inflammatory markers with ESR 90, CRP 87, LDH 450 and D-dimer 788.

In the hospital, her vision loss progressed to near total blindness. A CT head without contrast revealed a right optic nerve lesion, for which she was transferred to our hospital for biopsy. MRI brain/orbits confirmed a stable right orbital apex enhancing soft tissue mass surrounding the optic nerve sheath with associated mass effect. Biopsy was ultimately deferred due to high risk for optic nerve damage. There was concern for malignancy given high titer Ro/La antibodies (which are commonly seen in Sjogren’s syndrome) and the known association between Sjogren’s and elevated lymphoma risk. An axillary lymph node biopsy was performed which revealed DLBCL. Radiation therapy and high dose steroids were initiated, with plans for chemotherapy induction for treatment of DLBCL with presumed optic nerve involvement representing PCNSL.

IMPACT/DISCUSSION: PCNSL is an aggressive disease with neurological symptoms progressing over days to weeks, which should prompt further evaluation with consideration of MRI. Approximately 90% of PCNSL cases are DLBCL. Classic systemic “B symptoms” of fever, weight loss, and night sweats are present in only 30% of DLBCL patients and even fewer patients with PCNSL. Furthermore, Sjogren’s syndrome, which is characterized by anti-Ro and/or La antibodies and sicca symptoms, is clearly associated with increased lymphoma risk. Interestingly, our patient had highly elevated anti-Ro and La antibodies, but did not have clinical manifestations of Sjogren’s. This unique presentation illustrates the need for further research to determine whether anti-Ro and La antibodies are independently associated with lymphoma development. In our case, the abnormal serologies in the setting of diffuse lymphadenopathy, hypercoagulopathy, and optic nerve mass were critical to making the correct diagnosis and initiating treatment.

CONCLUSION: Our case illustrates the importance of thorough evaluation of progressive neurological symptoms like painful monocular vision loss, in order to expediently diagnose and treat PCNSL and DLBCL. Furthermore, it is paramount that physicians recognize the association between lymphoma risk and Sjogren’s, as this may also facilitate early diagnosis and treatment.

AN UNCOMMON CAUSE OF HEMOPTYSIS AND WEIGHT LOSS IN AN OLDER PATIENT

Elizabeth A. Bryant¹; Brian F. Gage². ¹Graduate Medical Education, Internal Medicine, Washington University in St Louis, St Louis, MO; ²Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #4048711)

CASE: The patient is an 85-year-old woman with past medical history of hypertension treated with multiple antihypertensives including hydralazine, lung adenocarcinoma status post radiation, chronic kidney disease stage IIIb, and hypothyroidism who presented to the emergency due to one day of hemoptysis, cough, and dyspnea. Review of systems was notable for low-grade fevers and unintentional weight loss. Physical exam showed increased work of breathing and pallor. She was hospitalized and started on empiric therapy for community acquired pneumonia, but her symptoms did not improve with antibiotics. Initial bloodwork was concerning for bicytopenia, acute kidney injury, elevated partial thromboplastin time, proteinuria, and hematuria. Given the patient’s past history of pulmonary malignancy, she underwent lung imaging, which did not show cancer recurrence but demonstrated airspace consolidations concerning for pulmonary hemorrhage. The primary team consulted hematology due to coagulopathy and bicytopenia, who recommended that rheumatology be consulted. Autoimmune panel showed positive beta-2 glycoprotein antibody, anti-cardiolipin antibody, histone antibody, myeloperoxidase-antineutrophil cytoplasmic antibody, and elevated inflammatory markers. The patient’s hydralazine was discontinued, and she was started on high dose prednisone taper and hydroxychloroquine. She was discharged and followed up in rheumatology clinic. While she had full resolution of symptoms, her kidney function did not return to its baseline.

IMPACT/DISCUSSION: Hydralazine is known to induce both vasculitis and lupus syndromes. Patients may present with vague symptoms, such as dyspnea and unintentional weight loss, making it difficult for providers to recognize and treat appropriately. Because continued exposure to hydralazine can cause irreversible organ damage, early recognition of these syndromes is critical in preventing morbidity and death.¹ In this case, the patient had been experiencing symptoms for several months before her hydralazine was discontinued, likely worsening her kidney function. Evaluation should include basic labs, urinalysis, and lung imaging.² Treatment includes immediate hydralazine discontinuation, steroids, and occasionally hydroxychloroquine. Patients should have close follow up with rheumatology.

CONCLUSION: In patients who present with symptoms of a new autoimmune disease and exposure to hydralazine, clinicians should have a high suspicion for hydralazine induced vasculitis or lupus. Hydralazine should be immediately discontinued and rheumatology should be consulted.

References

1. Gandhi P, Khurana B, Munjal R, Sekar A, Gandhi RGG. Hydralazine-induced vasculitis. Cureus. 2023 Feb; 15(2): e35306. doi: 10.7759/cureus.35306.

2. Kumar B, Strouse J, Swee M, Lenert P, Suneja M. Hydralazine-associated vasculitis: Overlapping features of drug-induced lupus and vasculitis. Seminars in Arthritis and Rheumatism. October 2018. 48 (2): 283-287. https://doi.org/10.1016/j.semarthrit.2018.01.005.

AN UNSUSPECTING CASE OF LITHIUM TOXICITY

Rebecca E. Tobet, Patricia Dharapak. Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4064050)

CASE: A 71-year-old woman with hypertension, subclinical hypothyroidism, bipolar disorder, and chronic low back pain presented with subacute, progressive gait imbalance and falls, associated with word-finding and memory difficulties. Bowel habits were newly irregular. Home medications were unchanged and included lisinopril, HCTZ, ziprasidone, and lithium. Her exam noted psychomotor slowing, bilateral upper extremity tremor, and hyperreflexia and clonus. Electrolytes and renal function were normal. Vitamin B12 was replete. Head CT and MRI brain and spine were negative for pathology. Serum lithium level was elevated at 1.8 mEq/L. Intravenous fluids were initiated and lithium, lisinopril, and HCTZ were held. By hospital day 2, the lithium level downtrended and her clonus and hyperreflexia resolved as her tremors, cognition and speech improved. While her previous lithium levels had been within range, this agent was permanently discontinued. One month after discharge, the patient endorsed improved strength and coordination with no further cognitive or balance concerns.

IMPACT/DISCUSSION: Lithium is well known for its neurotoxic effects, although GI symptoms such as nausea and diarrhea can occur. In chronic toxicity, neurologic symptoms predominate and are often superimposed on the effects of chronic use. The therapeutic range is 0.8-1.2mEq/L. Mild symptoms (slurred speech, mild tremor) are typically seen with levels between 1.5-2.5mEq/L, moderate-to-severe symptoms (lethargy, coarse tremor, clonus) at levels of 2.5-3.5mEq/L, and severe symptoms (seizures and encephalopathy) occur at levels >3.5mEq/L. Given its delayed CNS distribution, those with very high levels acutely can be relatively asymptomatic while those at therapeutic levels can develop severe toxicity. Risk factors include use of diuretics, NSAIDS, ACE/ARBs, and older age especially when compounded by recent illness, a decline in renal function or polypharmacy. Treatment includes hydration, withdrawal of offenders, and hemodialysis. While our patient’s antihypertensives increased her risk for toxicity, there was no obvious precipitant to her altered levels. Our case underscores the importance of routinely measuring drug levels and particularly when there is a clinical change. The case also illustrates that lithium levels do not always correspond with degree of toxicity, especially in chronic users. While a level of 1.8 mEq/L was mildly elevated, her coarse tremor and clonus suggested moderate-to-severe lithium toxicity.

CONCLUSION: Lithium toxicity is a clinical diagnosis with a range of presentations reflecting total body lithium burden and rapidity of onset rather than the actual lithium dose. It should be suspected in those presenting with any clinical change regardless of dose, prior or current therapeutic levels, or specific precipitating conditions.

AN UNUSUAL CASE OF AN ENDOCARDITIS MIMIC

Kathleen Mathieu, Michael D. Creager, Amar Kohli. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4064632)

CASE: Mr. K is a 70 year old man with a history of CVA, HTN, T2DM and recent admission to another hospital for proteus bacteremia secondary to UTI who presented with two days of right sided flank pain. He was found to have leukocytosis with left shift, with WBC 20.4. CMP was significant for AKI but otherwise normal. EKG and CXR were also normal. A CT abdomen with contrast demonstrated splenic and right renal infarcts concerning for septic emboli. Additional CT imaging was unremarkable. Initially, the differential for splenic and renal infarcts was broad, and included septic emboli from endocarditis, thromboembolism, and hypercoagulable disorder. Interestingly, the patient had three sets of negative blood cultures and a TTE negative for vegetation or shunt. When he developed a hoarse voice, concern for new septic emboli prompted a brain MRI revealing an acute right MCA stroke. CTA of the head, neck, and chest was significant for a linear filling defect of the ascending aorta, representing propagating thrombus from ruptured plaque. Discussion amongst the primary team, vascular surgery and infectious diseases led to the conclusion that the most likely source of his emboli was a seeded infectious thrombus of the aortic plaque. Confirming this diagnosis would require extracting the clots that were embolized and sending them for culture data, which was deemed impractical. He was treated with IV cefepime for 6 weeks for a presumed “endovascular equivalent” of ruptured aortic plaque seeded with proteus.

IMPACT/DISCUSSION: This case highlights the importance of advanced imaging when there is a high suspicion for septic emboli despite negative culture data and reassuring initial imaging. Advanced imaging should have been sought after Dukes Criteria for infective endocarditis was found to effectively be zero. According to data, this has an 80% sensitivity for ruling out endocarditis. Not until the patient had a CTA of his chest was his ruptured aortic plaque discovered. While his multidisciplinary team found him to not be a surgical candidate, they were appropriately able to time the duration of his antibiotic treatment given the comparability to endocarditis. Additionally, when he was informed of his increased risk of bacteremia and subsequent seeding given his atherosclerotic disease, he was prompted to limit his risk by quitting smoking. This case is unique due to the microbiology of the bacteremia as proteus is an unusual species to seed valves or endovascular structures. Because the emboli could not be cultured, the patient required empiric therapy for presumptive proteus endovascular infection. Despite technically clearing his bacteremia prior to admission, he warranted a full 6 weeks of treatment based on the concern for septic emboli.

CONCLUSION: If the source of septic emboli is at first unclear, advanced imaging such as CTA or TEE may be warranted. Atypical bacteria such as proteus can seed endovascular structures and should be considered for prolonged antibiotic treatment.

AN UNUSUAL CASE OF PEMBROLIZUMAB-INDUCED MYASTHENIA GRAVIS DISORDER. TREATMENT CAUSING MORE HARM THAN DISEASE ITSELF.

Rafael Cavalcante, Soumya Yemme, Elizabeth Chandy, Dhiman Basu. Internal Medicine, Texas Health Resources, Lewisville, TX. (Control ID #4038642)

CASE: An 83-year-old woman with hypothyroidism, type 2 diabetes, hypertension, and atrial fibrillation presented with two-week progressively worsening right-sided ptosis, dysphagia, dry mouth, generalized weakness, and recurrent falls. She denied chest pain, palpitation, dizziness, syncope, or seizure history. About 4 months prior to admission, she was treated for stage IV metastatic gastric adenocarcinoma intestinal type with fluorouracil, oxaliplatin, folinic acid, trastuzumab and pembrolizumab.

Head CT without contrast and MRI scans revealed no intracranial abnormalities including metastatic disease. Due to neuromuscular weakness and risk of airway compromise, she was admitted to ICU and required mechanical ventilation. Acetylcholine binding and blocking antibodies were negative. The diagnosis of seronegative myasthenia gravis was made based on her clinical presentation.

She completed five cycles of IVIG, and plasmapheresis with no improvement and was also started on pyridostigmine and high dose of IV steroids. There was no response to the treatment and due to clinical deterioration, her son decided on comfort care. The patient expired peacefully among family members shortly after extubating.

IMPACT/DISCUSSION: Prompt identification of immune checkpoint inhibitor (ICI)- related myasthenia gravis (irMG) is crucial due to the possibility of rapid deterioration and high mortality rate, especially when compared to de novo MG.^1,4 It is a rare but life-threatening adverse effect of ICIs.⁵

A strong clinical suspicion plays a pivotal role in diagnosing irMG. Such events may be less uncommon than previously observed, considering the anticipated substantial rise in exposure to ICI therapy within specific cancer populations.¹ Diagnosing and managing this condition poses significant challenges due to limited number of documented cases in the literature.^1,4

Onset of pembrolizumab-induced MG symptoms usually occurs during the first four cycles³. ICIs half life ranges from 14.7 to 27.3 days.¹ The 2019 National Comprehensive Cancer Network guidelines indicate that the diagnosis of irMG does not require positive antibody test.³ In fact, some studies have shown that detecting circulating autoantibodies is not clinically beneficial as serological positivity rates were lower in irMG cases than in de novo MG.^3,5

Certain systematic reviews indicate superior results in patients treated with IVIG and/or plasmapheresis early on compared to those solely administered steroids as primary therapy.¹ A recent study presented the first case of successfully treated irMG with rituximab.²

CONCLUSION: Pembrolizumab and other immune checkpoint inhibitors are emerging treatments for selected high-grade malignancies. Although rare, Pembrolizumab-Induced myasthenia gravis exhibits rapid clinical progression and often leads to a poor prognosis. Early diagnosis and immediate treatment are key for improving prognosis. In this case study, the patient achieved full cancer remission but succumbed to ICI-induced myasthenia gravis.

AN UNUSUAL CASE OF RHABDOMYOLYSIS SECONDARY TO INTRAVENOUS IRON SUCROSE INFUSION.

Prodip Paul¹; Syed Muhammad Hussain Zaidi²; Mishouri Paul¹; Gabriel A. Ramos³; Koushik Paul⁴; Julio A. Ramos⁵. ¹Medicine, Geisinger Community Medical Center, Scranton, PA; ²Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ³Medicine, University of Virginia, Charlottesville, VA; ⁴Geisinger Health, Danville, PA; ⁵Rheumatology, Geisinger Community Medical Center, Scranton, PA. (Control ID #4064214)

CASE: A 39-year-old female with a past medical history of Sjogren's syndrome, and iron deficiency anemia presented to the emergency department (ED) with generalized body aches. She recently received an intravenous iron sucrose infusion for iron deficiency anemia. Shortly thereafter, she developed significant discomfort in peripheral joints along with severe myalgia, She had no fever, chills, shortness of breath, or fall. In the ED, her vitals were within normal limits. Laboratory markers revealed creatine kinase (CK) 65,046 U/L, white blood cell count 11.4K/uL, and Hb 11.1 g/dL. She also had associated elevated transaminases and acute kidney injury. Nephrology and rheumatology consultations were sought who recommended continuing intravenous fluids and monitoring CK levels. She was started on intravenous fluids. Repeat laboratory work showed improvement in CK level to 22,000 U/L then 13,544 U/L, and subsequently returning to normal 161 U/L. Her generalized body aches improved significantly. Her acute kidney injury was resolved. The patient’s condition improved significantly, and she was discharged home in a stable condition

IMPACT/DISCUSSION: Rhabdomyolysis is a syndrome resulting from a direct or indirect muscle injury. Muscle injury causes the release of their contents into the bloodstream, and this can lead to serious complications such as renal failure. There are many traumatic and nontraumatic causes of rhabdomyolysis. In this case, the patient’s clinical findings suggest that she developed rhabdomyolysis after a parenteral infusion of iron sucrose. Myalgia, arthralgia, and leg cramps are reported among IV iron side effects. Iron formulations are not included in the list of drugs causing rhabdomyolysis. There are only a few reported case reports of rhabdomyolysis secondary to parenteral administration of iron sucrose, ferric gluconate, and iron dextran. It is postulated that rhabdomyolysis is likely provoked by the generation of increased free iron, following intravenous iron infusion, which promotes oxidative joint and muscular injury. In our patient, the pre-existing autoimmune disease might have increased her susceptibility to iron-induced oxidative stress. Another possible mechanism is that free iron within iron-dextran activates free radicals, initiating lipid peroxidation and leading to polymyositis, rhabdomyolysis, and myoglobinuria. Treatment is largely supportive including intravenous fluid resuscitation and monitoring of creatine kinase level. Our patient’s symptoms did improve significantly following this intervention.

CONCLUSION: We should pay more attention and closely monitor the more common side effect of myalgia after parenteral iron therapy, which can indicate rhabdomyolysis.

AN UNUSUAL CASE OF STERNOCLAVICULAR JOINT SEPTIC ARTHRITIS

Yixuan K. Du²; Ahyeon Cho²; Chloe Grzyb²; Nicholas Duca¹. ¹Division of General Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA; ²Penn State College of Medicine, Hershey, PA. (Control ID #4046059)

CASE: A 71-year-old male with a medical history of atrial fibrillation and deep vein thrombosis on apixaban presented with pain, swelling and erythema of the right sternoclavicular joint (SCJ). Two months prior, the patient underwent an emergency exploratory laparotomy with colostomy due to sigmoid colon perforation. Subsequently, he developed empyema in the right lower lobe and thrombosis of the right subclavian vein. On admission, his vitals were normal except the heart rate was 120 bpm and oxygen saturation was 94% on 2L nasal cannula. Labs showed sodium 131 mg/dL, WBC 10.71*10⁹/L, ESR 73 mm/hr, CRP 8.57 mg/L. He was not oriented to person, place, or time. His right SCJ was erythematous, swollen, and tender to palpation. A CT of the Chest noted worsening subclavian thrombosis that had embolized to the internal jugular vein and inflammatory soft tissue thickening surrounding the right clavicle and SCJ. There was concern for a septic joint of the SCJ. This was confirmed through an aspiration of SCJ, which revealed 550 WBCs with 96% neutrophils, and blood cultures growing Strep viridans. He was started on metronidazole, cefepime, and vancomycin. Throughout his 14-day hospitalization, erythema, and tenderness of his right SCJ gradually resolved. He was discharged in stable condition on metronidazole 500 mg TID and levofloxacin 750 mg daily for 6 weeks. The patient was lost to follow up.

IMPACT/DISCUSSION: Septic arthritis of the SCJ is a rare pathology, accounting for less than 1% of all joint infections. SCJ septic arthritis has an insidious onset and is frequently overlooked. Most patients present with tender SCJ, chest pain, and fever. It is often associated with systemic disease and impaired immunity. Pathophysiology encompasses direct bacterial inoculation of the joint, contiguous spread from a nearby area or hematogenous dissemination. In this case, the etiology might be secondary to bowel perforation, empyema, or bacteremia. The patient was under close surveillance for recent bowel perforation and subsequent empyema, allowing for early detection of the SCJ arthritis. Complications of SCJ septic arthritis consist of osteomyelitis, mediastinitis, abscess, or myositis, precipitating septic shock with a mortality rate of 8-15%. Management includes surgical debridement, aspiration and intravenous antibiotics.

CONCLUSION: Our case investigates the intricacies of septic SCJ arthritis, underscoring the pivotal role of vigilant surveillance in early detection. The nature of this pathology often leads to delayed diagnosis, with a mean interval of two weeks from symptom onset to therapeutic intervention. This case highlights the importance of early recognition, multidisciplinary teamwork, and prompt intervention of SCJ arthritis, which contributes to avoidance of complications and restoration of health.

AN UNUSUAL PRESENTATION OF CNS METASTASIS

Brent Kennis¹; Zach Rubnitz¹; Rachna Malani²; Mark Kelly¹. ¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²Neurosurgery, University of Utah Health, Salt Lake City, UT. (Control ID #4051892)

CASE: A 43-year-old female with recurrent, metastatic breast cancer (ER+/PR+/Her2-) is admitted with progressive vertigo and headache accompanied by rapid-onset polydipsia and polyuria. Four months prior to admission, the patient developed headache, pulsatile tinnitus, and photophobia. MRI Brain at the time demonstrated possible bilateral optic neuritis and lumbar puncture (LP) was bland with exception of elevated opening pressure of 29cm H2O. She was treated with high dose steroids and acetazolamide without significant improvement in her symptoms. Two weeks prior to admission, repeat LP had opening pressure of 52cm H2O and cytology found atypical cells consistent with known breast cancer.

She was admitted for an expedited ventriculoperitoneal (VP) shunt. Her subjective polyuria and polydipsia were quantified at greater than 10L per day with a peak serum sodium of 147. A modified water deprivation test revealed dilute urine and she responded well to DDAVP, confirming a diagnosis of argenine vasopressin (AVP) deficiency. Post-shunt MRI and PET CT of the brain showed no evidence of metastatic disease despite the presence of malignant cells on LP. We hypothesize that our patient had subacute onset of leptomeningeal disease resulting in intracranial hypertension, which ultimately precipitated AVP deficiency.

IMPACT/DISCUSSION: Leptomeningeal metastasis is most often associated with breast cancer, lung cancer, and melanoma. It commonly presents with nonfocal symptoms such as headache and nausea as well as multifocal signs such as cranial neuropathies, cerebellar dysfunction, and lower extremity deficits. More rarely, it can present with AVP deficiency due to involvement of the pituitary stalk and intracranial hypertension via disruption of the arachnoid granulations. Diagnosis of leptomeningeal disease involves MRI demonstrating enhancement of the leptomeninges or CSF cytology with malignant cells. The disease carries a poor prognosis and can be palliated with both radiation and chemotherapy.

Our patient’s subacute onset of nonfocal neurologic symptoms is a typical presentation for leptomeningeal metastasis. However, her simultaneous development of AVP deficiency and intracranial hypertension is unusual, especially in the absence of macroscopic disease or mass effect on neuroimaging. AVP deficiency secondary to intracranial hypertension has been reported. Our patient’s DDAVP reliance did not improve after VP shunt placement suggesting residual AVP deficiency from damage caused by her prolonged period of intracranial hypertension.

CONCLUSION: Leptomeningeal disease can have a subtle and subacute presentation requiring high index of suspicion to diagnose. It can be complicated by intracranial hypertension and AVP deficiency.

A PATIENT PRESENTING WITH PURPLE TOES

Baila Elkin¹; Megan A. McGervey². ¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Hospital Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4060723)

CASE: A 74-year-old woman came to the hospital from podiatry clinic for purple toes. History included JAK2 V617F positive Polycythemia Vera (PCV), Raynaud's, breast and thyroid cancer status post treatment, and previous DVT/PE on apixaban. Pain and ulceration had begun 5 months prior, with biopsy at that time showing livedoid vasculopathy. Pentoxifylline was started and hydroxyurea stopped. Her ulcers had been improving, but 3 weeks prior to presentation, her toes became purple and painful.

Exam showed violaceous discoloration of both feet with frank necrotic tissue. Feet were cold, with palpable dorsalis pedis pulses bilaterally. Sensation and strength were intact bilaterally, with unremarkable cardiopulmonary and joint exams. Laboratory workup was notable for WBC 38.27, hemoglobin 12.9, platelets of 323, and pulse volume recording with right and left ankle-brachial index of 1.08 and 1.02. Previous workup had shown negative anti-cardiolipin antibody, B2GP1, cryoglobulins, and positive ANA 1:640. Full antiphospholipid syndrome (APLS) testing could not be completed at that time due to the patient being on a direct oral anticoagulant (DOAC): apixaban.

Apixaban was discontinued and unfractionated heparin begun. Nifedipine and digital nitro paste were started. A CT chest/abdomen/pelvis, obtained for possible neoplastic syndrome, showed a new 8mm thrombus in the mid descending thoracic aorta, thrombus in the abdominal aorta near the bifurcation, and splenic infarcts. Echocardiogram showed no vegetations, and APLS panel revealed positive lupus anticoagulant. Heparin drip was continued for 72 hours, then transitioned to therapeutic lovenox for 4 weeks, followed by a bridge to warfarin with target INR 2-3. The patient’s burning foot pain continued despite heparin drip, and she underwent suction thrombectomy of her infrarenal aortic thrombus, with improvement in pain. Her PCV treatment was transitioned to roxolitinib.

IMPACT/DISCUSSION: Careful history with attention to timeline, as well as a diagnostic time-out, helped avoid misattributing this patient's symptoms of thrombosis to livedoid vasculopathy. Several differential diagnoses were taken into consideration with simultaneous workup and treatment, with heparin started until serious thrombosis was ruled out. Imaging then showed a large central clot. Careful review of this patient’s risk factors, including PCV not on hydroxyurea, high arterial thrombus risk in PCV and discontinuation of aspirin, as well as presence of the JAK2 V617F mutation, might have placed thromboembolism higher on the differential. Completing a previously unfinished APLS workup led to a diagnosis of APLS, changing management from a DOAC to vitamin K antagonist, warfarin.

CONCLUSION: Differential diagnosis for purple toes is broad.

Recurrent thrombosis on anticoagulation necessitates further work up.

Different thrombotic risk factors may change management.

A POTENTIAL CASE OF RARE NON-TUBERCULOSIS ASSOCIATED RASMUSSEN ANEURYSM PRESENTING WITH HEMOPTYSIS

Matthew Jenkins¹; Nathan Douthit². ¹Internal Medicine, East Alabama Medical Center, Opelika, AL; ²Internal Medicine Residency, East Alabama Medical Center, Opelika, AL. (Control ID #4063569)

CASE: A 63 year old male with a past medical history significant for depression, tobacco abuse, and known cavitary lung lesion presented to the ED overnight with a chief complaint of two day history of hemoptysis. Physical exam on arrival was unremarkable other than tachycardic heart rate (119 bpm) with regular rhythm. CTA chest on admission demonstrated a large spiculated mass in the right lung apex increased in size since radiograph seven months prior. Admission labs were unremarkable. The patient had no recent travel history but had received a childhood BCG vaccine, thus interferon gamma release assay (IGRA) was obtained. Bronchoscopy was performed on day 6 of admission. During the procedure, the patient had significant bleeding from the mass and was intubated for airway protection and started on tranexamic acid. Acid fast bacilli were found on bronchoscopy studies and treatment was initiated. IGRA was negative, as were 1-3-beta-d-glucan, aspergillus IgG, TB PCR, and cytology. On day 8 of admission, IR performed bead embolization of right bronchial artery. The patient self-extubated on day 10 of admission. He was referred to IR for CT guided biopsy of the mass, but IR requested repeat CTA first to assess for further bleeding. On day 14 of admission a repeat CTA chest demonstrated multiple areas of contrast blush suggesting pseudoaneurysms. In the end cultures were positive for Mycobacterium avium complex (MAC). The patient was treated with rifampin, ethambutol and azithromycin with plans for repeat CT Chest in 6-8 weeks

IMPACT/DISCUSSION: A Rasmussen aneurysm is a rare phenomenon caused by weakening of the pulmonary arterial wall, most commonly associated with reactivation tuberculosis. A 2017 case report of a Rasmussen aneurysm in a patient with MAC and negative TB, suggests it is possibly the first case of non-TB mycobacterium associated Rasmussen aneurysm. Etiologies of pulmonary artery pseudoaneurysms include traumatic, vasculitic, infectious, neoplastic, and pulmonary arteriovenous aneurysms. Additionally, multiple pulmonary and/or bronchial artery aneurysms with lower extremity thrombosis and/or thrombophlebitis is described as Hughes-Stovin syndrome, a syndrome of unclear etiology that may be related to Behcet’s disease. CT or CTA are the primary methods of diagnosis of pulmonary artery pseudoaneurysm. Treatment is generally some type of embolization; however, surgical interventions maybe necessary. Additionally, any underlying infectious etiology must be treated as well. In this case, given the infectious workup revealing of mycobacterium avium complex infection with negative laboratory evidence of tuberculosis infection, leaving MAC infection as the most likely etiology of the patient’s Rasmussen aneurysm.

CONCLUSION: - Pulmonary artery pseudoaneurysms can be a cause of life-threatening hemoptysis

- Diagnosis is made by CT or CTA

- Etiology includes trauma, inflammatory disease, and infection. The underlying cause must be treated.

A PROBLEM ON MAIN STREET: SPONTANEOUS CORONARY ARTERY DISSECTION IN THE LEFT MAIN

Maria G. Parra Riveros, Jan Hoffmann, Vaibhav Shah, Jawad Shabani, David Song, Rosy Thachil. Elmhurst Hospital Center Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY. (Control ID #4064161)

CASE: A 29-year-old Hispanic woman with a history of surgical repair of coarctation of the aorta presented with sudden onset of severe substernal chest pain radiating to the right neck and right arm. Vitals were stable, and the physical exam was unremarkable. Chest X-ray was normal. Initial electrocardiograms showed T-wave inversion in lead V1 and biphasic T-wave in lead V2, while the second showed persistent T-wave inversion in lead V1, T-wave inversion in lead V2, and biphasic T-wave in lead V3. Serial troponin-T levels were 0.241 ng/mL, 0.650 ng/mL, and 0.728 ng/mL respectively (reference range <= 0.010 ng/mL). The patient received aspirin, nitroglycerine, heparin, and eptifibatide. Echocardiography revealed a mildly reduced ejection fraction of 45% and akinetic apical septal, apical inferior, apical lateral, and apex left ventricular wall segments. Cardiac catheterization showed coronary dissections in the left main coronary artery, as well as the proximal and middle-left anterior descending coronary artery. Three drug-eluting stents were successfully placed. Subsequent diagnostic evaluation, including Fibromuscular Dysplasia (FMD) workup and computed tomography angiography (CTA) of the head, neck, and chest was unremarkable. The patient was discharged with plans for SCAD registry enrollment, outpatient CTA of the abdomen and pelvis, and repeat echocardiography to assess for left ventricular recovery.

IMPACT/DISCUSSION: SCAD accounts for up to 35% of acute coronary syndromes in women under 50, which is likely an underestimate due to underdiagnosis and misdiagnosis. Although advancements in the understanding of SCAD pathophysiology have been made, the reasons for its predilection for specific coronary artery segments remain unclear. SCAD predominantly affects distal coronary arteries and small branches, particularly the mid-to-distal sections of the left anterior descending coronary artery. Management strategies vary, with conservative approaches being favored for distal lesions, while proximal SCAD cases often require percutaneous coronary intervention (PCI). Proximal SCAD, as in our case, poses significant challenges in terms of intra-angiographic and post-PCI outcomes, including procedure failure, iatrogenic dissection, extension of dissection, and intramural hematoma propagation.

CONCLUSION: SCAD is a tear or separation within the coronary artery wall, creating an intraluminal hematoma, which can present as myocardial ischemia. Diagnosis of SCAD is made with angiographic evidence of non-iatrogenic and non-atherosclerotic radiolucent intimal flap and contrast staining. Treatment of SCAD is dependent on the location and extent of the lesion. Distal SCAD lesions are more amenable to conservative management, whereas proximal SCAD often necessitates invasive interventions such as PCI and has a higher potential for complications. Vigilant follow-up and enrollment in the national SCAD registry are essential to further our understanding of this condition.

A RAPIDLY GROWING NASAL MASS IN THE SHADOW OF CANCER

Spandana N. Jarmale¹; Vidya Gopinath². ¹Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI; ²General Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4064396)

CASE: A 59-year-old female with a remote history of Non-Hodgkin’s Lymphoma status post autologous HSCT who was recently diagnosed with biopsy-proven spindle cell carcinoma of the lung with three brain lesions presumed to be metastases presented with a rapidly growing nasal mass that protruded from her right nares. The mass was first noted five days prior to presentation. In addition to the protruding mass, she endorsed headache, persistent epistaxis, and tenderness around the mass.

A CT scan of her face showed osseous expansion and erosion concerning for an aggressive infection, likely fungal. She was admitted to medicine with ENT and ID following. She was started on amphotericin and zosyn. ENT performed nasal endoscopy, biopsy, and epistaxis control. Fungal, bacterial, acid-fast bacilli cultures and surgical pathology were sent.

Given imaging results and the patient’s history of autologous HSCT, the ID team was most concerned for mucormycosis or some other invasive fungal disease. There was also concern for super infection of a thrombus given recent initiation of anticoagulation, however patient had no leukocytosis, fevers or positive blood cultures. Given her diagnosis of a new malignancy with metastases, there was concern for a metastatic mass although the nasal cavity is a rare metastatic site.

ENT was most concerned for malignancy, since when they biopsied the lesion, there was significant bleeding. Since the vascular supply is typically less robust in fungal infections with more obvious necrosis, they recommended transitioning her from Zosyn to Augmentin. Pathology returned as high grade malignancy.

IMPACT/DISCUSSION: Deforming skin lesions of the nose can be caused by granulomatous diseases, vasculitides, fungal or atypical bacterial infections, and neoplasms.

In cases of infection, typical findings include nasal cellulitis, redness, swelling of the nasal bridge and cheek, with tissue necrosis and eschar formation in late stages of fungal infections. An intraoral examination can reveal palatal ulceration. Orbital spread results in proptosis followed by ophthalmoplegia and visual impairment.

In this patient with a remote hx of HSCT and immunosuppression, a fungal infection was high on our differential as well as HIV. The bony erosion on CT scan suggested an infectious etiology. However the findings in the OR of lack of necrosis and uninterrupted vascular supply to the lesion are not typical in fungal infection. Despite the rarity of metastases to the nasal cavity and maxillofacial region, it must remain on the differential especially for patients with known malignancy.

CONCLUSION: - Patients who are immunosuppressed or have a history of HSCT with a rapidly growing mass should be evaluated for HIV, aspergillosis and mucormycosis, even in the absence of fever and other systemic signs of infection

- Imaging findings suggestive of infection include osseous erosion, sinus opacification, and mucosal thickening

- Diagnosis requires tissue biopsy and histopathological study

A RARE CASE OF ACUTE PANCREATITIS MEDIATED THROMBOTIC THROMBOCYTOPENIC PURPURA

Sarah Soniwala. Department of Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4064704)

CASE: A 51-year-old woman with a past medical history of paroxysmal supraventricular tachycardia, neuropathy, peptic ulcer disease, alcohol use disorder, and tobacco use disorder presented with acute, constant epigastric pain with associated nausea and vomiting that was exacerbated by eating and drinking.

On initial presentation, patient was afebrile and hemodynamically stable. She was in mild distress due to pain and anxiety and had a diffusely tender abdomen to light palpation. Initial labs revealed WBC 13.7, hemoglobin 12.8, platelets 290, BUN 16, Cr 1.2 (baseline 0.9), lipase 685, and normal hepatic function panel. CT imaging revealed acute pancreatitis. She was managed supportively. On day 3 of her admission, her labs showed Hgb 9.2, platelets 19, BUN 28, Cr 1.6, T. bili 5.8 (indirect bili 2.5), and INR 1.2. Further investigation revealed D-dimer 9.68, fibrinogen 624, LDH 1582, haptoglobin <30, UA with large blood, bilirubin, 12 RBC, and 8 WBC, as well as a peripheral smear with many schistocytes. ADAMTS13 activity and antibody were sent but unfortunately hemolyzed. She was diagnosed with thrombotic thrombocytopenic purpura (TTP) and treated with plasmapheresis, prednisone, and Caplacizumab. She subsequently improved with remission of disease.

IMPACT/DISCUSSION: This case highlights the classic presentation of TTP in a patient diagnosed with acute pancreatitis. TTP is a rare and life-threatening disease characterized by fever, changes in mental status, thrombocytopenia, acute kidney injury, and hemolytic anemia with a high mortality when untreated. Acute pancreatitis is a well described consequence of TTP thought to be due to impairment of pancreatic circulation by thrombotic occlusion of small vessels and subsequent ischemia; however, there are few documented cases of TTP as a complication of acute pancreatitis. Acute inflammatory disease is known to reduce the activity of ADAMTS13 suggesting that uncontrolled systemic inflammation may trigger the onset of TTP by stimulating the release of ultra large vWF from endothelial cells and inhibiting their cleavage by ADAMTS13. Acute pancreatitis mediated TTP typically occurs early in the course of pancreatitis with a median of 3 days due to peak levels of inflammatory cytokines at that time. Given the brief interval between the diagnosis of acute pancreatitis and the onset of TTP, rapid identification of this association can lead to expeditious initiation of life-saving treatment.

CONCLUSION: Acute pancreatitis mediated TTP is less commonly recognized in the literature as a complication of pancreatitis. There is a short interval between the onset of acute pancreatitis and the development of TTP, which has a high mortality rate when untreated. Thus, early recognition of this association can lead to prompt life-saving treatment.

A RARE CASE OF ADULT-ONSET STILL’S DISEASE WITH MULTIPLE ORGAN INJURY

Zukhruf Tehreem, Susie Pham, Murwarit Rahimi, Alejandro Haag, John Nohren. School of Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4064216)

CASE: A previously healthy 28-year-old female with family history of systemic lupus erythematosus presented to the ED with days to weeks of nonspecific symptoms: fevers, fatigue, dyspnea, cough, vomiting, diarrhea, arthralgias, and intermittent erythematous rashes. Laboratory studies were significant for neutrophilic leukocytosis, transaminitis, troponinemia, and marked hyperferritinemia. Creatinine was initially normal but peaked at 7.7. Electrocardiogram showed nonspecific T wave inversions. CT of the chest, abdomen, and pelvis revealed bibasilar groundglass opacities, bilateral pleural effusions, pulmonary edema, and diffuse lymphadenopathy. Transthoracic echocardiogram was significant for a pericardial effusion.

She was initially treated with vancomycin and piperacillin-tazobactam for sepsis. Extensive infectious workup was negative. Diffuse lymphadenopathy prompted workup for lymphoma, which was negative on lymph node biopsy. Due to her acute kidney injury, she underwent renal biopsy which was consistent with acute tubular necrosis (ATN). Extensive workup for other rheumatologic diseases was also negative. Diagnosis of AOSD was made based on the Yamaguchi criteria. She was treated with pulse-dose steroids and anakinra with improvement in symptoms, laboratory values, pericardial and pleural effusions, pulmonary edema, and lymphadenopathy.

IMPACT/DISCUSSION: Outside of the Yamaguchi criteria, the patient presented with cardiopulmonary involvement and later developed intrinsic renal injury. Her troponin elevation was likely due to myocarditis in the setting of AOSD. Her pulmonary edema, pleural effusions, and bibasilar opacities were likely due to AOSD. Repeat imaging following treatment showed that these findings improved significantly. Her ATN was likely not due to AOSD but due to contrast, nephrotoxic antibiotics, and dehydration from diarrhea. Renal involvement in AOSD has been described in the literature, but there are no cases linking AOSD with ATN.

The Yamaguchi criteria are the most widely used, specific, and sensitive diagnostic criteria for AOSD. Although AOSD is known to affect multiple organ systems, it is a diagnosis of exclusion and shares features with various disease processes, which can make for a challenging diagnosis. Diagnosis is often delayed given its variable presentation. Anchoring on sepsis, hematologic malignancies, and other rheumatologic diseases can further delay diagnosis. As a result, AOSD can progress to life-threatening complications such as macrophage activation syndrome and multiple organ injury before the appropriate diagnosis is made. In this case, early recognition of rheumatologic etiology was imperative to an expedited workup and treatment.

CONCLUSION: Adult-onset Still’s disease is a rare systemic inflammatory disease. Presenting symptoms are broad and nonspecific, commonly including fevers, pharyngitis, lymphadenopathy, polyarthralgia, and transient salmon-pink maculopapular rashes. Cardiac, pulmonary, hepatic, and renal involvement may occur.

A RARE CASE OF BLAU SYNDROME IN A GERIATRIC PATIENT

Su Hyun Jeong¹; Nishitha Shekhar¹; Kennedy Ukadike²; Meghan Mahalawat¹. ¹Internal Medicine, University of Nevada Reno, Reno, NV; ²Rheumatology, Renown Health, Reno, NV. (Control ID #4064122)

CASE: A 70-year-old previously healthy male was referred by another rheumatology clinic with fevers of unknown origin, diffuse muscle weakness worst at the proximal lower extremities, shortness of breath, slow mentation, neck/lower back/hand pain with morning stiffness, and hand numbness/tingling ongoing for two years. Of note, these symptoms occurred a few months after receiving his second COVID and first Shingrix vaccine. He was already on a prednisone taper, which failed to control his symptoms. Pertinent medical history includes prostate cancer status post prostatectomy, pulmonary embolism, ten-pack year smoking history, and multiple hospitalizations for these unexplained symptoms. Physical exam revealed mild rales on the bilateral lower lung fields, 4/5 strength on the proximal lower extremities with difficulty rising from a seated position, and noticeable cognitive deficits with altered speech. There were no observed dermatologic or visual changes. Inflammatory markers were elevated with an ESR 122, CRP 16.79, and Ferritin 1186. A recent bronchoalveolar lavage demonstrated numerous multinucleated giant cells and histiocytes with a background of red blood cells and mixed inflammatory cells. CT chest was negative for masses or infection but was suggestive of interstitial lung disease. Previous negative workup was extensive and ruled out multiple rheumatologic, malignant, and infectious etiologies. The patient had already tried nonbiologic DMARDs, which were ineffective, so he was started on tocilizumab with additional genetic testing and outpatient physical therapy ordered. He showed improvement, but tocilizumab was discontinued and replaced with canakinumab after blood work showed pancytopenia. Genetic testing revealed a heterozygous mutation of the NOD2 allele, which is seen in autosomal dominant Blau Syndrome

IMPACT/DISCUSSION: Our case is significant as this geriatric patient was found with Autosomal Dominant Blau Syndrome. Given the temporal relationship between the patient’s antiviral inoculations and his symptomatology, we assume he was catapulted into full-blown Blau Syndrome presentation with the inoculations as a trigger. Furthermore, diagnosis was challenging as our patient lacked the classic clinical triad of uveitis, arthritis, and granulomatous dermatitis. This case serves as a reminder that physicians need to exercise caution when encountering diseases that manifest in unexpected ways. Awareness and proper recognition are crucial for timely management and treatment--and thus the focus of our clinical vignette.

CONCLUSION: This clinical vignette demonstrates an atypical presentation of Blau Syndrome, a rare autosomal dominant disease most often seen in children. Consideration of rheumatologic conditions requires a heightened level of suspicion as symptoms are frequently nonspecific or present in unexpected ways.

A RARE CASE OF BRASH SYNDROME : AN UNDER-RECOGNIZED CLINICAL CONDITION

Richi Kashyap, Amit Gupta. Internal Medicine, North Alabama Medical Center, Florence, AL. (Control ID #4064944)

CASE: Background : BRASH syndrome- Bradycardia, Renal Failure, AV blockade, Shock and hyperkalemia is an uncommon and under recognized clinical entity. Failure to recognize the condition can initiate vicious cylce of worsening renal failure unless we recognize it early on.

Case report : 78-year-old female with past medical history of CKD, essential hypertension and heart failure with preserved ejection fraction presented to emergency department with complaints of confusion and the caretaker found the patient in her feces. On arrival to ER patient was found to be hypotensive with blood pressure of 82/70 mmHg and saturating 87% on room air. Patient was bradycardic with heart rate 48 per/min, initial EKG showed A-fib with slow ventricular response. Initiated labs were remarkable for hyperkalemia with potassium of 7 mmol/l, BUN105 mg/dl and creatinine /4.2 mg/dl. Patient was treated with 2 doses of atropine 0.5 mg, IV calcium gluconate, insulin with dextrose. Patient also had lactic acidosis possibly secondary to bradycardia and decreased renal perfusion. During her hospital stay she recieved dialysis given the degree of renal dysfunction. Patient's home medication included metoprolol 50 mg twice daily, amiodarone 200 mg daily. 2D ECHO showed LV systolic function ejection fraction 60 to 65%. Patient had similar episode in the past and required dialysis for hyperkalemia.

IMPACT/DISCUSSION: Bradycardia can lead to hypoperfusion which results in renal injury which triggers hyperkalemia. The underlying kidney injury and bradycardia itself can trigger multiorgan dysfunction which itself exacerbates the hyperkalemia. As per literature hypovolemia and antihypertensive medications are the most common cause of precipitating BRASH syndrome. EKG changes in BRASH syndrome can range from sinus bradycardia toclassic findings seen in hyperkalemia.

CONCLUSION: BRASH syndrome remians widely under recognized. High index of suspicion should be there when we come across patients with resistant bradycardia coupled with hyperkalemia and renal failure.

A RARE CASE OF CARDIAC TAMPONADE IN THE SETTING OF ULCERATIVE COLITIS

Dawood Jamil¹; Samuel Gregerson²; Matthew Thomas³; Dee Dee Wang³. ¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Internal Medicine, Henry Ford Hospital, Detroit, MI; ³Cardiology, Henry Ford Health System, Detroit, MI. (Control ID #4046175)

CASE: A 33-year-old female with a history Ulcerative Colitis and medication nonadherence to Mesalamine presented to an outside facility with shortness of breath and chest pain. Her initial workup proved unremarkable, so she was sent home with Ibuprofen and follow-up.

Her chest pain progressively worsened, she developed abdominal pain with diarrhea, and she returned to the Emergency Department. On arrival, she was tachycardic (126), hypotensive (98/54), ill-appearing, and diaphoretic. An electrocardiogram (EKG) demonstrated diffuse ST-segment elevation, while her chest radiograph showed a mildly enlarged cardiac silhouette. An urgent transthoracic echocardiogram (TTE) was ordered, demonstrating excessive respiratory variation and mitral valve and tricuspid valve spectral Doppler velocities (more than 25% and 40%, respectively) with evidence of tamponade. Given these findings, she was transferred to our facility for further care.

She underwent urgent pericardiocentesis yielding 350 mL of exudative fluid, with high neutrophils and inflammatory markers, but negative fluid culture. Repeat echocardiogram demonstrated resolution of tamponade. GI was consulted given UC flare concerns; she was started on mesalamine 1000 mg four times/day along with colchicine 0.6mg twice a day. Her abdominal pain and diarrhea improved, and she was discharged on this medication regimen.

IMPACT/DISCUSSION: Cardiac Tamponade is a syndrome wherein the pericardial space accumulates sufficient fluid to produce impairment of diastolic filling, leading to hemodynamic instability and shock. Extraintestinal manifestations of Inflammatory Bowel Disease (IBD) are common in 25- 40% of patients, and of the rare cardiovascular manifestations of IBD, pericarditis is the most common. Although the exact etiology of this phenomenon is unknown, current hypotheses include autoimmune inflammation and/or direct cardiotoxicity of anti-inflammatory medication used in IBD. Patients with mild to moderate UC can be treated with biologic agents such as mesalamine, which impedes macrophages and reduces the native inflammatory response. Paradoxically, mesalamine has been reported to cause pericarditis due to molecular mimicry, causing cross-reactivity between myocardial antigens and mesalamine's molecular structure. Our patient stated she only took her Mesalamine once daily instead of the prescribed four times/day regimen.

CONCLUSION: We report a case of Cardiac Tamponade in a UC patient on subtherapeutic Mesalamine. We suspect the likely etiology of her presentation involves a possible molecular mimicry phenomenon, supported by the fact she was on subtherapeutic doses of Mesalamine that could cause cross-reactivity and inflammation, while the anti-inflammatory properties of the drug were insufficient. Once she started adequate dosing of Mesalamine, she experienced swift resolution in her symptoms.

A RARE CASE OF DELIRIUM TREMENS WITH LOW CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL SCORE

Susu Zhou, Erica Grabscheid. Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4014206)

CASE: A 77-year-old woman with past medical history of alcohol use disorder with prior hospitalizations for withdrawal but no history of withdrawal seizures or delirium tremens, HTN, HLD, cerebral infarction (with no sequelae), COPD on home oxygen, and hypothyroidism on levothyroxine presented to an inpatient detox unit. Patient reported drinking 1.75 liters of vodka every three days with the last drink being the night prior to presentation. Due to a complaint of chest pain and shortness of breath, the patient was transferred to the Emergency Room where the patient was noted to be restless with tremor and confused. Physical examination revealed a high blood pressure, sinus tachycardia, and the patient was febrile. The Clinical Institute Withdrawal Assessment (CIWA) score was 4. Work-up ruled out any acute coronary event, PE/DVT, dehydration, or infectious etiology. The TSH was mildly low, but the FT4 was within normal range. Urine toxicology was negative. Over time, the patient remained hypertensive (185/106) and tachycardic (142) with several fever spikes (101.4F). The CIWA score consistently was only 0 to 4. Given the history of excessive alcohol use and withdrawal symptoms such as tremor and disorientation, a diagnosis of delirium tremens (DT) was made. The patient was started on a lorazepam taper, and the patient’s symptoms improved.

IMPACT/DISCUSSION: Delirium tremens, the most severe and potentially fatal condition of alcohol withdrawal syndrome, is manifested by hallucinations, disorientation, agitation, tachycardia, hypertension, and fever. DT usually develops 48-96 hours after the cessation of heavy drinking. Mortality from DT is approximately 1 to 4%, but can be significantly higher dependent upon if timely diagnosis is made and proper management is implemented. The CIWA score is the most widely used tool for the diagnosis of alcohol withdrawal. CIWA criteria is dependent upon the presence of nausea/vomiting, tremors, anxiety, agitation, paroxysmal sweats, orientation, headache, and tactile/ auditory/ visual disturbances; criteria do not include vital signs. A CIWA score of 19 or greater indicates severe withdrawal. The patient described here exhibited clinical signs of severe alcohol withdrawal such as tremor, confusion, and noticeably unstable vitals. However, the patient only technically met criteria for ‘mild’ withdrawal based on CIWA scoring (<8). All the patient’s symptoms were successfully controlled by treating for severe alcohol withdrawal.

CONCLUSION: Our report suggests that the CIWA scale has limitations as a tool in assessment of the severity of alcohol withdrawal syndrome; physicians should be mindful to rule out DT regardless of the CIWA score when applicable.

A RARE CASE OF DE NOVO LUPUS NEPHRITIS PRESENTING AFTER GROUP A STREPTOCOCCUS INFECTION IN A YOUNG HISPANIC MALE WITH NORMALIZED KIDNEY FUNCTION

Wei Tang³; Vihanga Perera³; Arushika Yedla³; Nao Hara¹; Isaac Pak²; Christopher Nabors³. ¹Pathology, Westchester Medical Center, Valhalla, NY; ²Nephrology, Westchester Medical Center, Valhalla, NY; ³Medicine, Westchester Medical Center, Valhalla, NY. (Control ID #4033786)

CASE: A 37-year-old Hispanic man with compensated alcoholic cirrhosis and well-controlled diabetes presented with three weeks of lower extremity edema and new-onset proteinuria.

Vital signs were unremarkable; physical examination was notable for bilateral lower extremity pitting edema and posterior oropharyngeal crusting.

Initial urine studies showed evidence of glomerulonephritis (GN) with 85 RBC/hpf, cellular casts and urine protein-to-creatinine ratio (UPCR) of 3.2 g/g; serum creatinine was 1.77 mg/dL. In light of GN, a laryngoscopy was performed to exclude ANCA-associated vasculitis, and showed nasopharyngeal mucositis with positive rapid Streptococcal antigen test. He was subsequently found to have GAS bacteremia.

Extensive autoimmune workup was only remarkable for hypocomplementemia, high titer anti-nuclear antibodies with speckled pattern and weakly positive anti-La/SSB antibody. Anti-double-stranded DNA (dsDNA), anti-Smith, anti-glomerular basement membrane (GBM), anti-phospholipase A2 receptor (PLAR2), and anti-neutrophil cytoplasmic antibodies (ANCA); HIV and hepatitis A, B, and C were negative.

He was treated for suspected post-streptococcal GN (PSGN) with antibiotics, diuresis, and supportive therapy and had subsequent clinical improvement and normalization of serum creatinine.

Nevertheless, lower extremity edema persisted even one week later; urine studies were repeated and showed paradoxically worsening proteinuria (UPCR 19.6 g/g and 36.9 g/g three days apart) .

Renal biopsy was pursued and revealed focal-segmental GN with full-house immunofluorescence pattern and extensive podocyte foot process effacement, consistent with LN Class III + V.

A thorough history did not reveal any typical SLE manifestations including photosensitivity, malar rash, oral ulcers, arthritis, serositis, cytopenia, or any family history of autoimmune disorders.

IMPACT/DISCUSSION: LN in Hispanic populations tends to have a more severe presentation and higher incidence of mixed histological classes with up to 60% Class III+V or IV+V. Our case re-emphasizes such racial and ethnic differences in the time to onset and presentation of LN.

Of note, only 25-50% of patients with LN have abnormal kidney function, as demonstrated in our case.

The progressively worsening proteinuria in this case, despite normalization of the serum creatinine, suggests a possible interaction between the immune response to GAS and precipitation or exacerbation of LN.

Certain bacterial infections have been reported to precipitate LN and usually precede LN flare by 2-4 weeks; to our knowledge, this is the first case reporting association between GAS infection and LN, with a more rapid onset (within 2 weeks).

CONCLUSION: LN typically develops earlier in the disease course among patients who are younger, male, and non-white.

Contrary to popular belief, only 25% - 50% of patients with LN have abnormal kidney function.

Clinicians should manage any urinary abnormality in SLE patients with high suspicion for LN, regardless of renal function.

A RARE CASE OF EVALI PRESENTING AS PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA

Yawar Haq¹; krupa patel³; Amir M. Khan². ¹internal medicine, Semmelweis Egyetem, Budapest, Budapest, Hungary; ²Department of Pulmonology, Baylor Scott & White Health, Waxahachie, TX; ³Pulmonics Plus, Waxahachie, TX. (Control ID #4065017)

CASE: E-cigarette, vaping products, use associated lung injury (EVALI) is a relatively new condition characterized by shortness of breath, chest pain, and cough. The lung may be damaged due to the inhalation of smoke from E-cigarettes and vaping substances, leading to an inflammatory process which may precipitate aspiration pneumonitis, and with some rarity cause pneumomediastinum and subcutaneous emphysema. Diagnosis is made via exclusion. Due to the lack of data on EVALI, long term outcomes remain unknown. We present a rare case of EVALI detailing Pneumomediastinum and subcutaneous emphysema. A 19 y.o. male with a history of vaping complains of shortness of breath. He also complains of a sore throat, cough and congestion and states he had black mucus when clearing his nose. He was admitted to the ER for acute hypoxic respiratory failure from spray painting cars without a mask. His vital signs exam was normal, except for tachycardia. He had a CXR on admission which showed patchy focal opacities on the right greater than on the left. He had a subsequent CT scan which suggested pulmonary injury from electronic cigarette usage. Pneumomediastinum was present extending into a confluence with subcutaneous emphysema in the upper chest. On 6/5 a comparison CXR was done which revealed no significant change. Pulmonary opacities were scattered in both lungs, mostly pronounced in the right upper lobe. There was no visible pneumothorax or pleural effusion. IV steroids were started during his stay. The patient made an uneventful recovery & was discharged from the hospital with empiric antibiotics & a tapering oral prednisone course. Vaping cessation and counseling was given to the patient, and serves as a cornerstone of treatment.

IMPACT/DISCUSSION: Adolescent patients with history of EVALI use can present with severe pulmonary manifestations including subcutaneous emphysema and pneumomediastinum despite initial vitals being unremarkable.

The main teaching point in this case is to be cognizant of the subacute nature and rapid pulmonary deterioration, seen on CXR, in a young patient with EVALI history.

This case adds a new differential diagnosis to look for in patients of this demographic, as E cigarettes and vapes are becoming a widespread epidemic.

This case adds details to the little we know of EVALI cases as it is a relatively new phenomenon with unknown long term consequences.

CONCLUSION: This case illustrates an increasingly common presentation of EVALI seen in the adolescent patient population.

Recognition and treatment are dependent on timely clinical diagnosis and imaging.

Vaping cessation counseling serves as a cornerstone of treatment.

A RARE CASE OF HYDRALAZINE INDUCED ANCA VASCULITIS

Prakruti Pandya¹; Amna Shah¹; Mahak Bhatti¹; Aashi Parashar²; Akash Parashar³. ¹Internal Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY; ²Williamsville East High School, East Amherst, NY; ³Internal Medicine, South Buffalo Mercy Hospital, Buffalo, NY. (Control ID #4063864)

CASE: A 73-year old male presented to the hospital with worsening shortness of breath, productive cough with hemoptysis, and bilateral lower extremity swelling, ongoing for the past week. He also reported fatigue and unintentional weight loss of 40 pounds over the past 3 months. He has a past medical history of asthma. On presentation, his vitals were stable except for elevated blood pressure of 160/71. Physical examination was positive for bilateral decreased breath sounds, bilateral lower extremity swelling. Laboratory workup revealed leukopenia, anemia and elevated creatinine and BNP. Chest x-ray showed right upper and lower lobe pneumonia and mild pleural effusion. CT chest revealed bilateral central consolidation (R>L) and ground glass opacities. The patient was eventually admitted and started on furosemide for suspected congestive heart failure exacerbation. Serological workup revealed low C3 and C4 levels, with an elevated p-ANCA titer (>1:640), positive myeloperoxidase and proteinase3 antibodies. Bronchoscopy showed diffuse alveolar hemorrhage with a positive aspergillus galactomannan antigen. Both renal and pulmonary biopsies were negative. Hydralazine was discontinued.

IMPACT/DISCUSSION: Drug induced vasculitis is the most common form of vasculitis rarely with hydralazine. The diagnosis is based on the temporal relationship between start of the medication, clinical manifestation of vasculitis and positive biomarkers alongside evidence of pauci-immune glomerulonephritis. Our patient had been treated with 300 mg of hydralazine three times a day for the past six years. He was taking other medications, but none that are known to cause drug-induced lupus or ANCA-associated vasculitis. The clinical signs and symptoms of vasculitis vary depending on the duration of the offending agent. Like in our patient, concomitant pulmonary-renal syndrome is a severe presentation. With pulmonary hemorrhage being a strong mortality predictor. The pathogenesis of drug induced vasculitis is unclear and likely multifactorial. Our patient had positive MPO and PR3 antibodies, elevated p-ANCA titer with a negative renal biopsy. Ours is the first case of ANCA vasculitis with a negative kidney biopsy. We demonstrate that that apparent absence of kidney biopsy findings consistent with typical ANCA vasculitis could perhaps be explained by non-kidney involvement (pulmonary limited) at the time of kidney biopsy. Treatment includes cessation of the offending agent, glucocorticoids, rituximab, cyclophosphamide and plasmapheresis.

CONCLUSION: Hydralazine has often been reported to cause ANCA positive pauci-immune glomerulonephritis, concomitant pulmonary involvement is rare. The possibility of hydralazine-induced vasculitis should be considered when patients treated with hydralazine develop a pulmonary-renal syndrome. The apparent absence of kidney biopsy findings consistent with typical ANCA vasculitis could perhaps be explained by non-kidney involvement (pulmonary limited) at the time of kidney biopsy.

A RARE CASE OF IDIOPATHIC COLD AGGLUTININ DISEASE PRESENTING WITH RECURRENT SEVERE ANEMIA

Saima Hafiz, Fatema Mahjabeen, Mohamed Sleem, Basak Basbayraktar, Basheer Mohammed, Mazin Saadaldin. Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Texas, Amarillo, TX. (Control ID #4016243)

CASE: Our patient is a 79-year-old woman who has a medical history of morbid obesity, chronic obstructive pulmonary disease (on 2L of continuous home oxygen), chronic kidney disease stage IIIa, and chronic venous insufficiency. She was admitted to the hospital with complaints of progressive shortness of breath, weakness, and fatigue over a week. The patient denied the presence of hemoptysis, hematemesis, hematochezia, melena, hematuria, weight loss, fever, chills, or night sweats. She complained of always feeling cold but did not notice any change in the color of her fingers and toes in response to cold. In 2018, she had a similar episode of severe anemia and received blood transfusions and other supportive treatments. On admission, her hemoglobin was 6.8, hematocrit 19, red cell counts 2.03, MCV 93, RDW 17.3, reticulocyte counts 3%, Vitamin B12 284, folate 11.7, iron 14, ferritin 8.7, total bilirubin 1.09, haptoglobin 258 mg/dL (30-200), and lactate dehydrogenase 292 U/L (84-246). The Peripheral blood film showed severe normocytic hypochromic anemia and loose clumping of red blood cells. The direct antiglobulin test (DAT) was positive for C3 and negative for IgG. Cold agglutinin titer was positive at 1:512 (normal 1:32). The bone marrow biopsy showed no evidence of malignancy. Immunoperoxidase stains showed a mixed population of CD3-positive T cells and CD20-positive B cells in 10% of nucleated cells. The hematologist diagnosed the patient with idiopathic cold agglutinin disease and recommended measures to avoid cold exposure. Then the patient received two units of warm-packed red cell concentrate transfusions, which significantly improved her dyspnea and weakness.

IMPACT/DISCUSSION: The diagnosis of CAD (Cold Agglutinin Disease) was established due to several factors: low hemoglobin and hematocrit levels, loose clumps of red cells observed in the peripheral blood film, a positive Direct Antiglobulin Test (DAT) for C3, and a notably high cold agglutinin titer of 1:512. The absence of symptoms such as splenomegaly, jaundice, fever, lymphadenopathy, and bone marrow abnormalities helped rule out the possibility of a lymphoproliferative disorder. Additionally, the lack of a history of purpura made cryoglobulinemia unlikely. The patient also tested negative for hepatitis and HIV, which further guided the diagnostic process.

CONCLUSION: Cold Agglutinin Disease (CAD) is a rare autoimmune hemolytic anemia that is slightly more common in elderly women. CAD often goes undiagnosed in outpatient settings, particularly when patients show subtle or no cold-induced symptoms and experience recurrent unexplained anemia over time, even without evident active hemolysis. Educating healthcare professionals to consider CAD in these scenarios could lead to earlier detection and management. Simple lifestyle modifications, once understood and adopted by patients, can significantly aid in preventing CAD recurrence and managing the condition effectively.

A RARE CASE OF INFECTIOUS PURPURA FULMINANS LEADING TO ISCHEMIA OF BILATERAL LOWER EXTREMITIES

Abhishek Pant, Sai Priyanka Kodam, Rabia Rukhshan, Rutul Patel, Barney Soskin. Internal Medicine, Texas Tech University Health Sciences Center El Paso Paul L Foster School of Medicine, El Paso, TX. (Control ID #4064483)

CASE: A 54-year-old male with a history of chronic alcohol use and chronic subcapsular splenic hematoma presented with a five-day history of dyspnea, cough, and generalized weakness. Two days prior to presentation, a petechial rash emerged over his nose and ear lobes and rapidly spread to his trunk and extremities. On arrival, he was afebrile, tachycardic, tachypneic, and hypotensive. Physical examination revealed a non-blanching, purple-colored reticular rash involving the face and body with cold extremities. Blood work revealed leukocytosis, thrombocytopenia (platelet 29,000/mm3), elevated d-dimer, lactic acidosis, and mixed metabolic and respiratory acidosis. Coagulation studies showed elevated fibrinogen (550 mg/dl), and a normal PT(10.5 seconds) and INR (1.0). Bilateral dorsalis pedis pulses were nonpalpable and inaudible with a handheld Doppler. CTA chest showed a right lower lobe consolidation. Arterial duplex ultrasonography on admission illustrated a lack of flow in bilateral peroneal arteries. He was admitted to ICU for severe community-acquired pneumonia, septic shock, and oliguric renal failure. The patient was started on empiric broad-spectrum antibiotics, intravenous steroids, and was eventually intubated. Considering the high probablity of infectious PF, therapeutic anticoagulation with heparin was started on the day of admission. However, heparin was discontinued on day-2 due to bleeding from his central catheter site. The patient's overall status improved and he was transferred to telemetry unit. Over the next few days, he developed progressive blistering of both feet that progressed to necrosis. This limb ischemia was likely due to thromboembolic sequelae necessitating bilateral below-knee amputations. The patient is now recovering well without further complications.

IMPACT/DISCUSSION: Purpura fulminans(PF) is a rapidly progressing hematological emergency characterized by pro-thrombotic state. One of the settings in which it occurs is infection by encapsulated organisms. The endotoxins released by these organisms mediate consumption of Protein C, S, and antithrombin leading to a prothrombotic state. This causes dermal microthrombosis and endothelial damage leading to skin necrosis. This can lead to necrosis of the limbs. Therefore, early recognition and management are decisive in salvaging both limb and life. Upon review of the literature, there were several instances of limb ischemia associated with PF that advocated for early anticoagulation with heparin. Some studies also suggested concomitant use of fresh frozen plasma with heparin to replace deficient proteins, while others reported the use of hyperbaric oxygen to prevent complications.

CONCLUSION: Despite the aggressive management of sepsis, early use of mechanical ventilation, and therapeutic anticoagulation, the risk of complications and death remains high. This case report aims to assist in recognition of complications of PF and help formulate contingency plans early in the treatment.

A RARE CASE OF INHALED ALBUTEROL-INDUCED SYMPTOMATIC HYPOGLYCEMIA

Tanzina Afroze, Letisha Mirembe, Saima Hafiz, Imtiaz A. Khan, Basak Basbayraktar, Mahmoud Elmahi, Mazin Saadaldin. Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX. (Control ID #4062540)

CASE: An 83-year-old male with a past medical history of coronary artery disease and heart failure with preserved ejection fraction presented to the emergency department with increased shortness of breath and cough. The physical examination revealed a temperature of 36.9 C, a respiratory rate of 22 breaths/minute, and clear lung fields on auscultation. Laboratory investigations revealed a WBC count of 14.8x103/mcL, procalcitonin 0.36 ng/mL, troponin 14.4 ng/L BNP 65.3 pg/mL, and a negative respiratory viral panel. Chest X-ray showed bilateral lower lung haziness. CT chest showed patchy airspace opacification of the left lower lobe and lingula, suggesting pneumonia. The patient was diagnosed with community-acquired pneumonia and was started on ceftriaxone and azithromycin. During the hospital stay, the patient had an episode of symptomatic hypoglycemia with a capillary blood glucose of 53 mg/dL after nebulization with albuterol. The patient described experiencing hypoglycemia after receiving albuterol nebulization in the past.

IMPACT/DISCUSSION: Although predominantly active in the lung, β2-adrenergic receptors are found in a wide variety of organs and cell types. Increased insulin secretion is the result of specific β2-agonist effects on the pancreatic β cell; nevertheless, an overall increase in serum glucose is caused by increased glucagon secretion. An evaluation in male volunteers using isoproterenol infusion concluded that it was likely that β-agonist directly activated insulin secretion, but it also indirectly activated glucagon secretion. The overall effect is hyperglycemia. However, in our case, the patient experienced an episode of hypoglycemia following albuterol inhalation. After a thorough literature review, we found a few case reports on the pediatric population where one of the delayed complications of accidental albuterol overdose was hypoglycemia. Hypoglycemia has also been reported in newborns if the mother underwent prolonged use of sympathomimetics as tocolytic therapy. Initially, the plasma concentrations of glucose and free fatty acids rise quickly when exposed to beta-2-adrenergic agonists. Hyperglycemia can lead to compensatory hyperinsulinemia and hypoglycemia. Hypoglycemia can also result from glycogenolysis and the depletion of glycogen stores necessary for euglycemia.

CONCLUSION: Hyperglycemia is a common physiological response following beta-2 receptor stimulation. A rare occurrence of hypoglycemia with beta-2 agonists has also been reported in the literature. Our case report will be an essential resource for learning about a rare but serious side effect of beta-2 agonists. It will instigate further research linking the association between inhaled beta-2 agonists and hypoglycemia.

A RARE CASE OF INTRAMUSCULAR ABSCESS DUE TO NOCARDIA IN A PATIENT WITH CHRONIC STEROID USE

Monica Botros¹; Akanksha Togra¹; Emerald Zaw²; Sukhila B. Reddy¹; Swati Mahapatra¹; Aymara Chang¹. ¹Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX; ²Texas Tech University Health Sciences Center El Paso Paul L Foster School of Medicine, El Paso, TX. (Control ID #4016038)

CASE: A 64-year-old male with past medical history of Chronic Obstructive Lung Disease on chronic steroid therapy, and recurrent falls, presented with a complaint of dizziness. On admission, blood pressure was 81/52 mmHg, heart rate was 108 beats/minute, with normal respiratory rate and saturation. Physical examination was significant for a right arm fluctuant swelling without overlying skin changes. Laboratory findings revealed neutrophilic leukocytosis, normocytic anemia, and low random cortisol level. Computed tomography (CT) of the right arm showed a 9.4 cm cystic lesion centered in brachialis muscle. Patient was started on stress dose steroids, and empiric Vancomycin and Cefepime. Abscess was drained, and intraoperative culture revealed nocardia without identification of the species. CT of the head, chest, abdomen, and pelvis revealed no evidence of possible nocardia infection in other sites. Infectious disease recommended 6 months of oral Trimethoprim-Sulfamethoxazole (TMP_SMX) which was started with significant clinical improvement.

IMPACT/DISCUSSION: Nocardiosis is a rare infection caused by bacteria from the genus Nocardia. These bacteria live in soil and water .They can cause disseminated infections or local infections as in pulmonary or cutaneous nocardiosis. It is an opportunistic infection, often seen in immunocompromised patients, or patients with major risk factors such as chronic pulmonary disease. There are reported cases of cutaneous nocardiosis; however, intramuscular abscess due to nocardia is extremely rare. It is likely a result of direct inoculation of the bacteria, which was secondary to recurrent falls in our case. Diagnosis is challenging due to the non-specific findings seen Nocardiosis and is made through culture, microbiologic or molecular testing. Nocardia is identified on the gram stain as gram positive branching filaments that are sometimes beaded. Isolation of Nocardia and determining of the species are usually difficult and require genetic technologies as polymerase chain reaction. Once a nocardial infection is confirmed in one site, it is essential to rule out disseminated infections through blood cultures, sputum cultures and imaging specifically for the brain and lungs. Prognosis varies depending on the infection site with a favorable prognosis to cutaneous infections. Patient with isolated cutaneous infection or with mild to moderate pulmonary nocardiosis can be treated with TMP-SMX for 6 months to 1 year. On the other hand, patients with severe infections will require combination therapy such as Imipenem/Amikacin or Imipenem/TMP-SMX.

CONCLUSION: Nocardia is a rare opportunistic infection, commonly affecting immunocompromised individuals. It can cause isolated cutaneous infections, pulmonary infections and disseminated ones. Diagnosis is made by culture, gram stain and sometimes molecular testing. Treatment is either TMP-SMX monotherapy or combination therapy.

A RARE CASE OF LYME CARDITIS WITHOUT CONDUCTION SYSTEM ABNORMALITY

Shuja Malik, Akash M. Gupte, Hector Ojeda-Martinez. Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4064034)

CASE: This is a case of a 27-year-old male presenting with acute left-sided chest pain, flu-like symptoms, recent tick exposure, and a small oval-shaped rash with raised borders on his thigh. With a history of alcohol, tobacco, and daily marijuana use, he exhibited thrombocytopenia (platelets 142 x10^9/ L), elevated troponin T (665 ng/L) and normal alcohol level. Echocardiography revealed a reduced left ventricular ejection fraction 40-49% with hypokinesis of the anterolateral and inferolateral walls and normal RV size and function. Cardiac catheterization was negative for coronary artery disease. EKG and telemetry review consisted of a normal sinus rhythm with no evidence of AV nodal abnormalities. The infectious workup came back negative except for positive Lyme serology confirmed by Western Blot. Treatment with antibiotics was initiated. His symptoms improved and the patient was subsequently discharged. He opted not to proceed with further testing in outpatient follow-ups.

IMPACT/DISCUSSION: Lyme disease, caused by the vector Borrelia burgdorferi and transmitted by Ixodes ticks, progresses through three stages: early localized, early disseminated and late disseminated. Lyme carditis, occurring in the second stage, affects only 10% of Lyme disease patients and often involves the AV conduction system, causing AV blocks or malignant arrhythmias. However, this case presented with cardiomyopathy involving the myocardium without any conduction abnormalities or evidence of coronary artery disease. The pathophysiology involves borrelial proteins binding to integrin receptors, promoting dissemination and subsequent inflammatory myocardial injury.

Diagnosis relies on serology testing, including ELISA, Western blot, and clinical presentation. In challenging cases, EKG, echocardiography, cardiac biomarkers and cardiac catheterization aid in differentiating other etiologies. Treatment involves 14-21 days of oral antibiotics, with doxycycline, amoxicillin, cefuroxime, or azithromycin. IV antibiotics are reserved for hospitalized patients.

CONCLUSION: Lyme carditis should be considered in patients with cardiac symptoms, especially in endemic regions or those with tick exposure. Clinicians must be aware of varied clinical presentations and the need for a comprehensive approach to managing Lyme carditis to avoid life-threatening complications.

A RARE CASE OF MULTI-ORGAN DYSFUNCTION INCLUDING BILATERAL SENSORINEURAL HEARING LOSS AFTER COCAINE USE

Mohamed Mansour¹; Zainab Muslehuddin³; Sarah Merten²; Syed Bukhari³; Ahmed Chaudhary³; Johan Harris⁴. ¹Internal Medicine Residency Program, Wayne State University School of Medicine, Detroit, MI; ²All Saints University School of Medicine, Roseau, Saint George, Dominica; ³Internal Medicine, Detroit Medical Center, Detroit, MI; ⁴Wayne State University School of Medicine, Detroit, MI. (Control ID #4054679)

CASE: 41-year-old male presented to the Emergency Department (ED) with a sudden onset of difficulty hearing when he woke up that morning. The previous day, he felt fine, but his hearing became muffled and persisted throughout the day. He admitted to daily marijuana use and snorting cocaine the night before. He had no significant medical history. Upon admission, his was found to be tachycardic with a heart rate of 111 and his oxygen saturation was 88%, which improved on 3 liters of oxygen. An ear exam revealed right cerumen impaction, which the ED physician removed. Other than bilateral sensorineural hearing loss with a normal tympanic membrane, physical examination was unremarkable.

Lab results showed a white blood cell count of 12 and hemoglobin of 15. Electrolytes were normal, but creatinine and BUN were elevated. Urinalysis indicated +3 blood and < 2 RBCs. CPK levels were significantly high at 78,560. Urine drug screen confirmed the presence of cocaine and marijuana. Liver function tests showed elevated ALT and AST levels at 2609 and 6204, respectively. Troponin levels were elevated. EKG showed sinus tachycardia. Serum EtOH, acetaminophen, and salicylate were all within normal ranges.

Further investigations revealed a negative hepatitis panel and urine Legionella. A chest x-ray showed left lower lobe pneumonia. The patient received 4 liters of normal saline boluses, and was put on IV maintenance fluids to manage rhabdomyolysis. Cardiology recommended a heparin drip for 48 hours and an echocardiogram, which showed a left ventricular ejection fraction of 60%, global strain of -16.8% (normal = +18.5%), and a normal diastolic filling pattern. The right ventricular systolic pressure was estimated at 26-33 mm Hg. The patient received Ceftriaxone and Doxycycline for community-acquired pneumonia. Over the next two days, the patient's hearing gradually improved and returned to normal, and he no longer required oxygen supplementation. His CPK levels decreased from 75,560 to 13,368, and his creatinine, ALT, AST, and troponin levels all decreased significantly. On day three, the patient was discharged with instructions to take aspirin 81 mg daily, was advised to follow up with a cardiologist for an ischemic workup, and educated on the importance of discontinuing cocaine use.

IMPACT/DISCUSSION: Cocaine toxicity can lead to a wide range of clinical manifestations, making it challenging to predict the clinical outcome of a case.

When evaluating patients with multi-organ dysfunction and ruling out more common causes, cocaine use should be considered as one of the top potential differentials.

It is crucial to stress the importance of discontinuing cocaine use to counteract its vasospastic effects and prevent further damage to the organs.

CONCLUSION: This case highlights:

- the possibility of severe multi-organ failure caused by cocaine use, resulting in a diverse range of clinical manifestations across multiple systems.

- the importance of patient education and interventions to discontinue cocaine use.

A RARE CASE OF MYCOPHENOLATE MOFETIL-ASSOCIATED CYTOMEGALOVIRUS (CMV) ESOPHAGITIS

Christopher Itua¹; Reid Schalet¹; Raymond Janowski²; Mamoun Younes³; Lei Lynn¹. ¹Internal Medicine, The George Washington University Hospital, Washington, DC; ²Gastroenterology & Liver Diseases, The George Washington University Hospital, Washington, DC; ³Pathology, The George Washington University Hospital, Washington, DC. (Control ID #4059320)

CASE: An 89-year-old female with history of scleroderma on Mycophenolate Mofetil (MMF), presented with 3 weeks of dysphagia, epigastric pain, nausea, vomiting and 30-pound weight loss. She denied any fevers, changes in bowel habits or smoking history. Physical exam revealed a nontender, nondistended abdomen, hair thinning, bilateral sclerodactyly, stiffness and skin thickening extending to the elbows. Laboratory studies revealed anemia (Hgb 11.8 gm/dL), leukopenia (WBC 1.29 x 10³/mcL), mildly elevated Aspartate aminotransferase (64 units/L), C-reactive protein (58.6 mg/L) and CMV DNA (1,100 IU/ mL). HIV DNA testing was negative. The gastroenterology (GI) team was consulted and opted for an esophagogastroduodenoscopy (EGD), which revealed a 17 cm proximal esophagus stricture; 25 cm circumferential, non-bleeding ulcer of the distal esophagus, and peptic duodenitis. Biopsy of the esophageal ulcer revealed CMV positivity on immunoperoxidase staining. The patient was initially treated with ganciclovir and transitioned to valganciclovir for a treatment duration of 4 weeks. At time of discharge, WBC count had improved to 3.08 x 10³/mcL and MMF was discontinued with the plan to follow up with rheumatology and infectious disease clinics. Two weeks after discharge, the patient reported improvement in her dysphagia symptoms.

IMPACT/DISCUSSION: Cytomegalovirus infection is an opportunistic infection in patients in immunocompromised states such as solid organ transplants or AIDS. Nonetheless, the available literature is scarce regarding CMV infection along the upper gastrointestinal tract. Of documented cases in patients without HIV, identifiable risk factors for CMV esophagitis include the use of immunosuppressives, such as steroids, and/or chemotherapeutic agents. However, no reported cases of CMV esophagitis have been linked to mycophenolate as the immunosuppressive agent. In our case, the patient's dysphagia and leukopenia improved after discontinuing MMF, suggesting it as the potential inciting factor of the disease. MMF may result in severe bone marrow suppression, most commonly manifesting as anemia and/or leukopenia, which can increase the risk of infectious diseases. This case highlights the need to consider CMV esophagitis as a possible diagnosis in a patient with dysphagia and known MMF use. Identifying CMV infection in patients on any type of immunosuppressive therapy in the setting of known rheumatic disease is vital as this disease has a high mortality rate, especially in patients with GI involvement.

CONCLUSION: Mycophenolate Mofetil should be recognized as a potential cause of immunosuppressive-associated CMV esophagitis.

Management of Mycophenolate Mofetil-associated CMV esophagitis in the setting of scleroderma and/or other connective tissue disease may include temporary cessation of the immunosuppressant.

A RARE CASE OF PNEUMOCYSTIS PNEUMONIA ASSOCIATED WITH RITUXIMAB MONOTHERAPY IN RHEUMATOID ARTHRITIS

Keren George²; Soubhi Alhayek¹; Neelima Gonugunta²; Raman Desikan³. ¹Infectious Disease, University of California Davis, Davis, CA; ²Internal Medicine, White River Health System Inc, Batesville, AR; ³Hematology Oncology, White River Health System Inc, Batesville, AR. (Control ID #4054409)

CASE: 76-year-old female with rheumatoid arthritis (RA) receiving rituximab (RTX) (1000mg on days 1 and 15) every 6 months presented with intermittent fevers (T max of 102.2°F) for 3-4 weeks. She had poor appetite, fatigue, weight loss, and dry cough. Her white count was normal, however she was lymphopenic. Blood cultures and urine analysis were negative. A transesophageal echo (due to recent watchman placement) did not reveal endocarditis.

Two weeks later she was admitted with continued fever, dry cough, and dyspnea. Lab results revealed a normal white count with lymphopenia. Her creatinine and liver enzymes were not elevated. Procalcitonin level was normal and blood cultures were negative. PCR for CMV, EBV, serology for HIV, tick-borne illness were also negative. Chest radiography revealed multifocal pulmonary parenchymal opacities, CT scan of chest revealed scattered ground glass opacities. Inflammatory markers, LDH, CRP, ferritin, and sedimentation rate were elevated. Beta-D-glucan assay was normal. On account of radiology findings in conjunction with negative blood cultures and normal procalcitonin levels, other antibiotics were discontinued and Pneumocystis jirovecii (PCP) was strongly suspected, and she received intravenous trimethoprim-sulfamethoxazole. She had prompt resolution of fever, shortness of breath and hypoxemia. She had complete clinical and radiological resolution after 2 weeks without further relapse. BAL cultures were negative, GMS stain did not reveal PCP. Unfortunately, specimens were not submitted for DFA staining or PCR studies.

IMPACT/DISCUSSION: High clinical suspicion is essential for timely diagnosis of PCP. Immunocompromised patients with fever, cough and dyspnea should be evaluated promptly for PCP. Radiologic findings and laboratory findings can aid in diagnosis. Conventional stains and fluorescent antibody in respiratory secretion are standard procedures for diagnosis. However, they lack sensitivity due to dependence on obtaining adequate samples and skilled observers reviewing the slides. PCR is useful, however it could be positive on account of colonization in the absence of infection. Lower organism burden adds to the difficulty in establishing the diagnosis in non-HIV patients. In regards to LDH and Beta D- glucan levels; they are less reliable in non-HIV settings. PCP has been associated with rituximab combined with steroids and other chemotherapeutic drugs, but not commonly seen in patients with monotherapy and none in patients with RA.

CONCLUSION: Definitive diagnosis is not always feasible, and therapy must be initiated promptly based on high clinical suspicion in immunocompromised patients.

Only three cases have been reported and none reported with RTX monotherapy for RA. Incidence is so uncommon after RTX in RA, hence it does not warrant PCP prophylaxis. Increased awareness of PCP diagnosis after RTX therapy in RA will increase the odds of early diagnosis and improve outcomes

A RARE CASE OF PRIMARY EVANS SYNDROME

Siddharth Gupta¹; Sachi Singhal²; Anzi Salim³; Sanjana Kalvehallo Kashinath². ¹Internal Medicine, Baptist Memorial Hospital North Mississippi, Oxford, MS; ²Hematology/Oncology, Temple University Health System Inc, Philadelphia, PA; ³Internal Medicine, Crozer-Chester Medical Center, Upland, PA. (Control ID #4063943)

CASE: A 60-year-old female with no significant past medical history presented with petechiae, bruises, and gum bleeding ongoing for one week. Physical examination was significant for wet purpura encompassing her entire tongue, as well as bruises and small hematomas in various stages of healing on her extremities. The remainder of her physical exam was unremarkable.

Pertinent labs include Hemoglobin of 11.5 g/dl, Platelet count of 3/μl, and total bilirubin of 2.3 mg/dl with direct bilirubin 0.5 mg/dl. The rest of the labs including prothrombin time, partial thromboplastin time, fibrinogen, lactate dehydrogenase, Vitamin B12, Folic acid, and renal function were within normal limits. Given the severity of thrombocytopenia (TCP), the suspicion of Thrombotic Thrombocytopenic Purpura (TTP) was raised with a calculated PLASMIC score of 6 points, indicating an elevated risk of severe ADAMTS13 deficiency. Discussions of urgent plasma exchange were underway; the peripheral blood smear was examined, revealing no schistocytes but numerous spherocytes and markedly decreased platelet count with few large platelets. Given spherocytosis on the smear, severe TCP, mild anemia, and mild indirect hyperbilirubinemia, a Direct antiglobulin test was obtained which was positive indicating Autoimmune Hemolytic Anemia (AIHA). Plasma exchange was held off and instead, other causes of TCP were ruled out (with negative infectious workup, flow cytometry, and autoimmune testing). Empiric administration of weight-based steroids and intravenous immunoglobulin (IVIG) was tried. The etiology of TCP was diagnosed to be Immune Thrombocytopenic Purpura (ITP). In the light of concomitant ITP and AIHA, a diagnosis of Evans syndrome (ES) was made. The patient subsequently continued weight-based steroids and IVIG with significant clinical and hematological recovery. By day 7 of hospitalization, platelet counts improved to 72,000 /μl with a resolution of petechiae, bruises, and tongue blisters.

IMPACT/DISCUSSION: ES is a rare, potentially life-threatening phenomenon characterized by simultaneous or sequential development of AIHA, immune TCP, and/or autoimmune neutropenia. It can be primary (50% of patients) or secondary to autoimmune or lymphoproliferative disorders. A thorough workup for underlying causes must be undertaken on diagnosis and treatment should be focused on addressing the underlying cause, if any. Outcomes in adults with ES are poorly reported, and corticosteroids remain the cornerstone of therapy. Recognizing ES as the cause of severe TCP is crucial as the disease course is more severe with higher rates of relapse than with ITP or AIHA alone. It is important to note that oral purpura is a key clinical finding, and may be a harbinger of life-threatening bleeding in immune-mediated TCP.

CONCLUSION: Physicians must recognize and promptly address ES as a potential cause of severe TCP. Additionally, distinguishing it from TTP is crucial as both potentially life-threatening conditions have distinct management.

A RARE CASE OF PRIMARY INTESTINAL LYMPHANGIECTASIA (WALDMANN’S DISEASE) DIAGNOSED DEFINITIVELY AFTER 30 YEARS AND DEVELOPMENT OF EXTRA-INTESTINAL DIFFUSE LARGE B-CELL LYMPHOMA

Michito Sadohara, Kunihiko Matsui. General Medicine and Primary Care, Kumamoto Daigaku Byoin, Kumamoto, Kumamoto, Japan. (Control ID #4064257)

CASE: A 72-year-old man with a history of hypoproteinemia and hypoalbuminemia, likely due to protein-losing gastroenteropathy, presented with lower limb edema and pleural effusion. Initial labs revealed a total protein of 4.1 g/dL, albumin of 2.2 g/dL, Ca of 7.8 mg/dL, and IgG of 286 mg/dL. Thyroid function, ACTH, cortisol levels were within normal ranges, and urinary protein was negative. Chest X-ray and CT demonstrated bilateral pleural effusions. 99mTc-HSA protein leakage scintigraphy indicated leakage mainly into the upper ileum. Capsule endoscopy revealed circumferential white villi, partial redness, and erosion in the upper jejunum. Gastrointestinal tract biopsy confirmed lymphatic dilation consistent with primary intestinal lymphangiectasia. Edema and pleural effusion were managed with furosemide and tolvaptan, while continuing nutritional guidance of a low-fat diet with medium-chain triglycerides and were maintained permissively for quality of life. A lumbar compression fracture was identified as a pathological fracture due to diffuse large B-cell lymphoma upon biopsy one year later. The patient is currently undergoing R-CHOP therapy.

IMPACT/DISCUSSION: Primary intestinal lymphangiectasia (Waldmann’s disease) is a rare disorder, typically diagnosed in childhood (<3 years old), presenting with protein-losing gastroenteropathy. In addition to histological confirmation, protein leakage scintigraphy is a valuable tool for promptly identifying the site of protein leakage, enhancing our understanding of pathophysiology. In this case, minor protein leakage 30 years prior resulted in overt manifestations due to age-related homeostatic disruptions, leading to pleural effusion and leg edema. Advances in radio-nuclear medicine may increase reports of adult cases. Malnutrition, vitamin deficiencies, immunodeficiency, and susceptibility to infections are common complications. Several cases complicated with lymphoma were also reported. Most of them were B-cell type and of intestinal origin. Pathologies of the lymphatic system and immunodeficiency may be associated with lymphoma development.

CONCLUSION: Protein leakage scintigraphy is a powerful diagnostic method for demonstrating protein leakage into the gastrointestinal tract and understanding the pathophysiology of protein-losing gastroenteropathy. Vigilant medical follow-up is recommended for the early detection of complications, including lymphoproliferative disorders such as malignant lymphoma, in addition to well-known complications.

A RARE CASE OF PSEUDO-MIRIZZI SYNDROME PRESENTING WITH ACUTE ON CHRONIC CHOLECYSTITIS AND HEPATIC ABSCESSES

George G. Kidess¹; Kenan Abou Chaer²; Abdallah Almawazreh²; Jarrett J. Weinberger^3,2. ¹School of Medicine, 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 #4061293)

CASE: The patient is a 61 year old female with history of GERD who presented for intermittent right upper quadrant and epigastric pain, and was found to have a positive Murphy’s sign, leukocytosis, and hyperbilirubinemia. Workup with various forms of imaging including abdominal ultrasound, CT of the abdomen and pelvis, HIDA scan, and MRCP identified acalculous gallbladder inflammation resulting in extrinsic compression and obstruction of the common bile duct consistent with pseudo-Mirizzi syndrome, as well as several hepatic microabscesses. The patient was managed with an ERCP with sphincterotomy and eventual cholecystectomy, with histopathology of the gallbladder confirming chronic cholecystitis. The patient’s final diagnosis was acute on chronic pseudo-Mirizzi syndrome, and was discharged on prolonged IV antibiotics to manage the hepatic abscesses.

IMPACT/DISCUSSION: With a yearly incidence of less than 1%, Mirizzi Syndrome (MS) is an uncommon cause of symptomatic gallstone disease. It is caused by calculous cholecystitis from an impounded stone within the gallbladder which ultimately results in extrinsic obstruction of the common bile or hepatic ducts, causing concurrent obstructive jaundice. An acalculous variant of MS caused by a local inflammation of the gallbladder leading to obstruction and extrinsic compression of the common hepatic duct—at times referred to as pseudo-Mirizzi syndrome—occurs even more rarely. While certain symptoms might be nonspecific, pseudo-Mirizzi syndrome usually presents similarly to other diseases that cause biliary obstruction, including right upper quadrant pain, hyperbilirubinemia, and leukocytosis. No specific diagnostic modalities have been proposed, but imaging such as with MRCP has been shown to be helpful in some cases such as the one presented. Similarly to our case, treatment is usually surgical with cholecystectomy or biliary decompression with ERCP or percutaneous cholecystostomy in some cases. Notably, to our knowledge the case presented is the first in literature that identified pseudo-Mirizzi syndrome in a patient with pathology-confirmed chronic cholecystitis, and the first to be associated with hepatic abscesses—which usually occur with calculous rather than acalculous biliary disease.

CONCLUSION: The goal of this case report is to showcase a very rare phenomenon that is not widely published and can potentially be misdiagnosed, and to encourage further research.

A RARE CASE OF RAPIDLY PROGRESSIVE INTERSTITIAL LUNG DISEASE IN DERMATOMYOSITIS WITHOUT UNDERLYING MALIGNANCY

Vihanga Perera¹; Wei Tang²; Kyu-In Lee¹; James G. Miceli¹; Amy Wasserman¹; Julia Ash¹. ¹Medicine, Westchester Medical Center Health Network, Valhalla, NY; ²Medicine, Westchester Medical Center, Valhalla, NY. (Control ID #4059687)

CASE: A 68-year-old female was diagnosed with clinically amyopathic dermatomyositis (CADM) on biopsy of the thigh after she presented to a rheumatologist with shawl’s sign and Gottron’s papules. She then suffered from progressive dyspnea over several weeks leading to multiple ER presentations treated as community-acquired pneumonia. She rapidly developed an acute hypoxic respiratory failure requiring intubation. Initial autoimmune serology was notable for negative ANA, anti-Jo1, and anti-PM/SCL. Exam was significant for a subtle V-sign rash, periungual erythema, Gottron’s papules, giant nailfold capillaries, and coarse breath sounds but no overt muscular atrophy or cachexia. Chest CT was notable for patchy consolidative infiltrates predominantly within the periphery of the lung occupying 25-33% of the lung fields, consistent with ILD (Fig1). She deteriorated despite steroids, mycophenolate mofetil, and two treatments of intravenous immunoglobulin which raised suspicion for CADM with rapidly progressive interstitial lung disease (CADM-RP-ILD); immunosuppression was escalated to pulse-dose steroids and cyclophosphamide with a plan for tacrolimus. Prior to receiving tacrolimus, she developed progressive hypoxic respiratory failure and refractory shock resulting in cardiac arrest.

Autopsy showed: dermatomyositis with ILD associated with diffuse alveolar hemorrhage, diffuse interstitial fibrosis, and severe pulmonary edema; and type 2 selective atrophy of the rectus femoris. Notably, no tumors were identified on autopsy. An extended myositis panel resulted on the day of arrest with a low-positive MDA-5 (CADM-140) antibody (Table1).

IMPACT/DISCUSSION: Making the diagnosis of CADM can be challenging since, compared to dermatomyositis, creatine kinase is normal and weakness is absent. The management of CADM-RP-ILD associated with MDA-5 antibody can vary, with reports that higher titers of MDA-5 antibodies are associated with more severe disease courses and increased mortality (~60%); in fact, negative titers have been historically viewed as a different disease entity. Despite the low-positive MDA-5 antibody, our patient developed RP-ILD refractory to immunosuppressants within three months of initial diagnosis, which culminated in fatal hypoxemic respiratory failure. Our case was also distinguished by the contrast between the aggressive disease course and low-positive MDA-5 antibody, blurring the boundary between the two aforementioned disease processes. Considering the delay associated with confirmatory antibody testing, all cases of CADM-RP-ILD should be recognized clinically as early as possible with treatment initiated before antibody confirmation and regardless of MDA-5 titer.

CONCLUSION: Diagnosis of CADM-RP-ILD can be difficult based on the clinical picture alone. However, management of CADM-RP-ILD requires early recognition and prompt treatment with high-dose immunosuppression while awaiting confirmatory antibody testing in order to improve disease mortality.

A RARE CASE OF RECURRENT ASPIRATION PNEUMONIA WITH BACTERIAL MENINGITIS DUE TO CEREBROSPINAL FLUID RHINORRHEA FROM STERNBERG'S CANAL

Hiroki Matsuura^1,2; Masayuki Kishida²; Kentaro Deguchi³. ¹Emergency Medicine, Okayama Shiritsu Shimin Byoin, Okayama, Okayama, Japan; ²General Internal Medicine, Okayama Shiritsu Shimin Byoin, Okayama, Okayama, Japan; ³Neurology, Okayama Shiritsu Shimin Byoin, Okayama, Okayama, Japan. (Control ID #4044966)

CASE: A 64-year-old man admitted to our hospital with recurrent bilateral pneumonia and secondary spontaneous pneumothorax. He was treated with antibiotics and chest tube drainage while he was under rehabilitation receiving physical therapy. After the initial treatment, his pulmonary symptoms improved. However, the patient suddenly became febrile, experienced severe headache and disorientation. Physical findings revealed the presence of nuchal rigidity with positive Kernig’s signs. A lumbar puncture was performed and the cerebrospinal fluid (CSF) revealed severe pleocytosis with 8021 cells/μL for white blood cells and elevated protein level of 445 mg/dL. The CSF glucose level decreased slightly. Computed tomography and magnetic resonance imaging demonstrated a defect in the middle cranial fossa communicated to the lateral recess of the left sphenoid sinus with air and fluid. Based on the radiographic findings and clinical history, we made a diagnosis of recurrent aspiration pneumonia and bacterial meningitis with CSF leakage due to Sternberg’s canal. He was treated with antibiotics and his neurological symptoms improved. Subsequently, he was performed microsurgical transsphenoidal repair. After the procedure, postoperative recovery was uneventful without recurrence of CSF leakage and respiratory symptoms

IMPACT/DISCUSSION: Sternberg’s canal is a lateral craniopharyngeal canal due to incomplete fusion of the greater wings of the sphenoid bone with the basisphenoid. Previous studies have been reported that the prevalence of Sternberg’s canal in adults ranges from 0.1 % to 4 %. Risk factor for spontaneous CSF leakage and encephaloceles is obesity. It is postulated that obesity elevated intraabdominal and intrathoracic pressure which could cause the development of benign intracranial hypertension. The patient disclosed he had noticed chronic and intermittent clear rhinorrhea three months before admission, and his symptom deteriorated after the onset of pulmonary symptoms. Intermittent CSF rhinorrhea can lead to recurrent bilateral aspiration pneumonia and pneumothorax. Pneumothorax and persistent cough can be also associated with increasing intrathoracic pressure and worsening his medical condition. Symptoms of CSF leakage are often vague and nonspecific, including intermittent rhinorrhea, chronic headache, seizures, and vertigo. CSF rhinorrhea is generally intermittent and not voluminous and can be overlooked by the patient for a long time until complicated by recurrent meningitis.

CONCLUSION: Early detection of persistent CSF leakage due to Sternberg’s canal is important for preventing severe central nervous infection. When the unknown cause of recurrent aspiration pneumonia with intermittent and chronic rhinorrhea is present, clinicians should consider the CSF leakage due to Sternberg’s canal as a possible different diagnosis.

A RARE CASE OF SIMULTANEOUS STREPTOCOCCAL PHARYNGITIS AND FACIAL ERYSIPELAS.

Katsiaryna Murashka¹; David Bekhor²; Violetta Laskova¹. ¹Mount Sinai Beth Israel Hospital, New York, NY; ²Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4065057)

CASE: An 86-year-old female with compensated cirrhosis due to primary biliary cholangitis presented to PMD with fever 102.2, nasal congestion, and sore throat started two days prior and followed by a rapidly spreading malar rash. The rash started with tiny pustules and erythema over her nasal bridge and spread to cheeks and nasolabial folds. The patient was referred to the ED, where she was found to have pharyngeal erythema without tonsillar exudates, and painful bilateral cervical lymphadenopathy. Vital signs were normal.The oral examination did not show caries or periodontal disease. The skin exam revealed raised well-demarcated erythematous facial plaques in a butterfly pattern. The involved area was swollen, warm, and exquisitely tender to palpation. Labs were unremarkable except for chronic thrombocytopenia. Due to the rapid spread of the facial rash, the patient was admitted for treatment with IV antibiotics and started on ceftriaxone and vancomycin. Flu, COVID, and respiratory PCR panel were negative. A rapid strep test was positive for Group A streptococcus (GAS). Antibiotics were changed to ceftriaxone. The rash faded over the next two days, and pharyngeal discomfort subsided. The patient was discharged home on oral antibiotics.

IMPACT/DISCUSSION: Our patient is an immunocompromised elderly woman who presented with both acute pharyngitis and a rapidly spreading facial rash. The simultaneous presentation of skin and soft tissue infection and upper respiratory infection was caused by the common causative agent. GAS is the most common cause of erysipelas with Staphylococcus aureus occurring much less frequently. The infection rapidly spreads through the skin's superficial lymphatic vessels, giving the appearance of raised erythematous plaque with sharply demarcated margins. Half a century ago erysipelas classically involved the face but currently, the predominant location is the lower extremities. There are multiple portals of entry for streptococci: surgical incisions, insect bites, venous stasis ulcers, and small facial abrasions. In rare instances, facial erysipelas may be caused by a recent infection in the nasopharyngeal passage as in our case. GAS is an important cause of invasive disease and death affecting persons over the age of 65 at a very high incidence, particularly in residents of long-term care facilities. Complications of facial erysipelas include spread to deeper fascial spaces and necrotizing fasciitis.

CONCLUSION: GAS infections include many body sites and varying degrees of severity ranging from asymptomatic pharyngeal colonization to potentially lethal toxic shock and necrotizing fasciitis. The skin and pharynx are among the most common sites of GAS infection. Our case presented simultaneous microbiologically confirmed GAS pharyngitis and facial erysipelas caused by the same agent. Distinctive to this case was the indirect confirmation of the suspected causative agent of a skin infection via sampling of a throat specimen.

A RARE DISEASE WITH A COMPLEX PRESENTATION: T-CELL PROLYMPHOCYTIC LEUKEMIA WITH A PECULIAR KARYOTYPE AND DEVELOPMENT OF HLH

Logan Shaver¹; Clark Cutrer². ¹Internal Medicine, The University of Tennessee System, Knoxville, TN; ²Hematology/Oncology, The University of Tennessee System, Knoxville, TN. (Control ID #4043624)

CASE: A 69-year-old Caucasian male with type II diabetes mellitus and obstructive sleep apnea presented with 2-3 months of exertional dyspnea. Initial CBC and peripheral blood smear showed small-intermediate mature lymphocytes, anemia, and thrombocytopenia. Bone marrow biopsy (BMB)/flow cytometry showed 80% involvement with mature T-cell lymphoma/leukemia, positive CD4 and CD52, T cell receptor gene rearrangement, findings consistent with T cell pro lymphocytic leukemia (T-PLL). Fluorescence in-situ hybridization/genetic sequencing noted 44 XY karyotype with monosomy chromosome 13, ATM gene deletion, and JAK3 mutation. Afterward, patient developed jaundice with elevated total bilirubin 4.5 (mostly direct). He was started on IV alemtuzumab for induction though became hypotensive and had a severe grade 4 reaction, requiring volume resuscitation and admission to the hospital. Eventually, he transitioned back to outpatient therapy; but then developed dyspnea, edema, elevated bilirubin and hypotension, leading to readmission 1 week later. CT imaging showed hepatosplenomegaly, moderate ascites and bilateral pleural effusions. Thoracentesis was negative for malignancy. However, ferritin and IL-2 were markedly elevated, raising suspicion for hemophagocytic lymphohistiocytosis (HLH) developing in setting of T-PLL and so was started on prednisone and pentostatin. Initially had improvement in his bilirubin and edema but later was readmitted for pneumonia and febrile neutropenia. Repeat BMB showed little response and he ultimately transitioned to comfort care, passing shortly after.

IMPACT/DISCUSSION: T-cell prolymphocytic leukemia (T-PLL) is a rare, aggressive malignancy with proliferation of small to medium-sized prolymphocytes, consisting of hepatomegaly, splenomegaly, lymphadenopathy, and edema. Symptomatic patients are treated with IV alemtuzumab, a monoclonal antibody against CD52. It has a response rate of 90% though relapse may occur at around 2 years. Allogeneic stem cell transplant may lengthen remission and be curative in a small number of patients. Also, HLH has been known to have an association with hematologic/T-cell malignancies and has a 40% mortality rate. This case brings to light an extremely rare case of T-PLL, one with a significantly complex karyotype and development of HLH, demonstrating the complexity of T-PLL and its management.

CONCLUSION: T-PLL is a rare cancer with proliferation of small to medium-sized prolymphocytes, associated with a range of genetic abnormalities and first-line treatment consists of IV alemtuzumab though including other agents, such as pentostatin, can increase response rates.

HLH is a rare, often fatal sequela of aggressive T cell malignancies, presenting with cytopenias, hepatosplenomegaly, anasarca and elevated ferritin.

A RARE PRESENTATION OF PERNICIOUS ANEMIA

Anna Katrina Gutierrez¹; Scott J Schafler²; Paul Gallina²; Zhongyuan Zhang²; Rushnan Islam¹. ¹Medicine, Albert Einstein College of Medicine, Bronx, NY; ²Medicine, Montefiore Health System, Bronx, NY. (Control ID #4062269)

CASE: A 72 year old female with rheumatoid arthritis (RA) and COPD presented to the ED at the direction of her PCP for a hemoglobin of 6.1 g/dl. She endorsed various symptoms that occurred over three months prior to presentation including fatigue, shortness of breath, chest pain, lightheadedness, dizziness, fever, chills, mild abdominal discomfort, and nausea. She noted intermittent sticky, dark stools for the past two months; she denied any constipation or blood per rectum. Her colonoscopy screenings were up to date & normal; no family history of malignancy. She reported taking methotrexate, prednisone, and abatacept for her RA but no folic acid supplementation. No recent NSAID use.

On presentation, she was febrile to 100.6 F with physical exam notable for pale conjunctival rims, anicteric sclera, icteric tongue, mild diffuse abdominal tenderness, and no hepatosplenomegaly was appreciated.

Initial labs were significant for hemoglobin of 5.3 g/dl, which corrected with 2 units of packed RBCs. The anemia was megaloblastic (MCV 116 fl) with a high RDW & hypoproliferative reticulocyte index. Hemolysis labs were notable for a low haptoglobin and high LDH. She was found to have a vitamin B12 deficiency (<175 pg/ml) and started on cyanocobalamin supplementation (1,000 mcg daily). Additionally, she had a relative thrombocytopenia (218 k/uL from a baseline of ~400s k/uL). Further work-up revealed she was positive for anti-intrinsic factor antibodies & had a negative direct coombs test. Upon inspection a peripheral smear showed hypersegmented neutrophils and schistocytes. An esophagogastroduodenoscopy showed gastric mucosal atrophy, flattening of rugal folds, a 10 mm ulcerated polyp and a 3 mm polyp in the gastric body that were both resected with no signs of active bleeding.

This patient’s hemolytic anemia was secondary to vitamin B12 deficiency caused by pernicious anemia that was likely accelerated by her concurrent use of methotrexate without folate supplementation. Her anemia resolved with vitamin B12 supplementation.

IMPACT/DISCUSSION: A deficiency in vitamin B12 can cause gastrointestinal, neurologic, and hematologic symptoms, such as macrocytic anemia. In this case, our patient had a vitamin B12 deficiency due to pernicious anemia. In rare instances the deficiency can cause pseudothrombotic microangiopathy, which is hemolytic anemia, thrombocytopenia, and schistocytosis. Literature review revealed only a few similar cases. When a patient has hemolytic anemia, it is important to also check vitamin B12 levels and determine the etiology if they are low. This will also help you interpret a direct coombs test, which can be falsely positive in patients with pernicious anemia, resulting in unnecessary steroid use. This case highlighted a rare instance of pernicious anemia presenting as pseudothrombotic microangiopathy.

CONCLUSION: Low vitamin B12 levels can present as pseudothrombotic microangiopathy

Check vitamin B12 levels if a patient has hemolytic anemia

A RARITY WITHIN THE CHAMBERS

Margo B. Gerke¹; Joshua L. Chan²; Mani Daneshmand²; Anant Mandawat³. ¹Emory University School of Medicine, Atlanta, GA; ²Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA; ³Cardio-Oncology Program, Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA. (Control ID #4045417)

CASE: A 26-year-old woman with BMI 65 kg/m² and no other past medical history presented to the emergency department (ED) with a 5-day history of epigastric pain. Two days prior, she presented to the ED with similar symptoms and was discharged with antacids for suspected dyspepsia. This time, further cardiac workup was completed due to symptom persistence. Vitals were remarkable for blood pressure of 180/120 mmHg, heart rate of 91 bpm, and O₂ saturation of 95% on room air. Labs showed a troponin-I of 17 ng/L and a BNP of 180 pg/mL. A CT angiogram of the chest revealed a moderate-to-large pericardial effusion with no tamponade and a right-sided cardiac atrial mass. Cytology of pericardial fluid was negative for malignancy.

A cardiac-gated CT scan showed an infiltrative mass on the free wall of the right atrium measuring 9.0 x 9.1 x 7.1 cm³, filling over 50% of the right atrial chamber. The mass extended into the atrioventricular groove, abutting the right coronary artery, and was closely associated with the tricuspid valve. A cardiac MRI with gadolinium contrast further revealed heterogeneous arterial enhancement with a necrotic core. The mass was intensely FDG-avid on PET/CT (max SUV 18.3). Several subcentimeter, bilateral pulmonary nodules were identified. A TTE demonstrated a preserved left ventricular ejection fraction.

The case was discussed at a multidisciplinary cardiac tumor board and mass resection with right atrial reconstruction was recommended. The patient was bi-cavally cannulated and placed on cardiopulmonary bypass support. En-bloc mass resection was performed, which encompassed the right atrial free wall and extended to the SVC and IVC. On the ventricular side, the right coronary artery was skeletonized off the tumor. Bovine pericardium was used to recreate the interatrial septum and the free wall of the right atrium. The patient’s post-operative course was unremarkable.

Histology confirmed the diagnosis of high-grade angiosarcoma (Total Score: 7, Differentiation Score: 3; Mitoses Score: 3, Necrosis Score: 1). Despite an R0 resection, medical oncology recommended adjuvant chemotherapy based on the high-grade nature of the malignancy and identification of multiple bilateral subcentimeter pulmonary nodules. Doxorubicin will be considered for chemotherapy balanced by concerns for further cardiotoxicities.

IMPACT/DISCUSSION: Primary cardiac angiosarcomas have an estimated prevalence of 1/1,000,000 and due to this rarity, no standardized treatment approach exists. Collaboration between cardiology, cardiothoracic surgery, oncology, and cardio-oncology highlighted the importance of pooling expertise to formulate a comprehensive treatment plan and provide timely, well-coordinated care.

CONCLUSION: In this case, work up of common epigastric pain revealed a cardiac angiosarcoma. The identification of a cardiac mass prompted an interdisciplinary approach to care, resulting in prompt diagnosis and treatment including surgical resection, reconstruction, and adjuvant chemotherapy.

A RED CHEST AND BLUE NOSE

Andrew Sanchez, Thilan P. Wijesekera. Internal Medicine, Yale New Haven Hospital, New Haven, CT. (Control ID #4026803)

CASE: Aliquot #1: A man in his 60s with atrial fibrillation on apixaban presented to our hospital with a painful, erythematous, bullous chest wall rash in a dermatomal distribution. After 48 hours of IV acyclovir, the lesion developed central necrosis with a narrow, retiform, erythematous rim. Concurrently, he developed acute sinus pain, epistaxis, and new cyanosis of the entire nose. Aliquot #2: His PMHx was remarkable for unprovoked pulmonary embolism (PE) several years prior, as well as 2 recent hospitalizations for acute, severe sinus pain followed by left orbital swelling. During the most recent hospitalization, nasoscopy showed scattered, black mucosal patches over the left turbinates. The episodes of orbital swelling were attributed to orbital cellulitis, and symptoms reportedly resolved with antibiotics. The patient states his current sinus pain is identical in character to the 2 prior episodes. The ESR was 54 mm/hr and CRP 252.7 mg/L. The WBC was 6.7, hemoglobin 12.1, platelets 141, INR 1.22, PTT 26.3, and fibrinogen 417 mg/dL. D-dimer was elevated to 19.69 mg/L. CTA of the aortic branches showed no filling defects. Aliquot #3: Pulse-dose steroids were started. Labs collected prior to steroids showed normal: ANA, C3/C4, ANCAs, MPO/PR3 antibodies, cryoglobulin, cryofibrinogen, beta-2 GP-1/aCL antibodies, and lupus anticoagulant. Aliquot #4: Biopsy of the chest lesion showed microthrombi. DIF for vasculitis and telescoping biopsy for intravascular lymphoma were negative. HSV, VZV, HIV, and viral hepatitis testing was negative, as well as tissue cultures and TTE for vegetation. Apixaban was switched to heparin infusion. Protein C (on apixaban) and ATIII activity (on heparin) were both mildly low. Several years prior, he had high titers of beta-2 GP-1 IgG and IgA antibodies on measurements 12 weeks apart, taken within the same year of his prior PE. After heparin is switched to warfarin, the symptoms stabilize/resolve without recurrence at 1 year. Final Dx: Anticoagulant-refractory antiphospholipid syndrome (APS) with seronegative antibody conversion and microvascular thrombosis.

IMPACT/DISCUSSION: In their approach to a “red” chest rash, discussants will review the significance of retiform purpura (ie microvascular occlusion). Next, the “blue” nose will pose a challenge, as there is no standard approach to this issue. Making progress here requires analogical reasoning: the finding on prior nasoscopy of black, seemingly necrotic lesions suggests a potential link between the patient’s new chest necrosis and HEENT symptoms. Finally, recognition of a previous APS diagnosis will prompt discussion on whether seronegative APS antibody conversion poses lesser thrombotic risk. Warfarin as the optimal APS anticoagulant will be highlighted.

CONCLUSION: Patients with APS and seronegative antibody conversion carry continued thrombotic risk. Analogical reasoning remains a powerful tool for the diagnosis of novel clinical syndromes.

A RED HERRING MASKING ACQUIRED HEMOPHILIA

Sarah Grant. Internal Medicine Residency Program, East Alabama Medical Center, Opelika, AL. (Control ID #4057529)

CASE: A 75-year-old female with type 2 diabetes, hypertension, hyperlipidemia, and coronary artery disease with stenting one year ago on aspirin and clopidogrel initially presented to the hospital for swelling and bruising of her right arm.

Four days prior to admission she was seen by hematology for spontaneous extensive bruising of her left hand, left forearm, and majority of right arm. Labs were remarkable for an isolated elevated PTT and a PTT mixing study that did not correct.

On admission, she was found to have deep vein thrombosis in her right upper extremity. Her lupus anticoagulant was positive, a repeat mixing study did not correct, and her dilute russell venom viper test (DRVVT) was not prolonged. Her clopidogrel was switched to enoxaparin but two days into her admission a left periorbital ecchymosis developed and her hemoglobin was 6.3 requiring transfusion and cessation of enoxaparin. Since she remained stable, she was discharged home with aspirin and outpatient follow-up with hematology.

One day after discharge she was readmitted for acute respiratory failure secondary to a parapharyngeal hematoma requiring intubation. Due to her evolving clinical picture, the concern for an acquired hemophilia heightened and she was started on Factor VIIa and methylprednisone. Rituximab and cyclophosphamide were also started to suppress the inhibitor and four days into her second hospitalization she was successfully extubated. Her factor VIII levels were non-measurable whereas factors 9 and 11 levels were both normal. Her factor VIII inhibitor panel was positive confirming the diagnosis of acquired hemophilia and the Bethesda test noted 91 units indicating the presence of a strong inhibitor.

IMPACT/DISCUSSION: Acquired hemophilia is a rare life-threatening disorder and its diagnosis can be complicated by a false positive lupus anticoagulant. Mortality in patients with acquired hemophilia can be as high as 22% with the most life-threatening hemorrhaging occurring the first several weeks of initial presentation making early identification and treatment essential. This case shows the importance of utilizing a patient’s clinical picture to identify acquired hemophilia, a rare cause of isolated PTT, from a prior false positive lupus anticoagulant diagnosis.

Isolate prolonged PTT and non-corrected aPTT mixing study results are not specific for either disorder and a DRVVT test can help identify a false positive lupus anticoagulant, however a Factor VIII activity level and an inhibitor panel can help confirm the diagnosis of acquired hemophilia. The Bethesda test helps determine the strength of the inhibitor which helps identify treatment options.

CONCLUSION: Prompt clinical identification of acquired hemophilia allows for timely commencement of treatment and stabilization.

The DRVVT test can help identify a false positive lupus anticoaguant test, however waiting for labs to confirm the diagnosis of acquired hemophilia could delay lifesaving treatment.

ARE IMMUNE-RELATED ADVERSE EVENTS HIDDEN BLESSINGS?: ATEZOLIZUMAB AND BEVACIZUMAB-ASSOCIATED CEREBRAL TOXICITY WITH GOOD CANCER OUTCOME

Shristi Nepal¹; Navin Bhatt²; Mohamedtaki Tejani³. ¹Department of Internal Medicine, AdventHealth Orlando, Orlando, FL; ²Department of Medicine, NYC Health + Hospitals/Elmhurst, Icahn School of Medicine at Mount Sinai, New York, NY; ³Hematology and Oncology, AdventHealth Orlando, Orlando, FL. (Control ID #4064035)

CASE: A 74-year-old man with a medical history of hepatitis C cirrhosis post-treatment, presented with abdominal pain and weight loss for a couple of months. Abdominal magnetic resonance imaging (MRI) revealed hepatocellular carcinoma occupying almost the entire right hepatic lobe with macrovascular invasion without evidence of metastatic disease. The initial alpha-fetoprotein level exceeded 2000 nanograms per milliliter. Subsequently, the patient was initiated on a regimen that included the immunotherapy drug atezolizumab along with bevacizumab. After completing two cycles of this therapy, he was admitted to the hospital for his deteriorating mental status. An MRI of the brain showed features indicative of treatment-associated encephalopathy. Cerebrospinal fluid analysis by lumbar puncture ruled out meningeal carcinomatosis or infection. Owing to persistent confusion and altered mental status, both atezolizumab and bevacizumab were placed on hold—notably, the patient's mental status improved following the cessation of immunotherapy. The patient was also initiated on a prednisone regimen, initially at 60mg, which was subsequently tapered over four months. During the assessment of cancer status, the patient's alpha-fetoprotein levels had normalized, indicating a positive response to the initial immunotherapy. Subsequent computed tomography imaging revealed reduced tumor size and upper abdominal lymphadenopathy, with no new hepatic mass. Presently, the patient receives ongoing care from both the oncology and neurology departments on an outpatient basis. He has made an almost complete recovery from the encephalitis and is back at his baseline.

IMPACT/DISCUSSION: The Food and Drug Administration approved atezolizumab and bevacizumab on May 29, 2020, as a treatment of choice for individuals with unresectable locally advanced or metastatic hepatocellular carcinoma who have not previously received immunotherapy. However, the occurrence of encephalitis and treatment-related encephalopathy due to this combination is rare and has limited documentation in the existing literature. The diagnosis can only be made after carefully ruling out a variety of causes of encephalitis, including infection, ischemia, metabolic and electrolyte abnormalities, metastases, and paraneoplastic neurologic syndrome. While there are no established guidelines for treatment, these side effects have been managed by discontinuing the drug, using high-dose steroid pulse therapy, administering intravenous immunoglobulin, plasmapheresis, or employing medications such as infliximab or rituximab.

CONCLUSION: While instances of these cerebral toxicities demand heightened attention from healthcare providers due to their significant life-threatening risks, recent studies indicate improved tumor response and enhanced survival in patients who encounter immune-related adverse events (irAE). Further research remains crucial to refining our understanding of irAEs, as they may not always represent unfavorable cancer outcomes.

ARE WE ALL ABLE TO MAKE A DIAGNOSIS?

Tasniem Tasha¹; Matthew August McCarron¹; Cecil Jnawali¹; Waleed Kassabo²; Sami G. Tahhan². ¹Internal medicine, Eastern Virginia Medical School, Norfolk, VA; ²Internal Medicine, Eastern Virginia Medical School, Norfolk, VA. (Control ID #4064087)

CASE: We present a case of a patient who was first suspected to have Acute Lymphoblastic Leukemia (ALL) by having a positive BCR-ABL1 quantitative blood test by Reverse transcription (RT) PCR. A 28-year-old woman with recent endometritis following an abortion, presented to the ER with complaints of abdominal distension, weight gain, malaise, orthopnea, exertional dyspnea, and bilateral lower extremity edema, reported chills, nausea, and decreased appetite. Her systolic blood pressure ranged from 180 to 200 mmHg despite no history of hypertension. Examination revealed hepatosplenomegaly(HPM) and spontaneous bruising, Labs disclosed anemia (7.9 g/dL), thrombocytopenia (110k u/L), elevated proBNP (2,021 pg/mL), elevated LDH. The initial assessment suggested new-onset heart failure and volume overload due to hypertensive urgency. She responded to diuretics and antihypertensive therapy. Hematology was consulted due to anemia, thrombocytopenia, and HPM. Labs ruled out sickle cell anemia, thalassemia, and porphyria. The patient was discharged with close follow-up after a quantitative BCR-ABL1 test was drawn. Nine days later, the patient returned to the ER due to worsening bilateral in the upper thigh pain, along with vomiting, and dyspnea. Blood work revealed continued anemia, thrombocytopenia (12k u/L), and CT imaging confirmed HPM. In the interim, her quantitative BCR-ABL1 test had returned markedly positive. A bone marrow biopsy confirmed extensive B-lymphoblastic leukemia/lymphoma, accompanied by BCR-ABL1 fusion leading to immediate initiation of chemotherapy.

IMPACT/DISCUSSION: The Philadelphia (Ph) chromosome, a fusion between chromosomes 9 and 22 resulting in the BCR-ABL fusion protein, was first discovered in Chronic Myeloid Leukemia (CML). The Ph chromosome is also implicated in ALL, predominantly within the adult population, constituting approximately up to 30 % of cases and is a marker of poor prognosis. Such patients are routinely treated with allogeneic hematopoietic cell transplantation (HCT) after remission induction. RT-PCR quantitative BCR-ABL testing is low-cost, sensitive, rapid, and not labor intensive, it is the diagnostic test of choice for Ph-positive leukemia. It can also be used to assess response to treatment and to detect measurable residual disease (MRD) following allogeneic HCT. Identifying BCR-ABL positive ALL subtype early is pivotal. Tyrosine kinase inhibitors (TKIs) have notably curbed MRD, a pivotal prognostic marker in Ph-positive ALL. Dasatinib, a TKI, is commonly favored based on prospective studies and potential CNS penetration. Our patient received dasatinib with a subsequent bone marrow biopsy showing no disease and has continued follow-up with hematology.

CONCLUSION: This case highlights the utility of the blood RT-PCR BCR-ABL test and teaches us about the presence of it not just in CML but also in ALL. It might in time, in the right patient, become a tool useful to hospitalists as well as outpatient physicians while awaiting input from hematologists.

ARTIFACTUAL HYPOGLYCEMIA, A MISLEADING CONDITION

Aimal SHAH, Syed Muhammad Usama. Internal Medicine, Trinity Health Mid-Atlantic, Conshohocken, PA. (Control ID #4015214)

CASE: 72-year-old female with a past medical history of Raynauds and Hypertension admitted for Heart Failure exacerbation. Fingerstick glucose levels were measured at 58 mg/dL, 60 mg/dL upon repeat testing, and at one point, as low as 20 mg/dL. She did not have sympathetic (palpitations, diaphoresis, tremor) or neuroglycopenic (confusion, headache, visual changes, nausea) symptoms of hypoglycemia. Venous blood sampling indicated glucose levels of 96 mg/dL and 116 mg/dL at that time.

IMPACT/DISCUSSION: Two methods are available to measure glucose levels, capillary measurement using point-of-care (POC) glucose meters and through arterial or venous blood. Measurement of serum glucose by POC is quite a common practice. As blood sugar levels can change quickly, repeated measurements may be necessary to accurately assess the patient's condition making POC the easy method. However, taking blood samples from veins or arteries frequently is uncomfortable or even painful for patients, and it can also be costly, time-consuming, and put a strain on hospital resources. The accuracy of POC meters is required to be within 20% of the actual value for 95% of samples with glucose levels ≥75 mg/dL and ±15 mg/dL for samples with glucose levels <75 mg/dL, according to the International Organization for Standardization (ISO) and FDA standards.

This discrepancy between POC and actual blood glucose level due to pathological conditions is termed artifactual hypoglycemia as demonstrated by this patient. POC mirror the glucose concentration in the microcirculation and are significantly lower than the systemic plasma glucose due to slow capillary blood flow. This form is typically associated with medical conditions like shock, peripheral vascular disease, Raynaud phenomenon, or scleroderma, which can all contribute to poor peripheral circulation. Hypotension slows down blood flow in the capillaries of the fingers, resulting in increased transit time for glucose and increased glucose uptake by local tissues. This can lead to falsely low glucose levels when measured through POC.

The diagnosis of true hypoglycemia requires the fulfillment of Whipple's triad (presence of symptoms and signs consistent with hypoglycemia, low plasma glucose concentration, and resolution of symptoms/signs upon correction of hypoglycemia). Most patients with artifactual hypoglycemia lack signs and symptoms of hypoglycemia.

CONCLUSION: Artifactual hypoglycemia refers to the discrepancy between actual blood glucose levels and fingertip glucose levels obtained by point-of-care glucometer, in the absence of hypoglycemic and neuroglycopenic symptoms. It is essential to differentiate artifactual hypoglycemia from true hypoglycemia through a comprehensive evaluation, including a detailed history, examination, and alternative laboratory methods to avoid the occurrence of artifactual hypoglycemia. Failure to accurately identify this condition can result in extensive diagnostic workup, overtreatment, and unnecessary stress on the patients.

ART OF MANAGING ALCOHOL WITHDRAWAL

Cyrus Mowdawalla, Kristine Phung. Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4051458)

CASE: A 63-year-old male with history of schizoaffective disorder, alcohol use disorder (AUD) complicated by recurrent admissions for alcohol withdrawal and delirium tremens presented with shortness of breath, suicidal ideation and auditory hallucinations. He consumes 2L of vodka daily, with his last drink 24 hours prior to admission.

He initially presented with a Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar) score of ~30, though varied between each provider. The patient was given ~200 milliequivalents (mEq) of chlordiazepoxide. While his CIWA score reduced over time, due to escalating agitation and hallucinations, patient ultimately needed a total of ~500 mEq of chlordiazepoxide daily.

Due to increasing benzodiazepine requirements, the patient was transferred to the ICU to receive a phenobarbital protocol. Given his ongoing withdrawal, agitation, and tenuous respiratory status, he was intubated for airway protection. After extubation, he was treated for active delirium and was subsequently discharged home.

IMPACT/DISCUSSION: AUD is a common reason for hospital admissions and is the 7th leading risk factor for substantial morbidity and mortality worldwide.

For hospitalized patients at risk for alcohol withdrawal, the symptom triggered CIWA-Ar protocol is often utilized. Though the CIWA-Ar is the gold standard tool in alcohol withdrawal, the assessment is user dependent. With our patient, the CIWA-Ar score varied with each provider.

Though our patient’s CIWA-Ar score initially decreased, the patient’s benzodiazepine need continued to increase. When both alcohol withdrawal and psychosis/delirium overlap, it was challenging to determine appropriate treatments. Therefore, decisions based solely on CIWA-Ar scores may not be accurate.

The subjective nature of CIWA-Ar can lead to unwarranted benzodiazepine treatment which places patients at risk for over-sedation, respiratory depression and delirium. A retrospective chart review noted 57% of their sample had CIWA-Ar protocols that were inappropriately initiated in patients with no or low risk of alcohol withdrawal.

Two studies utilized the objective alcohol withdrawal scale or the Richmond Agitation-Sedation Scale in addition to the CIWA-Ar which obtained objective assessments of withdrawal symptoms and allowed for added accuracy in treatment decisions.

The speed of onset, duration, and pharmacokinetics are important considerations for treatment initiation. Given the treatment variability, providers should proceed with caution between treating withdrawal vs inducing respiratory depression. Therefore, treating serve alcohol withdrawal, especially among patients with psychiatric history, should consider the patient’s history and be a joint effort between hospitalists, psychiatry, and critical care.

CONCLUSION: Alcohol withdrawal scales are subjective measures and should be used in conjunction with the clinical picture.

Choosing and escalating alcohol withdrawal treatment is dependent on hospital resources and provider comfort.

A RUSH TO THE ED: METHEMOGLOBINEMIA IN A PATIENT AFTER USE OF INHALED NITRITES (RUSH) AND COCAINE.

Sara Heide, Brinda Raval, Silpa Yarra, Anjali A. Nigalaye, Lucy Zheng. Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4064912)

CASE: KK is a 45-year-old male with a medical history of hypertension who presented to the emergency room for shortness of breath, palpitations, and bluish discoloration of his face two hours after snorting cocaine. The patient regularly uses cocaine and has never experienced similar symptoms. He denied any other symptoms including chest pain, nausea, vomiting or diarrhea. The patient denied other drug use besides cocaine. He lives with his spouse and works as a doorman. His only medications are amlodipine and chlorthalidone. On arrival to the ED, the patient’s exam was notable for blue discoloration of the lips and fingers. His oxygen saturation was 89%, necessitating supplemental oxygenation at 4L/min. A venous blood gas revealed a pH of 7.43, lactate of 2.1 and methemoglobin level of 19.9%. Poison control was contacted and the patient was given 1 dose of methylene blue with improvement in symptoms. Upon further inquiry, the patient disclosed additional substance use with a type of inhaled nitrite, colloquially known as “rush”. Poison control did not offer any further recommendations based on this new information. The patient remained stable throughout the day and was discharged with counseling and resources for substance use disorder.

IMPACT/DISCUSSION: Methemoglobinemia is the oxidization of ferrous iron in hemoglobin into the ferric state which causes cyanosis at levels above 8-12% and hypoxia in more severe cases. Acquired methemoglobinemia can occur with certain prescribed medications but may also occur with recreational drugs such as “whip-its” or, as in our case, “rush”. While inhaled nitrites have long been known to cause methemoglobinemia, the association of cocaine use with methemoglobinemia has only occasionally been reported in the literature. It has been understood that local anesthetics used during cocaine administration or cocaine additives such as phenacetin may precipitate methemoglobinemia rather than cocaine itself. There have been several case reports of cocaine and inhaled nitrite-induced methemoglobinemia, but to our knowledge, there have been no case reports of methemoglobinemia developing in a patient after using a combination of both substances. It is possible that in our patient’s case, the use of cocaine along with ‘rush’ had a synergistic effect which precipitated his symptoms.

CONCLUSION: The interaction between inhaled nitrites and cocaine additives should be further studied to elucidate if these patients are at an increased risk for methemoglobinemia. Clinicians should maintain a high level of suspicion for methemoglobinemia in a patient with acute onset cyanosis that does not respond to supplemental oxygen, even without a known nitrite exposure. This is due to the risk of incomplete reporting of substance use by the patient and the potential for cocaine-induced methemoglobinemia. In patients with methemoglobinemia, poison control should be promptly contacted and partnered with to make decisions regarding treatment with methylene blue.

A SARCOMATOUS ROUTE TO DIAGNOSIS: A RARE CASE OF PULMONARY ARTERY SARCOMA

Evan Shegog¹; Neeraj Ramakrishnan¹; Vibha Mohindra². ¹Internal Medicine, Santa Clara Valley Medical Center, San Jose, CA; ²PCCM, Santa Clara Valley Medical Center, San Jose, CA. (Control ID #4064899)

CASE: A 47-year-old male with a recent history of unprovoked submassive saddle pulmonary embolism (PE) and previously treated stage III (T2N2M0) rectal adenocarcinoma presented to the emergency department (ED) with eight days of worsening exertional dyspnea. In the ED, the patient’s vital signs and physical exam were largely unremarkable. On admission, computed tomography angiography (CTA) showed an increase in pulmonary embolism burden and new evidence of right ventricular dilation. Thrombectomy was attempted but aborted due to cardiac arrest for which return of spontaneous circulation was quickly achieved. The patient was subsequently transferred to the intensive care unit (ICU) and started on a heparin drip. Prior to repeat thrombectomy attempt, Positron Emission Tomography and Computed Tomography (PET/CT) scan revealed hypermetabolic activity in the pulmonary artery suggestive of malignancy. The patient underwent excision of the tumor with a bilateral pulmonary arterial thrombectomy. Pathology showed pleomorphic undifferentiated high-grade primary pulmonary artery sarcoma (PPAS). Further debulking procedures improved central pulmonary artery patency, but complete tumor resection was not achieved. With symptomatic improvement of his dyspnea, the patient declined chemotherapy and chose to undergo surveillance imaging.

IMPACT/DISCUSSION: This case highlights the rare diagnosis of primary pulmonary artery sarcoma (PPAS). The clinical and radiographic similarity of presentation between PPAS and PE frequently leads to increased mortality due to delayed diagnosis and treatment. The true incidence of PPAS remains largely unknown and is likely underreported due to patients with PPAS who are incorrectly diagnosed with PE. Several factors that can aid in distinguishing PPAS from PE include: gradual onset of symptoms, persistent cough and hemoptysis, lack of clinical improvement with anticoagulation therapy, and absence of deep vein thrombosis. Additionally, specific radiographic findings on CTA and PET/CT can aid in distinguishing PPAS by identifying expansion beyond vessel walls, evidence of distant metastasis, and regions of heightened metabolic activity. The treatment landscape for PPAS is challenging as there are no standardized guidelines. Treatment involves a multimodal approach with interventions such as chemotherapy, debulking or extensive surgical resection, radiation therapy, and palliative stenting. In comparison to single-modality treatments, the application of a combined approach with surgery, radiation and chemotherapy yields a more favorable prognosis and extends the median survival to approximately 28 months.

CONCLUSION: PPAS is a rare diagnosis that requires additional research to increase awareness, enhance diagnostic precision, and establish standardized treatment guidelines. These efforts are crucial to counteract the adverse prognosis linked to this uncommon malignancy, since more rapid diagnosis may lead to earlier definitive care and better outcomes.

A SHOCK TO THE SYSTEM: INFERIOR VENA CAVA THROMBOSIS IN A PREGNANT PATIENT WITH LUPUS NEPHRITIS

Nagma Shah^2,1; Maryam Hajiabbasi^2,1; Maria G. Parra Riveros^2,1; Daniel Mozell^2,1; Nitzy M. Casablanca³. ¹Internal Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; ²Internal Medicine, New York City Health and Hospitals Corporation, Queens, NY; ³Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #4065085)

CASE: A 31-year-old woman, G2P1A0, at 31 weeks of gestation, with a history of systemic lupus erythematosus (SLE), presented with two weeks of worsening abdominal, genital, and bilateral lower-extremity edema. Initial laboratory workup revealed normal renal function, but nephrotic-range proteinuria, and elevated anti-dsDNA. A lower extremity doppler showed no evidence of deep vein thrombosis (DVT). A presumptive diagnosis of membranous Lupus Nephritis (LN) was made, and she was initiated on high-dose steroids and azathioprine as mycophenolate, the first-line therapy, is contraindicated during pregnancy. Despite ongoing immunosuppression and diuresis, the patient's edema and proteinuria worsened, prompting the delivery of the baby.

On the second day of postpartum, the patient developed a fever, tachycardia and hypotension, prompting further investigation. A CT of the abdomen and pelvis revealed a thrombus in the inferior vena cava (IVC) extending to the renal and gonadal veins with a massive pulmonary embolism (PE). Therapeutic enoxaparin was started. Infectious and antiphospholipid syndrome (APLS) workup was negative. The fever was attributed to venous thromboembolism (VTE), and hypotension was thought to be secondary to decreased venous return. Given the negative APLS workup, enoxaparin was switched to apixaban, and the patient was discharged on mycophenolate for LN. During outpatient follow-up, there was significant improvement in peripheral edema and proteinuria (from 5g to 1.8g in six months).

IMPACT/DISCUSSION: IVC thrombosis is rare, accounting for 1.3% of diagnosed VTE cases in hospitalized patients in the United States. Due to its rarity and nonspecific symptoms, underdiagnosis is common, especially in those with coexisting nephrotic syndrome. Clinical presentations can range from asymptomatic cases to severe cardiovascular collapse, depending on the extent of the thrombus. Symptoms arise from blood pooling within the IVC and reduced venous return to the heart. While there is no single specific symptom or test for differentiation, there are clues that raise concern for an IVC thrombus in patients with nephrotic syndrome. These include unexplained pelvic or back pain, caput medusae, diuretic-refractory edema, or presence of other predisposing factors for VTE, such as pregnancy or SLE. An IVC thrombus can be detected using CT with IV contrast or MRI. Initial treatment typically involves systemic anticoagulation with fibrinolytic therapy or mechanical thrombectomy for cases not responding to systemic anticoagulation.

CONCLUSION: Due to its rarity and the nonspecific nature of symptoms, underdiagnosis of IVC thrombosis is common, especially in those with coexisting nephrotic syndrome due to overlapping symptoms. This case demonstrates that, given the risk of life-threatening complications, prompt diagnosis of IVC thrombosis and treatment with anticoagulation is paramount.

A SLOW LUB-DUB: A MYXEDEMA COMA CLOSE CALL

Raihan El-Naas. internal medicine, Weill Cornell Medicine, New York, NY. (Control ID #4023752)

CASE: 60yo woman smoker w/ COPD & Hashimoto’s thyroiditis p/w a mechanical fall. She reports tripping at home & falling. Denied any prodromal symptoms such as lightheadedness, CP, or SOB. Denied any LOC or headstrike. Afebrile. Pulse in 50s-60s. Normotensive. On exam, she was sitting up comfortably in bed. Alert & oriented to time, place & person. Heart sounds were normal but bradycardic. Labs notable for trop 22-->23 & BNP elevation to 121. EKG showed sinus bradycardia & low voltage. CXR w/ markedly enlarged cardiac silhouette. Given the enlarged cardiac silhouette, an urgent TTE was obtained. TTE showed a large pericardial effusion w/ echocardiographic findings of tamponade. She was admitted to the CCU for closer monitoring. She continued to become more bradycardic to the 30s w/ frequent PACs & PVCs. Pericardiocentesis was done & 800cc of straw-colored fluid was removed w/ negative cytology & fluid analysis. TSH level came back at 77 & the free thyroxine level was undetectable. She then admitted to not having taken her synthroid for a while due to issues w/ her insurance. Endocrinology was consulted & she was started on IV synthroid 200mcg after receiving IV hydrocort 100mg prior to ruling out adrenal insufficiency w/ a cosyntropin test. Anti-TPO & anti-thyroglobulin Abs were positive while anti-TSI & anti-TSHR Abs were neg which was consistent w/ the patient’s known Hashimoto’s thyroiditis. IV synthroid was continued until FT4 normalized then she was switched to PO synthroid 175mcg. The pericardial effusion did not reaccumulate & her HR normalized so she was discharged home.

IMPACT/DISCUSSION: Thyroid hormone abnormalities can result in a myriad of cardiac pathologies. Specifically, hypothyroidism can lead to bradycardia, AV block, intraventricular conduction delay, low QRS voltage, hypertension, dyslipidemia, coronary artery disease, heart failure, pericarditis and pericardial effusions. The pathophysiology is often related to a hypothyroidism-induced increase in oxidative stress, elevation in inflammatory markers, and promotion of atherosclerosis. Given the absence of altered sensorium, slurred speech, hypothermia, and hypotension, the presentation was unlikely myxedema coma but more of a severe hypothyroidism picture that could have progressed to myxedema coma (decompensated metabolic state w/ a mental status change) had the patient presented later than she did. Treating severe hypothyroidism requires IV synthroid (in case there is hypothyroidism-induced gut edema preventing adequate PO absorption of medications) and IV hydrocort administration (due to the risk of concomitant autoimmune adrenal insufficiency). Testing for both autoimmune thyroid disease (through anti-TSH, TG, TSI, TSHR Ab) and autoimmune adrenal insufficiency (through AM cortisol and cosyntropin test) is necessary to guide further management.

CONCLUSION: Key takeaway is recognizing the cardiac complications of hypothyroidism & differentiating between severe hypothyroidism & myxedema coma.

A STICKY SITUATION: MANAGEMENT OF RIGHT ATRIAL THROMBUS

Yajaira S. Jimenez¹; Nivita Sharma¹; Tareq Aljurf^1,2; Christina Barkauskas^1,2. ¹Internal Medicine, Duke University Health System, Durham, NC; ²Pulmonary, Allergy, and Critical Care Medicine, Duke University Health System, Durham, NC. (Control ID #4064120)

CASE: A 78-year-old-male with stage IV metastatic prostatic adenocarcinoma, T5 spinal cord compression complicated by neurogenic bladder, and provoked pulmonary emboli (PE) one year ago (not on anticoagulation) presented with one week of weakness. Initial vital signs and physical exam were remarkable for temperature of 103.1 F, blood pressure 65/50 mmHg, pulse 137, respirations 33, oxygen saturation 96% on 8 liters nasal cannula, somnolence, accessory respiratory muscle use, hepatomegaly and bilateral lower extremity weakness. Transthoracic echocardiogram (TTE) revealed a large right atrial thrombus (RAT) prolapsing into the right ventricle with every heartbeat and severe right heart strain. Chest computed tomography showed acute bilateral PE. He was transferred to the medical intensive care unit for treatment of mixed shock with fluid resuscitation, intravenous antibiotics, and escalating doses of norepinephrine. He was started on a heparin infusion and Pulmonary Embolism Response Team (PERT) was consulted for further management of his PE and RAT. Over the next 96 hours he remained on a heparin infusion and underwent serial bedside TTE’s to visualize the location of the RAT. After the fourth day on heparin therapy, he developed signs of worsening obstructive shock, suggesting the RAT had exited the heart (as confirmed by absence of RAT on TTE) and entered the pulmonary vasculature. Interventional radiology (IR) performed aspiration thrombectomy and removed the right internal jugular vein port from which the RAT likely originated. He recovered well and was discharged on rivaroxaban.

IMPACT/DISCUSSION: Right atrial thrombus, while uncommon in patients with PE, increases risk of mortality in patients with PE. However, standardized treatment guidelines and algorithms do not exist. Thus, optimal treatment for RAT is individualized based on co-morbidities, hemodynamic status, and thrombus characteristics. PERTs are becoming prevalent across institutions to streamline decision making and execution of interventions. In this case, there were four possible management options (systemic thrombolysis, surgical embolectomy, aspiration thrombectomy, or observation with anticoagulation) each carrying significant risks of procedural complications and mortality, so PERT was consulted. PERT at our institution is composed of cardiology, pulmonary vascular disease, cardiothoracic surgery, and IR and intensive care teams. Given the size of the RAT and tenuous clinical status with multiple existing PE’s, PERT consensus agreed that observation with systemic anticoagulation carried the least immediate mortality risk. Once the RAT entered pulmonary circulation, there were clear benefits of removing the pulmonary emboli to relieve right heart strain with minimal risk of further embolization.

CONCLUSION: While this patient initially improved without immediate intervention, management of RAT in transit remains complex and requires multidisciplinary input to determine optimal strategy on a case-by-case basis.

A TALE OF THREE TOXICITIES A CASE OF GENTAMICIN INDUCED NEPHROTOXICITY METFORMIN ASSOCIATED LACTIC ACIDOSIS AND CEFEPIME INDUCED NEUROTOXICITY

Rayan Elhag¹; Shim Roh¹; Kemar Barrett¹; Dipal R. Patel². ¹Internal Medicine, Englewood Health, Englewood, NJ; ²Dept of Medicine, Englewood Health, Englewood, NJ. (Control ID #4060751)

CASE: A 76-year-old male with a history of Diabetes presented with altered mental status. He was hospitalized a week prior for Pseudomonas prosthetic mitral valve endocarditis and discharged to complete a 6-week course of cefepime and gentamicin. At baseline, he was alert and oriented with no focal deficits. However, 2 days prior to admission, he progressively became confused. He was adherent with his medications including metformin, furosemide, gentamicin, and cefepime.

On exam he was confused, agitated, and unable to follow commands. Vital signs were unremarkable. Labs were significant for new acute kidney injury (AKI) with serum creatinine 6.6 mg/dL, potassium 6.4 mmol/L, lactic acidosis of 13.5 mmol/L, and glucose 40 mg/dL. His gentamicin trough was elevated at 11.6 mcg/mL. CT head was normal. All nephrotoxic drugs were stopped, and he was admitted to the ICU, where he was started on hemodialysis (HD). Antibiotics were switched to renally dosed Daptomycin and Zosyn. Renal US showed increased echogenicity of the kidneys. His ICU course was remarkable for possible seizure activity, and he was started on Levetiracetam. Video EEG was normal. MRI brain showed old infarcts. Serum creatinine improved to 4.55 mg/dL with hyperkalemia and lactic acidosis resolving. His neurological status significantly improved with return to his baseline. He was discharged to continue outpatient HD.

IMPACT/DISCUSSION: AKI is a relatively common complication of aminoglycoside therapy affecting 10-20% of patients and can lead to major drug toxicities.¹ Here we present a case of Gentamicin-induced nephrotoxicity leading to metformin-associated lactic acidosis (MALA) and Cefepime-induced neurotoxicity.

Despite its nephrotoxic potential, gentamicin/cephalosporin combination is commonly chosen as initial therapy for complicated gram-negative infections.² It was therefore the regime of choice for our patient with Pseudomonas endocarditis. Unfortunately, there is a suspected synergistic nephrotoxicity associated with the concomitant administration of aminoglycoside and cephalosporin antibiotics.²

AKI also leads to increased cefepime serum concentrations and is associated with proteinuria and altered protein binding, increasing the unbound fraction of cefepime available for entry into the CNS.³ Neurotoxic symptoms ensue and includes encephalopathy, seizures, and coma. Another complication of AKI is MALA which represents a rare but worrisome complication, with a mortality rate 10%-45%.⁴ Treatment includes discontinuation of these medications and HD which is the most effective method in terms of drug clearance and solving the acid-base problem.⁵

CONCLUSION: Appropriate antibiotic therapy requires a careful balance of achieving therapeutic levels and avoiding nephrotoxicity. Recognizing and addressing factors known to potentiate toxicity is key to decreasing morbidity.

ATHEROSCLEROTIC ACUTE CORONARY SYNDROME MIMIC: A RARE CASE OF MULTIVESSEL SCAD

Rebecca A. Scharf¹; Gene F. Kwan². ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Boston Medical Center, Boston, MA. (Control ID #4064353)

CASE: A 58-year-old man with no significant medical history presented with acute-onset left-sided chest pain and diaphoresis. Vital signs on admission were BP 155/78, HR 68, RR 16, and SpO2 99% on room air. Chest x-ray was unremarkable. ECG showed normal sinus rhythm without ischemic changes. Labs were notable for high-sensitivity troponin 4,596 (uptrended to 18,223), d-dimer <150, LDL 122, and Hgb A1c 5.3%. The patient reported recent emotional stress, endorsed daily exercise, and denied tobacco or alcohol use.

Given significant troponin elevation and patient’s symptoms, there was concern for type I NSTEMI. The patient was given aspirin, atorvastatin, and continuous infusion heparin. Cardiac catheterization showed a diffuse 50% lesion of the upper pole of the OM3 and a long 60% lesion of the right posterior descending artery, suspicious for spontaneous coronary dissections (SCAD). No intervention was performed and the patient was treated with metoprolol with suggestion for repeat angiography in 4-6 weeks. TTE showed LVEF 62% with normal diastolic function and no wall motion abnormalities. Given SCAD’s association with fibromuscular dysplasia (FMD), the patient underwent renal artery duplex that did not show significant stenosis. CTA head/neck showed no evidence of aneurysm, normal common and internal carotid arteries, and normal vertebral arteries.

IMPACT/DISCUSSION: This case represents an extremely rare presentation of a male patient with multivessel SCAD. SCAD may be suspected in patients without cardiovascular risk factors who present with chest pain similar to that of an atherosclerotic acute coronary syndrome (ACS) and are found to have elevated cardiac biomarkers +/- ECG changes. Approximately 1-4% of cases of ACS are due to SCAD and multivessel SCAD is implicated in 9-23% of these cases. The majority of patients with SCAD are women (~90%) and middle-aged, though younger pregnant women are also at increased risk; it is thought that estrogen and progesterone contribute to the pathogenesis of SCAD. Emotional stress is also a risk factor. In this case, stress was the patient’s only known risk factor.

Although the diagnostic work-up of SCAD is identical to that of other ACS, the management and evaluation differs. Percutaneous coronary intervention (PCI) is generally deferred given most patients improve with conservative management. Further, PCI is associated with higher complication rates than when used for atherosclerotic ACS. Antiplatelets and statins are not routinely recommended. Hypertension management is recommended to prevent recurrence; beta blockers may have a similar benefit, likely due to decreased wall stress. Patients with SCAD should undergo workup for FMD with imaging of carotid, vertebral, and renal vasculature as the prevalence of FMD among patients with SCAD ranges from 25-86%.

CONCLUSION: SCAD clinically presents similarly to atherosclerotic ACS, but is associated with different risk factors.

Conservative management is preferred over invasive therapy in SCAD.

A TRANSAMINITIS BY ANY OTHER NAME: A CASE OF OVERLAPPING IMMUNE-RELATED ADVERSE EVENTS

Lucia A. Joseph^1,2; Alexander Miller^1,2; Chase Skarda^1,2. ¹Internal Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH; ²Internal Medicine, White River Junction VA Medical Center, White River Junction, VT. (Control ID #4059534)

CASE: A 76 year old male Army veteran with resected early stage non small cell lung cancer and recent 12 month course of adjuvant atezolizumab presented with 3 weeks of fatigue and jaundice. Past medical history included gout, atrial fibrillation, and stage III chronic kidney disease. No alcohol use or family history of liver disease. Exam notable for jaundice without abdominal distention or tenderness. On evaluation had AST 1179, ALT 864, GGT 1276, Alkaline Phosphatase (Alk Phos) 2190, total bilirubin (T. Bili) 10.6, and direct bilirubin (D. Bili) 8.3. Abdominal imaging benign. Diagnosed with immune checkpoint induced hepatitis (ICH), started on IV solumedrol, and LFTs slowly improved. Transitioned to oral prednisone taper. At discharge, ALT 639, AST 784, T. Bili 4.2, D. Bili 3.4, and Alk Phos 1574. He fell in the parking lot on the way home but declined work-up, only to return 4 days later with muscle aches and bilateral symmetric proximal lower extremity weakness, confirmed on exam with lower extremity areflexia. MRI lumbar spine ruled out acute cord syndrome, AST 1488, ALT 713, Alk Phos 1337, T. Bili 3.8, D. Bili 2.8, lipase 236, and creatine kinase (CK) over 33,000 (above the upper limit of the lab assay). This second presentation with elevation of AST>ALT and CK was attributed to immune checkpoint myositis (ICM). Started on pulse-dose solumedrol and mycophenolate mofetil, later transitioned to IVIG due to worsening anemia and thrombocytopenia. Symptoms and lab abnormalities improved and he was discharged home on a steroid taper, ambulating with a walker. At discharge: ALT 317, AST 144, T. Bili 2.2, D. Bili 1.5, Alk Phos 526, and CK 30.

IMPACT/DISCUSSION: ICH and ICM have been linked to nivolumab and pembrolizumab, however to the best of our knowledge, this is the first case of ICH and ICM overlap related to atezolizumab. Retrospective reviews show that <10% of patients treated with ICI monotherapy develop ICH and <1% develop ICM. The presentation of these two entities are distinct but often subtle early in their course with similar laboratory findings including elevations in AST and ALT. In our case, the high LFTs, Alk Phos, and bilirubin present on initial admission were consistent with ICH. The patient did not report proximal muscle weakness until after being discharged and tapered to oral prednisone. However, a targeted history and physical exam or a CK level earlier in his course may have facilitated earlier diagnosis of overlapping ICM. Delay in recognition of ICM resulted in progressive muscle weakness, a second admission, and failure to screen initially for myocarditis and myasthenia gravis, highly morbid complications of ICM. Treatment of ICM typically requires higher dose glucocorticoids and often another immunosuppressant.

CONCLUSION: Clinicians need a high index of suspicion to identify instances of overlap syndromes where multiple immune-related adverse-events are possible. AST elevation out of proportion to ALT and Alk Phos can indicate a non-liver source.

ATYPICAL COCCIDIOMYCOSIS MENINGITIS IN AN IMMUNOCOMPROMISED PATIENT

Joshua Clason, Ross Hardin, Bao Nguyen, Stewart R. Malave, Sameer Khan, Nathan T. Douthit. Internal Medicine Residency Program, East Alabama Medical Center, Opelika, AL. (Control ID #4060586)

CASE: A 24-year-old Spanish-speaking undocumented immigrant with no significant past medical history presented to the emergency department with left-sided upper and lower extremity paralysis which started acutely 2 days earlier and dizziness, fevers, and lethargy which started several weeks prior. The patient has lived in the Southeast United States since immigrating from Guatemala 4 years ago. He works locally as a machine worker and endorsed unprotected sexual encounters with multiple male partners. He denied alcohol, tobacco, or illicit drug use.

Initial imaging showed a sub-acute basal ganglion and lentiform nuclei infarct. CT chest showed several 6-8mm nodules throughout the lungs. Initial tests were found to be positive for HIV (CD4 count 60) and EBV (IgG/IgM Positive). Lumbar puncture (LP) testing with rapid PCR was positive for CMV and no obvious source of stroke was found. The patient was started on ganciclovir and foscarnet due to immunocompromised status. The patient’s mental status failed to improve despite 7 days of treatment. Repeat LP was performed and Coccidiomycosis antigen test was added and found to be positive. Amphotericin B was added to the antimicrobial regimen. Additional IgG testing confirmed Coccidioidal Meningitis. The treatment course was complicated with MSSA bacteremia and complicated UTI which were both treated appropriately. 5 weeks after admission, patient was started on anti-retroviral therapy. Ultimately the patient was discharged with follow-ups with physical therapy, a local HIV clinic, neurology, and primary care physicians.

IMPACT/DISCUSSION: Coccidioidal Meningitis is a rare and fatal form of disseminated Coccidioidomycosis. Onset of symptoms is often subacute or even chronic after initial pulmonary manifestation. Persistent and/or worsening headaches, nausea, vomiting, and changes in mental status are common symptoms. Ischemic or hemorrhagic stroke due to vasculitis caused by the Coccidioidal Meningitis is a rare but documented complication. On CSF examinations, glucose can be profoundly low and protein is elevated. Coccidioides can be seen rarely on microscopic examination and culture is only positive in minority of cases. History is key due to endemic regionality of both C. Immitus (Southwestern United States) and C. Posadasii (Central and South America). EIA and IgG/IgM testing does not distinquish between the two strains. Clinically, symptomatology and treatment are the same. However, recent studies using PCR testing can differentiate the two strains and have suggested C. Posadasii may have a larger endemic region then currently taught.

CONCLUSION: 1. Coccidioidal Meningitis is a rare and fatal form of disseminated coccidioidomycosis.

2. Stroke scan be the initial presentation of Coccidioidal Meningitis due to vasculitis.

3. Importance of understanding endemic regionality of both C. Immitus and C. Posadasii

ATYPICAL DIFFUSE B CELL LYMPHOMA WITHOUT LYMPH NODE INVOLVEMENT PRESENTING AS HEMOLYTIC ANEMIA

Vikas Kilaru¹; Moyan Sun²; Abijha Boban¹; Steven Barker². ¹Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; ²Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #4064879)

CASE: A 44-year-old man with a history of hypertension presented to ED with progressive abdominal pain and unintentional 40lb weight loss. Vital signs were stable, and physical examination noted diffuse abdominal tenderness to palpation. Computed Tomography (CT) of the abdomen and pelvis identified a constellation of abnormalities, including lytic lesions of thoracic and lumbar spine, lung infiltrates, and heterogeneous signal intensities in both kidneys. Laboratory evaluation revealed hemoglobin 9.2 g/dL, Alkaline Phosphatase 235 U/L, and total bilirubin 1.8 mg/dL. 48 hours later, hemoglobin decreased to 4.9 g/dL without obvious bleeding, along with lactate dehydrogenase 686 U/L, haptoglobin 10 mg/dL, and positive direct antiglobulin IgG consistent with autoimmune hemolytic anemia. He received 2 units packed red blood cells and prednisone to control his acute hemolytic process. CT-guided biopsy of the previously identified lumbar lesion revealed a highly aggressive B-cell lymphoma, stage IV. Unfortunately, he suddenly developed large-volume hematemesis requiring intubation despite improvement in abdominal pain over the hospital course. Esophagogastroduodenoscopy revealed multiple bleeding ulcers, which were biopsied, and molecular testing showed BCL-6 rearrangement, confirming the diagnosis of diffuse large B cell lymphoma (DLBCL). Due to his multiple complications, he was initiated on chemotherapy in the hospital with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), which he tolerated reasonably. He was finally discharged and underwent 6 total rounds of R-CHOP in the outpatient setting, with surveillance positron emission tomography (PET) showing good response to the therapy.

IMPACT/DISCUSSION: Primary extranodal DLBCL with multiorgan involvement, presenting with acute hemolytic anemia, represents an exceedingly rare and challenging clinical scenario. While DLBCL is the most common type of non-Hodgkin lymphoma, it rarely presents with multiorgan involvement at the time of diagnosis without lymph node involvement. Although 40% of patients with DLBCL present with extranodal involvement, simultaneous disease of the GI tract and bone has been limited only to case reports. Recognition of hemolysis as a paraneoplastic feature led to timely diagnosis and prevented further complications. Additionally, the rapidly evolving clinical picture required prompt management of the complications arising from the underlying malignancy.

CONCLUSION: Despite the lack of nodal involvement, the presentation of hemolytic anemia and weight loss should prompt hematologic malignancy to be included in the differential. If complications are life-threatening, a multidisciplinary approach to treatment should be pursued.

A YOUNG HEALTHY FEMALE PRESENTING WITH ISCHEMIC STROKE

Hala Baaj¹; Malik Shehadeh²; Rafle Fernandez²; Christos Mihos². ¹HWCOM, Florida International University Herbert Wertheim College of Medicine, Miami, FL; ²Mount Sinai Heart Institute, Miami Beach, FL. (Control ID #4064010)

CASE: A previously healthy 20-year-old female presented to our hospital with an abrupt onset of left-sided hemiplegia. There were no prior medical issues or significant family history mentioned.

Brain magnetic resonance imaging showed an acute infarction within the right middle cerebral artery territory. No significant stenosis noted in the neck vasculature. Thrombolysis and thrombectomy were deferred due to the time of presentation and size of the infarct. Blood workup including blood cultures for infective endocarditis, Factor V Leiden, protein C, S deficiency, and anti-thrombin III deficiency were all negative.

Initial transthoracic echocardiogram (TTE) showed no evidence of patent foramen ovale or intracardiac thrombus. However, subtle mitral valve changes were noted, prompting a subsequent transesophageal echocardiogram (TEE). The two dimensional-TEE identified Libman-Sacks vegetations on the atrial side of both mitral valve leaflets. Transitioning to three dimensional-TEE further revealed additional vegetations, confirming the diagnosis of Libman-Sacks endocarditis.

Serologic testing revealed positive anti-cardiolipin antibodies, beta-2-glycoprotein and lupus anticoagulant antibodies supporting the diagnosis of antiphospholipid syndrome. Patient was started on warfarin after neurology clearance, and continued to follow up with our clinic. Repeat testing for antiphospholipid antibodies after 12 weeks was persistently positive.

IMPACT/DISCUSSION: Libman-Sacks endocarditis manifests in patients with malignancy, systemic lupus erythematosus, or antiphospholipid syndrome. It is seen in approximately 30-40% of patients with anti-phospholipid syndrome and involves the presence of sterile vegetations on the cardiac valves, mainly the mitral valve. Dislodgement of these vegetations is commonly associated with embolic cerebrovascular events.

Antiphospholipid syndrome is a well-established cause of ischemic stroke, particularly in younger patients, and represents up to 20% of stroke events in patients under 45 years of age. Most antiphospholipid syndrome-related thrombosis requires lifelong anticoagulation.

The detection of Libman-Sacks vegetations might be challenging depending on their size, number and location. TEE has greater sensitivity and specificity than TTE in the detection of Libman-Sacks vegetations. Therefore, if TTE was unrevealing, proceeding with TEE merits consideration in those who are suitable candidates.

CONCLUSION: In young patients presenting with ischemic stroke, Libman-Sacks endocarditis must be considered. The use of two dimensional and three dimensional TEE allow for comprehensive assessment and localization of vegetations that might be missed by conventional imaging methods.

A YOUNG WOMAN PRESENTS WITH DIARRHEA, TACHYCARDIA AND HYPOXEMIA

Joseph Obiajulu¹; Ethan Loftspring²; Abhishek Bhattacharya²; Kathryn Havranek²; Anand Kornepati²; Candace Tong-Li¹; David J. DiTullio²; Nina Devas²; Alexandria Imperato²; Alexander Bain²; Roxana Sulica²; Rogelio Cruz². ¹Department of Medicine, New York University Grossman School of Medicine, New York, NY; ²Medicine, NYU Langone Health, New York, NY. (Control ID #4053756)

CASE: A 25 year-old woman with a congenital myopathy and ulcerative colitis (UC) presents with severe, watery diarrhea for 3 days, found to be tachycardic and hypoxic. After UC flare was ruled out, she was admitted to medicine for persistent tachycardia and hypoxia.

The present illness begins ten months prior to admission (PTA) when the patient presented to her PCP with chronic, progressive shortness of breath (SOB) and decreased exercise tolerance that she attributed to a SARS-CoV-2 infection months prior. At the time, all labs were within normal limits and a transthoracic echocardiogram (TTE) showed no pathologies. PTA she took mesalamine, calcitriol, and an oral contraceptive.

On admission, she was hemodynamically stable, tachycardic to 110 and hypoxic (SpO2 of 80s on room air). She denied palpitations, chest pain, cough, night sweats, congestion, PND, leg swelling, or SOB at rest. Original CBC, BMP, and LFT labs and ED imaging were unremarkable. An EKG showed sinus tachycardia with RV hypertrophy and her CT angiography was concerning for interstitial pulmonary edema or an inflammatory process.

Tachycardia was attributed to low volume from persistent diarrhea, and she was fluid resuscitated and given loperamide; her tachycardia persisted. She was given ceftriaxone and azithromycin for possible pneumonia.

All infectious, rheumatological, and hormonal work-ups to explain her hypoxia were negative, as was a V/Q scan. A TTE with bubble study, sent to assess for shunt, revealed signs of severe PH. The patient underwent right heart catheterization (RHC) which confirmed PAH (precapillary disease). Pulmonary function tests were notable for severe restrictive physiology with decreased maximum inspiratory pressure. She started furosemide and sildenafil with improvement of her tachycardia and hypoxia and was discharged with further outpatient testing.

IMPACT/DISCUSSION: This case shows the importance of including PH on the differential for dyspnea and hypoxia. There is an anchoring bias to attribute dyspnea and hypoxia in a young patient to an acute etiology, but young patients can exhibit these chronically. The PH diagnosis was critical for our management, moving us away from fluid repletion for diarrhea, to diuresis for PH.

This case also demonstrates when to suspect and how to diagnose PH. Our patient’s symptoms warranted a TTE (a low-cost, zero-radiation and non-invasive imaging) which can show findings consistent with PH. A true diagnosis, however, can only be made via RHC.

Finally, given this patient’s complicated medical history, she was a candidate for several PH WHO groups. A take-away from this case is how to differentiate between the various groups systematically.

CONCLUSION:

- Include PH on the differential diagnosis for hypoxia in young patients

- Use a TTE for initial assessment of PH, RHC for final diagnosis, and then systematically determine the WHO group

A “TOUGH DIAGNOSIS TO SWALLOW” – ANCA ASSOCIATED PERICARDITIS CAUSING DYSPHAGIA

Anna K. Shah¹; Jane Abernethy². ¹Department of Medicine, Johns Hopkins University, Baltimore, MD; ²General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4064988)

CASE: A 60-year-old woman with history of Barrett’s esophagus, hypertension, and depression presented to the hospital for one month of dysphagia, chest pain, weight loss and night sweats. The patient’s left-sided, sharp chest pain was relieved when sitting forward. She denied fever, rash, respiratory symptoms and joint pain. On exam, she was noted to be cachectic and uncomfortable. Her cardiac and abdominal exams were unremarkable. Laboratory work up revealed elevated ESR (78) and CRP (29) and proteinuria with normal renal function. She also developed new atrial fibrillation with rapid ventricular rate.

A dysphagia work up was pursued. Endoscopy showed only mild gastritis, while esophagram revealed extrinsic compression of the esophagus. CT chest was initially concerning for pericardial effusion, but echocardiogram and cardiac MRI better characterized this as a complex pericardial thickening consistent with acute pericarditis. She was treated with a three-month high dose aspirin taper and colchicine. Her dysphagia resolved within two weeks of pericarditis treatment. Following discharge, an echocardiogram was repeated which had no further signs of pericarditis. Immunologic workup after discharge was significant for positive C-ANCA and PR3, ANA 1:80, consistent with ANCA-associated vasculitis (AAV).

IMPACT/DISCUSSION: Pericarditis usually presents with sharp, positional chest pain and is attributed to viral or idiopathic causes in 80-90% of cases. 1, 2 Due to this, investigation into the cause is not recommended unless there are accompanying symptoms pointing towards a particular diagnosis, or there is evidence of recurrent pericarditis or pericarditis refractory to NSAID therapy.3 While pericarditis does not commonly cause dysphagia, moderate to severe pericardial thickening can cause extrinsic compression of the esophagus.4

Although typically thought of as a small vessel vasculitis, ANCA-associated vasculitis may rarely present with pericarditis or pleuritis as the first and only manifestation of disease; in one study, when present, they were a presenting feature in over 80% of cases.5 Overlooking an association between pericarditis and AAV may delay diagnosis and lead to further organ involvement of AAV. Early recognition of possible AAV with sooner initiation of treatment may improve morbidity. In patients like ours without other systemic signs of illness, close monitoring for recurrence of pericarditis, fever, weight loss, excess fatigue, renal dysfunction, and respiratory involvement is central to ongoing management.6

CONCLUSION: - Pericarditis can be an early manifestation of ANCA-associated vasculitis.

- Dysphagia can be caused by extrinsic compression of the esophagus from moderate to severe pericarditis.

- Autoimmune evaluation is not routinely part of the workup of pericarditis but can be considered in patients with other signs of systemic inflammation or recurrent/refractory pericarditis.

BACKHANDED COMPLIMENTS: FROM INSULT TO INJURY

Yue-Ting K. Lau¹; Mark E. Heslin²; David Li³. ¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Internal Medicine, University of Pennsylvania, Philadelphia, PA; ³Nephrology, University of California San Francisco, San Francisco, CA. (Control ID #4053810)

CASE: An 84 year old man presents with fever and subacute encephalopathy. His evaluation revealed a severe AKI and worsening hypertension. The following day, he developed isolated thrombocytopenia. Hemolysis labs and blood smear were negative. Repeat CBC revealed worsening thrombocytopenia and a new hemolytic anemia with abundant schistocytes. ADAMTS 13 activity and inhibitor were sent and emergent plasma exchange was started. Renal failure persisted and he required dialysis.

Plasma exchange was not efficacious and ADAMTS 13 activity level returned >10% with negative inhibitor levels. He was switched to empiric eculizumab therapy which resulted in complete recovery of his encephalopathy and cytopenias, confirming a diagnosis of complement mediated TMA/atypical HUS.

IMPACT/DISCUSSION: Thrombotic microangiopathy (TMA) should be suspected when there is MAHA with thrombocytopenia and evidence of vascular end-organ damage with a disproportionate propensity for the neurologic and renal vascular beds. Our patient’s TMA revealed itself initially as a subacute encephalopathy followed by rapidly progressive renal failure. The team maintained a high index of suspicion for a TMA and trended hemolysis labs. This eventually resulted in the discovery of a MAHA, which highlighted the following point: the absence of hemolysis and schistocytes on initial smear does not rule out a TMA.

The disproportionate presence of TMA-resultant renal injury typical of a-HUS may offer earlier clues as to the type of MAHA affecting the patient to guide preliminary steps, such as vaccination, for management. After TTP and shiga-toxin-HUS are ruled out, all patients should undergo complement testing, as this guides management with terminal comoplement blockade. Complement levels take time to come back and can be negative in 30% of cases, therefore the decision regarding terminal complement blockade can be made based on the pretest probability of a complement-mediated TMA and the severity of kidney injury.

The pathophysiology of a-HUS lies in constitutive complement activation resulting in endothelial damage and thrombosis; thus, renal injury from TMA is the dominant feature of this disease process. Conversely, TTP is driven by autoantibody against ADAMTS13 leading to dysregulation of von Willebrand factor multimer processing, leading to the more prominent development of hemolysis from disrupted microvascular flow and more severe thrombocytopenia, with renal injury from microvascular occlusion developing later and often to a lesser degree.

CONCLUSION: Trend the smear and UA, TMAs are subacute progressive diseases that can unfold in front of your eyes.

When approaching TMAs, take into consideration the proportional degree and earlier timing of AKI (more consistent with aHUS), the severity of thrombocytopenia, and the prominence of neurological symptoms (more consistent with TTP)

At first sign of TTP, check ADAMTS13 level for confirmation and discuss empiric plasmapheresis

A TMA with a normal ADAMSTS13 is suggestive of aHUS

BACK TO THE DRAWING BOARD TO RESOLVE A CAUSE FOR CONFUSION

Emma Osterhaus²; John Flickinger¹; Nicole Curtis¹; Anisha S. Das¹; Alvin Thalappillil¹; Kristian Feterik¹. ¹Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4063472)

CASE: 61-year-old man with past medical history of remote squamous cell carcinoma of the larynx, alcoholic cirrhosis, hepatic encephalopathy with nonadherence to treatment, esophageal varices and recurrent ascites status post transjugular intrahepatic portosystemic shunt, admited with unresponsiveness and bilateral upper extremity clonic movements for 24 hours. Vital signs on arrival were normal. There was leftward head deviation and gaze preference. All four extremities were in flexed posture. Due to suspected status epilepticus he received intravenous lorazepam and levetiracetam. Neuroimaging was negative and edlectroencephalogram without signs of epileptiform discharges. Serology revealed acute kidney injury and anion gap metabolic acidosis. Plasma ammonia level was 114 μMol/L. Neurology suggested a working diagnosis of focal seizures secondary to hyperammonemia. The patient received cefuroxime for acute bacterial cystitis as a potential cause for acute encephalopathy. Serum creatinine rapidly improved with intravenous fluids. He continued to have intermittent increased muscle tone while plasma ammonia levels peaked at 183 μMol/L. On the following day, thyroid stimulating hormone (TSH) returned as 121 μIU/mL. Triiodothyronine (T3) and free thyroxine (FT4) levels were low at 0.4 ng/mL and 0.35 ng/dL respectively. Levels of anti-thyroid peroxidase and anti-thyroglobulin were normal. After one week of intravenous levothyroxine, repeat ammonia level was 36 μMol/L, TSH 15 μIU/mL, T3 0.56 ng/mL, and FT4 0.89 ng/dL. The patient clinically improved. He was alert, interactive, and was able to increase ambulation distance to 15 feet with physical therapy.

IMPACT/DISCUSSION: Hyperammonemia can be a life-threatening condition. Clinical symptoms include irritability, lethargy, seizures, and tachypnea. Plasma ammonia levels rise with hepatocellular damage or enzymatic defects. Hyperammonemia in adults is most frequently due to cirrhosis. Other causes include hematological disorders, infections, unmasked urea cycle defects, medications, increased muscle catabolism, and hypothyroidism. Hypothyroidism causes decreased urea synthesis and glutamine synthase activity, which leads to reduced ammonia metabolism. Normal thyroid function is dependent on a functioning thyroid and liver axis. Liver and kidneys account for approximately 30-40% of T4 to T3 conversion by type 1 deiodinase enzyme. Furthermore, the liver is involved in synthesis of thyroid binding globulin, as well as thyroid hormone conjugation and excretion. Patients with chronic liver disease develop altered thyroid hormone metabolism resulting in euthyroid sick syndrome, hypothyroidism, hyperthyroidism, or thyroiditis.

CONCLUSION: Neurological disturbances in cirrhosis with concomitant hypothyroidism are refractory to hypoammonemic therapy and improve with thyroid hormone replacement. It is important to reduce bias and always create a broad differential as patients can have multifactorial etiologies for their chief complaint.

BACTERIAL BALL IN THE BLADDER: DIAGNOSIS AND MANAGEMENT OF A RARE CONDITION

Elizabeth Bernstein¹; Erin Tully¹; Shirley Wang²; William Jaffe²; Felicia R. D'Souza¹. ¹Department of Medicine, University of Pennsylvania, Philadelphia, PA; ²Department of Urology, University of Pennsylvania, Philadelphia, PA. (Control ID #4046057)

CASE: A 51-year-old female presented to the emergency department with two days of dysuria, hematuria, abdominal pain, and vomiting. Six weeks prior, the patient had been hospitalized and treated for Proteus mirabilis cystitis. A foley catheter was placed at that time and removed 18 days prior to this admission. On presentation, the patient was afebrile with vital signs within normal ranges. Her physical exam was notable for a soft, distended abdomen that was diffusely tender to palpation. Urine culture grew Proteus mirabilis and cefepime-resistant Klebsiella pneumoniae. Fungal and blood cultures were negative. CT showed a 9.5 x 7.8 cm mass surrounded by gas in the urinary bladder lumen. The upper urinary tract was normal. The patient received one dose of fluconazole 200mg in the emergency department. A foley catheter was placed and the patient was started on ertapenem 500mg q12H.

Cystourethroscopy revealed a smooth, white, mobile mass occupying most of the bladder lumen. Small strips of the mass were resected but its unbreakable nature prevented complete evacuation. An intraoperative urine sample was positive for vancomycin-resistant Enterococcus faecium and Enterococcus faecalis, so daptomycin 800mg q48H was added to the patient’s antibiotic regimen. Pathological analysis of the tissue pieces showed rare foci of reactive squamous mucosa in a background of non-viable squamous cells, bacterial colonies, and calcifications. No fungal organisms were identified.

Four days later the patient underwent cystotomy. Foul smelling, rubbery, off-white material was removed from the bladder in 4 large fragments. Tissue culture was positive for vancomycin-resistant Enterococcus faecalis, Proteus mirabilis and Actinotignum schaalii.

Post-operative course was complicated by low grade fevers and hematuria which resolved prior to discharge. The patient was discharged with a foley catheter and a right chest tunneled small bore catheter for home IV antibiotic infusion. Ertapenem 500mg q12H and daptomycin 800mg q48H were continued for 1 week post-discharge.

IMPACT/DISCUSSION: Urinary tract bacterial balls are rare. Lack of familiarity and experience with this condition likely leads to underdiagnosis and delays in treatment. Our initial differential in this case included fungal bezoars and emphysematous cystitis. Bacterial balls can present similarly to fungal balls which, while still a rare entity, have been more comprehensively described in the literature. Currently, it appears as though the treatment strategy used for fungal balls – combined surgical and systemic treatment – is also effective for bacterial balls; however, follow-up will be required to assess long-term outcomes.

CONCLUSION: Further characterization of urinary tract bacterial balls will help to identify key distinctions between this and similar diseases. Gas-containing bladder masses should be biopsied and cultured. Definitive treatment may require cystoscopy or more invasive surgical methods.

BACTERIAL PERICARDITIS IN AN IMMUNOCOMPROMISED PATIENT WITH NO CLEAR SOURCE OF INFECTION

Lauren Lewis¹; David Dobrzynski². ¹Internal Medicine, University of Rochester Medical Center, Rochester, NY; ²Infectious Disease, University of Rochester Medical Center, Rochester, NY. (Control ID #4064004)

CASE: A 37-year-old male with past medical history significant for recent diagnosis of autoimmune hepatitis presented to the hospital due to bacteremia on surveillance blood cultures and was found to have endocarditis with course complicated by bacterial pericarditis. Three weeks prior to presentation, patient was admitted for workup of painless jaundice and diagnosed with autoimmune hepatitis based on liver biopsy pathology, elevated antinuclear antibody and positive f-actin IgG antibody. He was discharged home on a steroid taper. Nine days after discharge, blood cultures were obtained due to leukocytosis higher than expected in the setting of steroid use. His cultures were positive for methicillin sensitive staph aureus (MSSA). The only identifiable risk factor for bacteremia was immunosuppression on steroids. On presentation, patient had symptoms of generalized weakness, night sweats and loss of appetite. Physical exam was significant for Osler nodes and soft systolic murmur. Given MSSA bacteremia, transthoracic echocardiogram (TTE) was obtained. TTE showed no significant valvular abnormalities but was significant for large circumferential pericardial effusion with evidence of impaired diastolic filling suggestive of cardiac tamponade. Low voltage was observed on ECG. Patient remained hemodynamically stable and received appropriate treatment with pericardiocentesis and IV cefazolin. Approximately 295cc of serosanguinous pericardial fluid was removed and cultures were positive for MSSA.

IMPACT/DISCUSSION: Although the incidence of bacterial pericarditis has declined with the use of broad spectrum antibiotics, it can lead to purulent pericarditis, which has a mortality rate of 40% in treated patients. These cases can be challenging to recognize as chest pain is often not a reported symptom. The most common causes of bacterial pericarditis include staphylococcus, streptococcus, haemophilus and mycobacterium tuberculosis. Infection usually stems from a direct source such as spread from intrathoracic, myocardial or subdiaphragmatic infection, hematogenous spread from a distant infection, trauma, thoracic surgery, or catheter drainage. Our patient had no clear source for bacteremia. It is possible that the skin breaks from numerous blood draws during prior hospitalization and recent liver biopsy site may have been areas prone to infection but there were no signs of superficial skin infection observed on exam. Therefore, this case illustrates the need to be vigilant for bacterial pericarditis in an immunocompromised patient.

CONCLUSION: Bacterial pericarditis is a rare phenomenon, but some populations, such as the immunocompromised and those with underlying diseases of the pericardium, appear to be more susceptible. It is important for physicians to recognize that immunocompromised patients with staphylococcus bacteremia are at higher risk for bacterial pericarditis. Additionally, clinicians should aim for an early assessment for the life-threatening complication of cardiac tamponade.

BAD TO THE MUSCLE: A CASE REPORT OF SKELETAL MUSCLE METASTASIS OF NON-SMALL CELL LUNG CANCER

Linda Youn¹; Amber Kuta²; Mirra Srinivasan²; Jacyln Barnard³; Serena Thomas². ¹Internal Medicine, St. Bernards Hospital, Jonesboro, AR; ²Internal Medicine Residency Program, St Bernard's Medical Center, Jonesboro, AR; ³Family Medicine, University of Arkansas for Medical Sciences, Joensboro, AR. (Control ID #4057619)

CASE: A 54-year-old male with extensive smoking history was found with right upper lung mass suggestive of non-small cell carcinoma. Biopsy followed by pathology positive for pancytokeratin and CK7 and negative for CD45, CK 20, TTF-1, and p40. Due to swelling in the right shoulder, a CT scan was done that confirmed the presence of a mass in the right deltoid muscle. Subsequently a biopsy revealed poorly differentiated carcinoma favoring non-small cell carcinoma, compatible with metastatic disease. Immunohistochemical staining showed strongly positive CK7. Next generation sequencing reported PD-L1 80% and K-RAS G12C pathogenic variant. Although he would have benefited from immunotherapy, the patient's poor performance status, poor overall condition, and poor prognosis precluded him from being able to undergo aggressive treatment. Medical oncology recommended palliative or hospice care.

IMPACT/DISCUSSION: Non-small cell lung cancer metastasis to skeletal muscle is a rare occurrence. Lung cancers are more likely to spread to the brain, bone, liver, and adrenals. Here we present a rare case of non-small cell lung cancer skeletal muscle metastasis.

Primary metastasis to muscle remains a rare phenomenon. Although the incidence of skeletal muscle metastasis remains unknown, an autopsy series suggests that incidence may be closer to 0.08%. Lung carcinoma seems to be the leading cause of skeletal muscle metastasis followed by kidney, pancreas thyroid, breast, ovary, prostate and bladder cancers. Despite rich vasculature, metastasis to muscle is an unusual occurrence. Contractility and muscle metabolism which leads to low pH, lactic acid build-up, and presence of oxygen radicals creating an environment not conducive to tumor growth may be an explanation for why this is an uncommon phenomenon.

Diagnostic workup with MRI, PET-CT, Ultrasound, FNA is warranted with resistant muscle pain in patients with lung cancer. Although CT and MRI can assist in diagnosis, evaluation should include core biopsy as clinical findings and imagining cannot differentiate sarcoma from metastatic malignancy.

The treatment for muscle metastasis is often palliative in the form of radiation therapy, chemotherapy, immunotherapy or surgical removal of the mass. As with our patient, the presence of skeletal muscle mass is considered an aggressive disease with poor survival, usually less than one year.

CONCLUSION: The most frequent presentation of skeletal muscle metastasis is muscular pain with or without swelling. Thus, muscular pain can have an underlying connection to malignancy and should not be ignored. Imaging modalities as discussed above as well as core biopsy should be included in the workup as it may affect staging and treatment modalities.

BALANOPOSTHITIS AND PREPUTIAL CAVITY ABSCESS IN A PATIENT WITH TYPE 2 DIABETES ON SODIUM-GLUCOSE COTRANSPORTER-2 INHIBITOR

Ishida Yuya¹; Takaaki Kobayashi²; Hiroki Matsushita¹; Miki Aikawa¹; Akihito Yoshida¹. ¹General Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan; ²Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #4053949)

CASE: An 83-year-old male, undergoing treatment with sodium-glucose cotransporter-2 inhibitor (SGLT2i) for type 2 diabetes mellitus (T2DM), presented to the emergency department with fever and altered mental status. Physical examination revealed phimosis, swelling of the glans penis, tenderness in the left costovertebral angle, and a bump on the shaft due to an artificial penile pearl. Blood glucose measured 800mg/dL, and urinalysis indicated pyuria. Computed tomography (CT) displayed a preputial cavity abscess of the penis, urinary retention, and bilateral hydronephrosis. The abscess didn’t involve the artificial pearl. The patient was admitted with a diagnosis of hyperglycemia-hyperosmotic syndrome due to a complicated urinary tract infection. Ceftriaxone and insulin were initiated. Immediate suprapubic cystostomy was performed due to difficulty in inserting a urethral catheter caused by the swelling of the glans penis. Incision and drainage were performed, and cultures from the abscess grew Candida albicans and Serratia marcescens susceptible to ceftriaxone. The patient's condition improved after repeated drainage, 35 days of ceftriaxone, and 29 days of fluconazole. The disease process was considered to begin with balanoposthitis due to phimosis and the use of SGLT2i, leading to a preputial cavity abscess and urinary retention.

IMPACT/DISCUSSION: Balanoposthitis, defined as inflammation of the glans and foreskin of the penis, has a prevalence of 12-20% in males overall, with a 2.3 times higher incidence in T2DM compared to non-diabetics. This incidence is particularly elevated in those taking SGLT2i, where prevalence is 2-5 times higher. Initial symptoms are minor, but if left untreated, it can lead to serious infections, including preputial cavity abscess. This abscess, a complication of severe balanoposthitis, accumulates between the glans foreskin and the distal portion of the penis. Candida albicans is the most common pathogenic organism in infectious balanoposthitis. A significantly higher percentage of patients with Candida balanoposthitis present with phimosis. Serratia marcescens is a common organism causing urinary tract infections. Although historically presumed to be at risk for clinically significant ampC expression, it is no longer considered to overexpress ampC based on both in vitro analysis and clinical reports. The IDSA recommends selecting antibiotic treatment solely based on susceptibility testing results.

CONCLUSION: Candida balanoposthitis may present with minimal initial symptoms, but if left untreated, it can progress to a preputial cavity abscess requiring surgical drainage. Diabetic patients, especially those with poor control or taking SGLT2i, should be educated about this risk and advised on genital hygiene.

BAL-DFA NEGATIVE PNEUMOCYSTIS JIROVECII PNEUMONIA

Yusuke Hirao¹; Joseph Lee¹; Eyrica Sumida²; Timothy Vossler^3,2; Alena Velasco-Hughes³. ¹Internal Medicine, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, HI; ²John A. Burns School of Medicine, University of Hawai'i at Manoa, Honolulu, HI; ³The Queen's Health Systems, Honolulu, HI. (Control ID #4063337)

CASE: A 67-year-old male with Stage II Breast cancer vs metastatic carcinoma of unknown primary and polymyalgia rheumatica who presented to ED from the oncology office with dyspnea on exertion and hypoxia.

One week prior to admission, the patient started experiencing worse than usual fatigue where he just wanted to sleep all the time. He endorsed dyspnea upon exertion, particularly noticeable when ambulating rapidly. Notably absent symptoms included chest pain, shortness of breath at rest, and orthopnea. He denied fevers, chills, cough, nausea, and diarrhea.

Breast cancer was initially diagnosed eight months prior with a left axillary lymph node biopsy revealing invasive ductal carcinoma. He received three cycles of adjuvant adriamycin, cyclophosphamide, and pegfilgrastim, with the last dose occurring 12 days before admission. He was also taking prednisone 10mg for his polymyalgia.

On admission, vitals were significant for oxygen saturation of 82% which improved to 98% on 2L of oxygen. He was afebrile and his respiratory rate was normal. Physical exam was unremarkable including a normal lung exam. Labs were significant for leukocytosis at 17.78x10^3/μL, with a neutrophil count of 15.03x10^3/μL and a lymphocyte count of 0.69x10^3/μL. Other significant labs included a lactate dehydrogenase (LDH) level of 576 IU/L and Fungitell at 140 pg/mL. Computed tomography angiography of the chest excluded pulmonary embolism but revealed diffuse ground glass opacities. The patient was unable to produce sputum due to the absence of a cough. Following a bronchoscopy with bronchoalveolar lavage (BAL), he was started on empiric intravenous Bactrim at 20mg/kg of the trimethoprim component and Prednisone at 40mg twice daily. Direct fluorescent antibody (DFA) testing for pneumocystis jirovecii pneumonia (PJP) returned negative, but subsequent polymerase chain reaction (PCR) was positive. Patient gradually improved clinically over 9 days and was eventually discharged on 1.5L of oxygen, oral antibiotics and a prednisone taper

IMPACT/DISCUSSION: PJP is a prevalent cause of pneumonia in individuals who are immunosuppressed. Patients that are at higher risk include those with underlying malignancy, immunosuppressive treatment, and administration of corticosteroids. The gold standard for diagnosis of PJP from BAL fluid is cytology, followed by DFA. However, the lower burden of P. jiroveciiin non-HIV-immunocompromised patients remains a challenge for diagnosis. In this group, the sensitivity of conventional microbiological tests for sputum specimens is approximately 38 to 53%. Staining methods have largely been supplanted by high sensitivity PCR targeting P. jirovecii-specific genes. Recent meta-analyses have reported an aggregated sensitivity of 98%, 99%, and 97%, alongside a combined specificity of 91%, 90%, and 94%, predominantly in BAL samples.

CONCLUSION: In non-HIV cases of PJP, the rate of false negative results in DFA testing increases

PCR retains superior testing characteristics over DFA in non HIV PJP

B-ALL PRESENTING WITH PANCREATIC INFILTRATION AND OBSTRUCTIVE JAUNDICE

Hanqing Shang¹; Jun Yang Jiang²; Elizabeth Eisenmenger²; Martha Mims². ¹Internal Medicine, Baylor College of Medicine, Houston, TX; ²Hematology/Oncology, Baylor College of Medicine, Houston, TX. (Control ID #4023747)

CASE: A 43-year-old man with alcohol use disorder presented with 3 weeks of fevers, right upper quadrant abdominal pain, and jaundice. Labs revealed WBC 29.4 K/μL (80% lymphocytes), Hgb 14 g/dL, Plt 112 K/mm3, total bilirubin 6.5 g/dL, direct bilirubin 5.3 g/dL, AST 65 units/L, ALT 132 units/L, ALP 268 units/L, and lipase 44 units/L. Acute hepatitis panel was negative. Initial US showed gallbladder wall thickening concerning for acute cholecystitis. MRCP showed a diffusely enlarged pancreas, causing encasement and narrowing of the common bile duct, and hepatomegaly with mild steatosis. The patient’s fevers and leukocytosis persisted despite empiric antibiotics. A repeat hemogram 3 days later showed WBC 32.8 K/μL (75% lymphocytes). Peripheral blood flow cytometry showed 50% B-lymphoblasts, and bone marrow biopsy exhibited 92% B-lymphoblasts. Fluorescence in situ hybridization detected a dominant IgH::CRLF2 clone consistent with a Philadelphia-like B-cell acute lymphoblastic leukemia (B-ALL). Due to concern for leukemic infiltration of the liver and pancreas, dexamethasone was started, with improvement of total bilirubin to 2.4 g/dL. Liver biopsy confirmed involvement by B-ALL. Induction chemotherapy with hyperCVAD and rituximab was initiated. Cerebrospinal fluid analysis also demonstrated B-ALL involvement. The patient developed acalculous cholecystitis due to leukemic infiltration and ultimately died from septic shock after 3 cycles of chemotherapy.

IMPACT/DISCUSSION: B-ALL may involve extramedullary sites, such as the liver, kidneys, nervous system, and testes, in 20% of cases. Pancreatic infiltration is a rare manifestation and may present as biliary obstruction, pancreatic mass, or acute pancreatitis. Radiographic findings can range from nodular lesions in the pancreas, diffuse pancreatic infiltration, or both. In this case, leukemic infiltration of the pancreas led to obstructive jaundice mimicking acute cholecystitis/cholangitis as the initial presentation of B-ALL. Nevertheless, persistent fevers and clonal lymphocytosis pointed to the diagnosis of an underlying hematologic malignancy. Liver dysfunction resulting from hepatic infiltration and pancreatic enlargement led to therapy-limiting hyperbilirubinemia. Therefore, glucocorticoids were initiated to reduce the hepatic/pancreatic leukemic burden, although dose reduction of hepatically metabolized chemotherapy agents was still required.

CONCLUSION: - Pancreatic infiltration is a rare manifestation of B-ALL, which may mimic other disease processes and present as biliary obstruction, pancreatic mass, or acute pancreatitis.

- Pancreaticobiliary involvement of B-ALL can lead to therapy-limiting hyperbilirubinemia, which may improve with the initiation of glucocorticoids to reduce leukemic disease burden.

BEHAVIORAL CHANGE IN A MIDDLE-AGED FEMALE LIVING WITH HIV

Francesca Garofalo¹; Michael Houghan¹; Linda Baier Manwell²; David A. Feldstein². ¹Department of Medicine, University of Wisconsin-Madison, Madison, WI; ²Department of Medicine, Division of General Internal Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4060612)

CASE: A 55yo female with a history of longstanding HIV/AIDS complicated by latent syphilis, HIV enteropathy, inconsistent adherence to antiretroviral therapy (HAART), and housing insecurity presented to the hospital with altered mental status. She presented after removal from a relative’s home. She denied fevers, chills, and neurologic symptoms. On exam she was afebrile, tachycardic, cachectic, and without focal deficits. Mental status exam was notable for disorganized and easily derailed thought process, speech content with confabulation versus delusion, and quick to anger. CD4 count was 84. A comprehensive metabolic panel, urine drug spectroscopy, and blood cultures were unrevealing. Lumbar puncture and infectious workup were negative. Head CT and MRI/MRA revealed remote ischemic insult in the right MCA territory. Psychiatry determined that her presentation was not consistent with a primary thought disorder. Patient’s friends reported cognitive decline over the past year. As all infectious and acute neurologic conditions had been ruled out, Neurology and Infectious Disease arrived at a tentative diagnosis of HAND. Patient was continued on prior antiretroviral therapy and discharged to a shelter. Two days later, she was readmitted with altered mental status. EEG, vitamin levels, Lyme titers, serum autoimmune and neoplastic markers were unrevealing. Health care power of attorney was activated. Social Work, the patient’s outpatient Infectious Disease provider, and her family were critical in developing a safe discharge plan to live with a relative.

IMPACT/DISCUSSION: HAND is a neuropsychiatric complication of HIV and prevalence may be as high as 45%. Its development is associated with nadir CD4 count and lower current CD4 count, as in the case of our patient. HAND is a diagnosis of exclusion. Neuropsychological testing finalizes the diagnosis. Patients primarily have concentration and memory challenges, but may progress to poor executive function, apathy, irritable mood, and restlessness.

Interdisciplinary team care (e.g., Ryan White model) has improved outcomes for patients with HIV. This model is crucial for HAND patients; they not only need to adhere to HAART, but also cope with the sequelae of cognitive impairment. The team should include primary care, infectious disease, neurology, psychiatry, pharmacy, neuropsychology, and social work. Goals are to reduce diagnosis barriers, engage caregivers, and encourage HAART adherence. In this case, an interdisciplinary team may have been able to recognize HAND symptoms earlier. Our care team was able to diagnose the patient and develop a safe plan for discharge.

CONCLUSION: - HAND is common among people living with HIV and characterized by functional impairment and cognitive difficulties.

- The complexities of caring for these patients require an interdisciplinary team to ensure diagnosis, treatment and follow up.

BELLY DANCER’S DYSKINESIA: A NOVEL PRESENTATION OF ABDOMINAL SEGMENTAL MYOCLONUS

Christopher Hill¹; Kimberly L. Yan¹; Molly A. Kantor². ¹School of Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4057067)

CASE: A 70-year-old woman with hypereosinophilic syndrome (HES) complicated by recurrent organizing pneumonia (OP) was admitted to a hospital medicine service with four weeks of involuntary spasms of her abdominal wall muscles and hypoxemia. She reported having similar episodes during past OP flares which resolved quickly with prednisone.

Notable admission vitals included a heart rate of 112 bpm and oxygen saturation of 82% on room air that normalized with 2-3 L of supplemental oxygen. On exam, the patient had episodic abdominal spasms lasting from twenty minutes up to several hours. The movements localized to the abdominal wall and were characterized by rapid, repetitive, and involuntary contractile spasms. The movements occurred only in the abdomen and did not radiate. During episodes, patient developed increased work of breathing and desaturations requiring 4-6 L of supplemental oxygen.

Neurology and pulmonary were consulted. MRI brain and spine did not reveal suspicious structural lesions. CT chest showed ground-glass consolidation and septal thickening consistent with an OP flare, for which she was started on prednisone 60mg daily. With unrevealing work up and further literature review, she was diagnosed with presumed abdominal segmental myoclonus (ASM), also known as “Belly dancer’s dyskinesia”.

Given the severity of her symptoms, she was started on baclofen and flexeril, which were ineffective and discontinued. Clonazepam 0.25mg twice daily was started and significantly reduced the frequency and severity of abdominal spasms. Clonazepam was subsequently increased to 0.5mg twice daily. Over a nine-day hospitalization, the patient’s abdominal spasms decreased substantially, and her hypoxia gradually resolved.

IMPACT/DISCUSSION: ASM is a very rare disorder largely described in case reports and characterized by focal dyskinesia of abdominal wall musculature causing writhing movements. ASM should be included in the clinical differential for abdominal spasms and is associated with various etiologies including central and peripheral neurologic lesions of structural, autoimmune, osmotic demyelinating, and drug-induced origins.

Although similar presentations of ASM have been observed in patients with upper respiratory infections including SARS-COV2, this is the first report of ASM in a patient with HES and recurrent OP. Acute hypoxia is an additional, uncommon complication.

This patient’s ASM preceded symptoms of an OP flare. Her hypoxemic respiratory failure was likely due to both the underlying OP flare and impaired chest wall mechanics due to ASM, as her hypoxia was observed to worsen during episodes of ASM.

The patient’s symptoms of ASM improved substantially with both treatment of underlying OP flare and low-dose clonazepam.

CONCLUSION: Internists frequently care for patients with interstitial lung disease, and this is the first known case of ASM as a presenting complaint for an OP flare. Additionally, this adds support for the use of clonazepam for symptomatic control in these patients.

BEYOND THE ABDOMEN: UNVEILING MOLLARET'S MENINGITIS WITH AN ATYPICAL ONSET.

Pranav Chalasani, Ahmad Refai, Wadid Sirry, Vamsi Krishna Lavu, Vesna Tegeltija. Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4062753)

CASE: A 45-year-old male with past medical history of marijuana use, chronic lower back pain, gastritis and multiple episodes of viral meningitis (at ages 4 months, 20yrs and 39yrs) presented for work-up of persistent nausea, vomiting and abdominal pain. CT abdomen/pelvis with contrast was done at that time which showed no evidence of diverticulitis/colitis, bowel obstruction or free fluid. The patient underwent esophagogastroduodenoscopy (EGD) which showed erosive esophagitis, gastritis and erythematous duodenopathy. After the procedure,rapid responses were called for severe headache, severe agitation, and delirium. A full neurological exam could not be completed to assess for neck stiffness due to severe agitation. However, the patient was afebrile and the only pertinent finding was white blood cell count of 15.1thous/mcL. Infectious etiologies were ruled out through laboratory workup and clinical findings. Imaging studies including CT head without contrast, CTA head/neck, and MRI brain revealed no acute intracranial process or evidence of infectious/inflammatory pathology. A decision was made to intubate and sedate the patient due to severe refractory agitation and for airway protection. Given his previous history, the patient was treated empirically for meningitis with Decadron, Rocephin, Vancomycin and Acyclovir. On Lumbar puncture (LP) and CSF analysis: white blood cells 18 /cumm, Lymphocyte 88%, Glucose 41 mg/dl, Protein 131.6 mg/dl, positive serology for herpes simplex virus type 2 (HSV-2). Antibiotics were discontinued but IV Acyclovir continued. He was extubated two days later,altered mentation resolved and the patient was cleared by infectious disease to be discharged home on oral Valacyclovir for 14 days.

IMPACT/DISCUSSION: Mollaret's meningitis, usually caused by HSV-2 infection, is characterized by recurrent episodes of meningismus, typically resolving on its own within a week and are followed by symptom-free intervals. Symptoms present abruptly with signs of meningismus such as neck stiffness and pain, headache, nausea, vomiting, photophobia, myalgias, and fevers. The initial presentation of gastrointestinal symptoms and the onset of severe headache, agitation, and delirium after EGD made it challenging to recognize underlying neurological involvement. Clinical improvement after initiating treatment can be an indication for chronic suppressive therapy as it could lead to an avoidance of hospitalization, unnecessary diagnostic tests and therefore a reduction of costs and morbidity associated with many aseptic recurrent meningitis. But studies done showed suppressive treatment was not shown to prohibit recurrent meningitis and cannot be recommended for this purpose after HSV meningitis in general.

CONCLUSION: Mollaret's meningitis has an excellent prognosis without lasting neurological issues. A prompt lumbar puncture and CSF analysis aid in diagnosis. Patients may be managed with supportive care, avoiding immediate antiviral therapy.

BEYOND THE SURFACE: A COMPREHENSIVE LOOK AT AIDS-RELATED VISCERAL KAPOSI SARCOMA

Isabella Narvaez, Erika Hancock, Luis Barrientos, Reem M. Hanna. Department of Medicine, University of Colorado, Denver, CO. (Control ID #4064872)

CASE: A 49 year-old Hispanic male with a history of Tourette’s Syndrome, IVDU, and recent HIV diagnosis presented with worsening dyspnea, dry cough, and chest pain directly from a local airport. Two months prior to presentation, he was living in a rural area and working as a chef when he was hospitalized for suspected PJP pneumonia and diagnosed with HIV (CD4 20). ART was not initiated given concern for IRIS and bronchoscopy was unable to be performed due to lack of trained providers in the area. He was discharged with a two-month course of TMP/SMX and prednisone, yet re-presented to the hospital twice with persistent respiratory symptoms. Given an increasing concern for underlying pathology, transfer to a higher level of care was recommended. The patient was on route to his home state to establish care when he developed respiratory distress on the plane.

Vitals at admission showed tachycardia, tachypnea, and hypoxia. Physical exam was pertinent for cachexia, cervical LAD, wheezing in the left upper lung field, and coughing throughout the exam.

Labs showed CD4 of 18 and Hgb of 9.9. CT chest noted advanced bilateral multifocal pulmonary process inconsistent with PJP. Bronchoscopy revealed a spindle cell neoplasm with positive HHV8 stain and negative CMV stain, consistent with pulmonary Kaposi Sarcoma (KS). Patient was initiated on doxorubicin and HAART, and follow-up was scheduled.

IMPACT/DISCUSSION: Pulmonary KS is a rare and uncommon form of initial presentation for the disease. Given symptoms of KS can present similar to PNA, persistent symptoms, unresponsiveness to PNA treatment, and imaging inconsistent with infectious processes in immunocompromised patients should prompt evaluation for pulmonary KS.

HIV is a life-altering and stigmatized diagnosis. We can improve patient outcomes and diminish societal stigma by practicing comprehensive care. This includes addressing emotional and psychosocial barriers such as fear of disclosure, increasing access to care in rural areas, and practicing patient-centered communication and social support to encourage ART initiation, which is the only proven therapy to prevent KS.

In addition, racial disparities affect health outcomes for people with HIV. The incidence and mortality of KS is higher for non-white Americans compared to white counterparts. Higher incidence of HIV in marginalized populations and decreased access to quality care contributed to the progression of KS in our patient.

CONCLUSION: - Comprehensive HIV treatment includes acknowledging social determinants of health, fighting stigma, and addressing racial disparities in healthcare.

- It is important to consider a diagnosis of KS in patients with HIV who present with progressive respiratory symptoms. Increasing awareness of risk factors, clinical course, and treatment for KS can decrease complications.

- Increasing access to appropriate HIV care in rural areas can decrease the burden of disease and decrease time to diagnosis and treatment.

BREAKING THINGS DOWN: HEMOLYSIS IN THE SETTING OF ACUTE HEPATITIS B INFECTION

Price Rainwater, Katherine Quinn N. Hudson, Pranav Shah. College of Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4063427)

CASE: A 77-year-old male with no past medical history presented with painless jaundice. He presented with fatigue, decreased appetite, and dark urine for three weeks. He denied use of any medications, alcohol, and illicit substances or recent sexual partners. He had experienced homelessness but recently obtained transitional housing. Family history was noncontributory. On exam, scleral icterus and jaundice were noted. Vital signs were within normal limits. Notable laboratory data included hemoglobin 11.7 g/dl, total bilirubin 19.7 mg/dl, indirect bilirubin 6.3 mg/dl, direct bilirubin 13.4 mg/dl, alkaline phosphatase 227 U/L, AST 603 U/L, ALT 799 U/L, PT 14 seconds, INR 1.4, and aPTT 31.8 seconds. CT abdomen pelvis followed by MRCP ultimately revealed no evidence of biliary obstruction. HBsAg, IgM anti-HBc, and HBeAg returned positive, and HBV load was 11.5E6 IU/mL. Two days later, the patient described new weakness and pre-syncope. Labs revealed worsening anemia to 8.8 g/dl and increasing total bilirubin to a peak value of 39.4 mg/dl. Additional workup displayed elevated LDH, undetectable haptoglobin, reticulocyte count of 0.082 M/mm3 (3.6%), reticulocyte index of 0.92, negative Coombs test, and unremarkable peripheral smear. The patient was not started on anti-viral treatment. Over the hospital course, the patient had anemia to a nadir of 6.3 g/dl and in total required 10 units of packed red blood cells, each given for a hemoglobin value less than 7 g/dl. Three weeks after discharge, the patient demonstrated improving hemoglobin to 11.1 g/dl. At three months following discharge, hemoglobin was further improved to 13.3 g/dl, ALT, AST, and alkaline phosphatase continued to downtrend, HBV load was decreased to 21,500 IU/mL, and HBeAg was non-reactive.

IMPACT/DISCUSSION: HBV infections can lead to extrahepatic manifestations in as many as 20% of affected individuals. These sequelae include arthritis, vasculitides, nephritis, and hematological disorders. Non-immune hemolytic anemia is one such complication and should be suspected in patients with decreasing hemoglobin, low haptoglobin, elevated LDH, and increased indirect bilirubin. Patients typically present with anemia within one month of HBV diagnosis. Care for these patients is supportive as evidence for the use of antiviral agents in acute HBV is limited to patients with fulminant liver failure. With supportive measures, anemia typically resolves within 3 months of HBV diagnosis.

CONCLUSION: Non-immune hemolytic anemia is an uncommon complication of acute hepatitis B that should be suspected in patients with decreasing hemoglobin, low haptoglobin, high LDH, and increased indirect bilirubin. Treatment is largely supportive and conservative with frequent blood transfusions.

BREATHLESS INTRIGUE: UNMASKING A CASE OF ACUTE EOSINOPHILIC PNEUMONIA IN A TOBACCO USER

Madhuri Martin¹; Ricardo Cruz². ¹Internal Medicine, Boston Medical Center, Boston, MA; ²General Internal Medicine, Boston Medical Center, Boston , MA. (Control ID #4064173)

CASE: A 58 year old female with history of asthma, opioid use disorder, and tobacco use presented to the ED with acute onset of dyspnea described as waking up in the middle of the night “gasping for air”. She denied any preceding fevers, chills, chest pain or exposure to sick contacts. She reported smoking tobacco daily but denied any alcohol or substance use.

On presentation, she was afebrile but her RR was 30 and O2 saturation was 50% on room air. On exam she was tachypneic and lethargic. She had diffuse bibasilar crackles and 3+ bilateral lower extremity pitting edema. Her labs were unremarkable and VBG showed a pH of 7.30 CO2 of 51. Chest x-ray demonstrated interstitial and alveolar opacities and a bedside ultrasound showed B lines suggesting marked pulmonary edema. She was suspected to be in acute decompensated heart failure and was transferred to the ICU for aggressive diuresis. Despite this, there was no improvement in her subsequent x-rays or respiratory status. Her ECHO was without evidence of ventricular dysfunction. She was ultimately intubated and BAL revealed 48% eosinophils which was consistent with Acute Eosinophilic Pneumonia. She was started on high dose steroids and showed rapid improvement in her respiratory status.

IMPACT/DISCUSSION: Acute Eosinophilic Pneumonia (AEP) can be a fatal lung disease if not diagnosed promptly. In the initial phases, chest x-rays show bilateral reticular markings. These later evolve into patchy alveolar infiltrates resembling ARDS/cardiogenic pulmonary edema. In our patient, the absence of any objective signs of infection made heart failure a reasonable first diagnosis. Alternatively, dyspnea from heart failure is a relatively gradual- subacute process that was not seen in our patient.

Bronchoscopy is a reliable diagnostic tool for AEP. Peripheral eosinophilia may increase during the course of the disease but studies suggest that this may never be seen in patients with a smoking history. Bronchoscopy not only rules out infectious ARDS/alveolar hemorrhage but also demonstrates marked eosinophilia (>25%) versus neutrophilia in ARDS.

Studies on the cause of AEP are ongoing. Some research shows increased risk of AEP in new smokers or those with changes in smoking habits. Our patient had an active smoking history; understanding any recent increase in her daily use may help contextualize her presentation further.

CONCLUSION: AEP must remain on the differential for patients with acute respiratory failure with risk factors such as active tobacco use and poor response to initial treatment interventions. Prompt diagnosis can lead to an excellent prognosis despite need for mechanical ventilation. Bronchoscopy is a preferred diagnostic method and lack of peripheral eosinophilia does not exclude AEP.

B-SYMPTOMS AND BENIGN: KIKUCHI-FUJIMOTO DISEASE AS A GREAT MIMICKER IN A HISPANIC MALE

Cherry Au¹; Vida Ehyaee²; Irene Dehghan-Paz³. ¹Internal Medicine, Rush University Medical Center, Chicago, IL; ²Pathology, Rush University Medical Center, Chicago, IL; ³Hematology/Oncology, Rush University Medical Center, Chicago, IL. (Control ID #4045074)

CASE: A 25-year-old Hispanic man presented for fevers and lymphadenopathy. He was initially evaluated at Urgent Care with neck pain and took amoxicillin-clavulanate 875-125 mg twice daily for 7 days. He had continued lymphadenopathy, fatigue, daily fevers, night sweats, and weight loss, and presented for evaluation.

On arrival, his temperature was 100.7° F. Physical exam showed tender cervical right lymphadenopathy. Labs were notable for WBC 2.63, ANC 1.19, and platelets 117. Viral panel, mononucleosis spot test, strep, blood cultures, HIV test were negative. CT neck showed multiple enlarged right cervical lymph nodes with the largest being 2.0 cm.

He was admitted for further management. Additional labs showed lactate dehydrogenase (LDH) 416 U/L. Urine protein electrophoresis, antinuclear antibody (ANA) screen, peripheral smear, and flow cytometry were all normal. Due to a concern for lymphoma, multiple core needle biopsies of an enlarged cervical lymph node were obtained and revealed histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease (KFD).

He followed up with Rheumatology with low suspicion for rheumatological disease. His symptoms resolved and LDH normalized to 187 U/L two months after discharge.

IMPACT/DISCUSSION: KFD is a rare and self-limited disorder commonly observed in Asian females in their twenties. There are only 5 cases of KFD reported in Hispanic patients, only 2 of which were males in the current literature.

KFD typically presents with a constellation of B symptoms and shares clinical features with conditions like lymphoma, SLE, lymphadenitis, and tuberculosis. A lymph node biopsy is needed to confirm the diagnosis. KFD consists of proliferative, necrotizing, and xanthomatous histological phases. The proliferative phase involves immunoblasts with background apoptosis. Atypia of immunoblasts can occur, making accurate pathologic review essential. Immunohistochemical stains reveal CD68-positive, CD3, CD20-negative cells, distinguishing KFD from lymphoma.

The relationship between KFD and SLE is well-established. There have been cases of patients with KFD with negative ANA screening initially who eventually were diagnosed with SLE. In a large review of both diseases, SLE was diagnosed before (18%), simultaneously (51%), and after KFD (31%). Clinical and serologic follow-ups should be considered years from diagnosis.

Treatment of KFD consists of analgesics to alleviate pain and fever. In severe cases, glucocorticoids or intravenous immunoglobulin (IVIG) have demonstrated benefit. Overall, KFD has an excellent prognosis with most cases resolving within six months, overall mortality of 2.1%, and a low recurrence rate of 3%.

CONCLUSION: Diagnosis of KFD requires a lymph node biopsy and an accurate histopathological analysis to distinguish this disease from lymphoma.

Patients with KFD should be considered at high risk for developing SLE even after initial negative ANA screening.

The treatment for KFD is supportive, but glucocorticoids or IVIG can be used in severe cases.

B SYMPTOMS OR Q-FEVER? A RECURRENT FEVER CONUNDRUM

Shea Claflin, Yasmin Sacro. Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4059765)

CASE: Mr. A is a previously healthy 49 yo male with a history of tobacco use presenting for 6 months of recurrent fevers, night sweats, and weight loss. The fevers last for 10 days at a time before resolving and cycling again 1-2 weeks later. He lives in a rural mountain town and presents to a large academic center after initial attempts at management were unsuccessful. During his first hospitalization, extensive testing for infectious causes including viral, bacterial, fungal, and parasitic studies were negative, other than positive Q-Fever IgG Phase I and II titers. Imaging including CT head, CTPE, CTAP, MR abdomen, renal ultrasound, TTE, TEE, and EGD with biopsy were unremarkable other than hepatomegaly. Other rheumatologic and neoplastic workups were negative. He was treated for CAP and empiric treatment for tickborne illness then re-presented 2 weeks later, at which time his Phase I and II titers had increased. A presumptive diagnosis of chronic Q-fever was made, and he was discharged on doxycycline while awaiting the results of a liver biopsy. Ultimately his biopsy showed large B-cell lymphoma with a sinusoidal growth pattern highly suspicious for Intravascular Large B-Cell Lymphoma (IVLBCL).

IMPACT/DISCUSSION: Our patient’s presentation was consistent with classic B symptoms; however, the episodic nature of his fevers proved to be confounding and raised suspicion for an infectious process. This was reinforced by rising Q-fever titers that were not diagnostic, but allowed for a treatment plan until his liver biopsy returned the diagnosis of IVLBCL.

IVLBCL is a rare condition and is a challenging diagnosis to make because the majority of disease involvement occurs in extra-nodal tissues without mass formation, and typical lab findings are non-specific. Still, there are two prototypical presentations: a “classical” presentation with cutaneous and CNS involvement, and a “hemophagocytic associated” variant with hepatosplenomegaly and constitutional symptoms. When it is suspected, there has been reported value in performing random skin biopsies or utilizing FDG-PET/CT to identify involved tissue, though definitive diagnosis is made with biopsy. This case illustrates how it is imperative to maintain a broad differential while working up FUO, especially in the presence of a “red herring” such as the rising Q-Fever titers. Recognizing that less common malignancies such as IVLBCL can present in a myriad of ways is critical in reaching an accurate diagnosis.

CONCLUSION: Chronic Q-Fever is diagnosed with Phase I IgG titer ≥1:1024

IVLBCL is a “great mimicker” and can present with a wide range of symptoms

There are no specific labs diagnostic of IVLBCL, but there are suggestive lab abnormalities

IVLBCL diagnosis is made with biopsy of involved tissue, most commonly in extra-nodal sites

BURNING DILEMMA: A PATIENT WITH PERSISTENT TONGUE PAIN

Shreya Mathur¹; Nishant Uppal²; In Guk Kang³; Christopher Tessier^4,5; Rahul Ganatra^6,2. ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Brigham and Women's Hospital Department of Medicine, Boston, MA; ³Neurology, Boston Medical Center, Boston, MA; ⁴Endocrinology, VA Boston Health Care System West Roxbury Campus, West Roxbury, MA; ⁵Endocrinology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ⁶Internal Medicine, VA Boston Health Care System West Roxbury Campus, West Roxbury, MA. (Control ID #4060159)

CASE: A 74-year-old man presented to the emergency department with 2 months of burning tongue pain. He reported a sharp, burning sensation at the tip of his tongue while eating solid foods, leading to poor oral intake and a 15lb weight loss. During the past two months, he tried lidocaine mouthwash, nystatin mouthwash, Kenalog dental paste, and B12 supplementation without symptom improvement. He did not use tobacco products but reported occasional alcohol and marijuana use. Physical exam was notable for the absence of oral thrush or ulcerations, as well as the presence of a wide-based gait and decreased distal sensation to light touch, vibration, and proprioception to the level of the bilateral ankles. Strength and mental status exams were normal. Laboratory workup revealed a macrocytic anemia (hemoglobin 11.7 g/dL, mean corpuscular volume 100.3 fL) and potassium of 2.4 mEq/mL. Thyroid function was normal. Upon admission, an extensive laboratory and imaging workup was performed. Folate deficiency was diagnosed on hospital day 2 (2.32 ng/mL, normal range: >5.2 ng/mL), and thiamine deficiency was diagnosed on hospital day 6 (<6 nmol/L, normal range: 8-30 nmol/L). Further discussion with the patient’s family revealed daily alcohol use (approximately 16 drinks/day), chronic poor oral intake, and progressive confusion for several months at home. High-dose parenteral thiamine was initiated, which was followed by rapid and complete resolution of his burning tongue pain, peripheral neuropathy, and ataxia.

IMPACT/DISCUSSION: Burning Mouth Syndrome is a burning, scalding, or tingling sensation in the mouth that may occur as often as daily and persist for months to years, sometimes accompanied by dry mouth or altered taste. It may be idiopathic or occur due to underlying conditions including oral candidiasis, hypothyroidism, nutritional deficiencies, or psychiatric conditions. Our patient’s burning tongue pain and overall presentation were ultimately attributed to thiamine deficiency. His neuropathy was consistent with dry beriberi, and his gait ataxia was consistent with Wernicke’s encephalopathy.

CONCLUSION: - Burning Mouth Syndrome presents as an abnormal sensation in the mouth or tongue occurring for several weeks or more

- Burning Mouth Syndrome may be idiopathic or secondary to hypothyroidism, vitamin or mineral deficiencies, oral candidiasis, allergies to dental products, or psychiatric disease

- Thiamine deficiency should be considered in any patient with altered oral sensation and evidence of malnutrition or malabsorption, particularly when co-presenting with other neurological symptoms

BYSTANDER EFFECT IN MEDICINE: PYODERMA GANGRENOSUM DIAGNOSIS AND TREATMENT DELAYED BY LACK OF PHYSICIAN OWNERSHIP

Sharon I. Choe²; Austin Saugstad¹; Christine Firth¹. ¹Internal Medicine, Creighton University School of Medicine Phoenix Health Sciences Campus, Phoenix, AZ; ²Creighton University School of Medicine Phoenix Health Sciences Campus, Phoenix, AZ. (Control ID #4027213)

CASE: A 73-year-old female with a history of ulcerative colitis, atrial fibrillation, CKD, and CAD presented to the ED with a longstanding painful ulcer on her right leg. Over the course of a year, she was evaluated in two clinics and hospitalized for her wound. She received multiple partial diagnostic work-ups and limited follow-up. Her dressings had not been changed in several weeks. She denied fevers, chills, and night sweats. Examination revealed a deep, well-demarcated, severely tender black circumferential ulcer around her right ankle to the middle of her shin. The ulcer was infested with maggots and draining copious amounts of purulent, foul-smelling discharge. Her CRP and ESR were elevated at 194.3 mg/L and 52 mm/hr respectively. Her white blood cell count was 10.3 thousand/uL. X-ray was unrevealing.

She was started on vancomycin and ceftriaxone for concerns of superimposed infection. Three days later, the patient underwent a wound biopsy. Two days later, she was transitioned to doxycycline as recommended by infectious disease. One week after admission, biopsy results revealed acutely inflamed granulation tissue, and cultures showed no growth. Due to the lack of infectious parameters, she was subsequently started on prednisone for pyoderma gangrenosum (PG) and showed clinical improvement.

IMPACT/DISCUSSION: PG is a sterile, inflammatory skin disease that is typically treated with steroids or immunomodulators. Surgery, including debridement, can often exacerbate PG ulcers, which is one reason why it is important to accurately diagnose. Misdiagnosis is common, and delaying diagnosis can have serious clinical consequences including disfigurement and amputation.

In this report, we describe a case of PG on the lower extremity that was repeatedly treated as an infectious ulcer and continued to expand due to lack of ownership from multiple providers. This case illustrates the bystander effect in medical care, with physicians assuming passive roles rather than taking responsibility for patient care. Based on the history provided by the patient, it is likely that multiple providers had suspicion of PG but failed to perform a proper work-up, instead passing on the burden of responsibility to another provider. The initial treatments were ineffective, and the wound ultimately developed complications and resulted in recurrent admissions. Diagnostic errors and delays lead to increased medical costs, contributing to the burdens of physical, financial, and emotional distress.

CONCLUSION: PG should be considered in patients with non-healing ulcers with typical characteristics or if there are other suggestive features including lack of response to antibiotics, negative cultures, or predisposing inflammatory diseases. Physicians must take ownership of patients’ care by taking the necessary measures to accurately reach a diagnosis rather than being bystanders.

CANDIDEMIA AND BACTEREMIA AFTER PROSTATE BIOPSY IN AN IMMUNOCOMPETENT PATIENT - A CLINICAL VIGNETTE

Arham Siddiqui¹; Emily Sherry¹; Luci K. Leykum². ¹Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ²Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4063662)

CASE: A 59-year-old Caucasian male with a past medical history of hypertension, hyperlipidemia, and enlarged prostate presented to the ED one day after a prostate biopsy for chills, body aches, and hematuria. He has no recent surgical history, non-contributory family history, and social history negative for tobacco, alcohol, and recreational drug use. At home he takes lisinopril, atorvastatin, and tadalafil. Physical exam was normal. He took his pre and post-procedural cephalexin and ciprofloxacin. Patient had clinical deterioration with worsening rigors, chills, and fevers with blood cultures found to be positive for both E. coli and Candida tropicalis. He was HIV negative. Patient was started on IV fluconazole and IV ceftriaxone for two days and after clinical improvement, he was discharged on four weeks of oral fluconazole and oral Bactrim. Patient was found later to have prostate adenocarcinoma from the biopsy.

IMPACT/DISCUSSION: Diagnosis of prostate adenocarcinoma is done through prostate biopsy; however, this can lead to infection. Risk factors for post-biopsy infection include non-white race, immune status, prostate enlargement, and recent hospitalization. Although most commonly due to acute bacterial prostatitis, we present a case of acute prostatitis in an immunocompetent patient with enlarged prostate which was complicated by both candidemia and bacteremia.

To reduce the rate of infection after prostate biopsy, augmented and targeted prophylaxis has been recommended via the use of multiple antibiotics and using rectal swabs to identify resistance. Our patient was adherent to his antibiotics and was immunocompetent, but developed both a fungemia and a bacteremia. Although there is no literature to suggest fungal prophylaxis after prostate biopsy, our case emphasizes consideration of a multi-microbial differential in post-biopsy prostatitis. The signs and symptoms of fungemia and bacteremia are nonspecific, but the high mortality rate reported with candidemia necessitates awareness, even with low pretest probability (i.e. immunocompetency).

Although targeted prophylaxis is intended for bacterial prostatitis, rectal swab culture has also been shown to grow Candida and could be a useful tool to screen for fungal complications (i.e. mortality) in both low-risk and at-risk patient populations. (1)

(1) Carlos Gustavo Trujillo, Mauricio Plata, Juan Ignacio Caicedo, Juan Guillermo Cataño Cataño, Angela Marcela Mariño Alvarez, Diana Castelblanco, Daniela Robledo; Impact of Rectal Swabs on Infectious Complications after Transrectal Prostate Biopsy. Urol Int 11 October 2016; 97 (3): 340–346.

CONCLUSION: Fungemia in an immunocompetent patient is a rare and unusual presentation of post-prostate biopsy infection. The clinical manifestations of fungemia are non-specific but are associated with high mortality. Although targeted prophylaxis via rectal swab is intended for bacterial screening in at-risk patients, it may have benefit in reducing mortality in patients with fungal growth.

CARDIAC AMYLOIDOSIS, THE CHERRY ON TOP

Kaari Hultgren, David Signarovitz. Internal Medicine, Jefferson Health - Northeast, Philadelphia, PA. (Control ID #4065135)

CASE: 73-year-old male with a past medical history of Afib, HFpEF, hematuria, and hypothyroidism presented to the hospital with worsening shortness of breath and leg swelling. Patient has a family history significant for amyloidosis, however outpatient workup for amyloidosis was inconclusive (SPEP normal, urine electrophoresis consistent with glomerular pattern, and stress test negative for ischemia). While hospitalized the patient was treated with bumetanide and beta blockers with improvement of his respiratory status. Echo demonstrated left ventricular ejection fraction of 45%, biatrial enlargement, abnormal global longitudinal strain of 10.1% (regionally reduced in longitudinal and mid left ventricular segments but preserved in apical segments consistent with infiltrative cardiomyopathy) and grade II diastolic dysfunction. Transthyretin amyloidosis was confirmed with an abnormal pyrophosphate scan showing increased activity in his heart greater than bone. The patient was started on tafamidis for his specific form of amyloidosis and was discharged with significant improvement of his symptoms.

IMPACT/DISCUSSION: While heart failure is commonly treated in the hospital, it is important to identify the root cause of the heart failure to ensure adequate treatment. This patient responded well to basic heart failure medications and would not have received necessary management if further testing had not been conducted. This case should encourage clinicians to maintain a wide differential when diagnosing and treating common medical issues. This case gives the medical community an opportunity to learn the importance of diagnosing the underlying cause of heart failure.

CONCLUSION: While heart failure is a commonly treated disease, the root cause of the heart failure needs to be addressed for the patient to receive adequate treatment.

Amyloidosis can be present in patients with a normal SPEP and stress test and further testing should be pursued if there is a high level of suspicion for amyloidosis.

Identifying the specific type of amyloidosis is vital in identifying the specific treatment for these patients.

CARDIAC CATASTROPHE: A CASE OF EMBOLIC STROKE FROM ATRIAL MYXOMA

Kevin S. Tang²; Spencer Gibson¹. ¹Internal Medicine, University of California Irvine, Irvine, CA; ²Internal Medicine, UC Irvine Douglas Hospital, Orange, CA. (Control ID #4060674)

CASE: Ms. A was an 86-year-old female with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia who presented from an outside hospital for acute basilar artery occlusion seen on CTA obtained for a chief complaint of acute encephalopathy. On physical exam, she was found to be confused and disoriented. Neurologic exam was limited by confusion, but no gross motor deficits were observed. Cardiovascular exam was significant for a diastolic murmur in the mitral area. She was found to be in hyperosmolar hyperglycemic syndrome (HHS) with acute kidney injury (AKI) and was started on an insulin drip and intravenous fluids. Repeat imaging concluded that the basilar artery occlusion was most likely chronic atherosclerosis; further intervention by specialty services was deferred. Her HHS and AKI improved rapidly with treatment, however she remained persistently encephalopathic. Repeat brain MRI demonstrated new acute infarcts in the left frontal and parietal lobes. Further workup including echocardiography revealed a large left atrial myxoma with intermittent partial mitral valve obstruction. Cardiothoracic surgery was consulted; however, the patient was deemed to be a poor surgical candidate due to her age, comorbidities, and poor neurologic prognosis.

IMPACT/DISCUSSION: Atrial myxoma is the most common primary cardiac tumor but retains a low absolute incidence of 0.5 per million per year. Although classically presenting with a syndrome of fever, weight loss, cerebral or systemic embolization, and symptoms of mitral valve obstruction including dyspnea, presyncope, and dizziness, these features rarely present together. Constitutional symptoms appear in less than 60% of cases, and neurologic symptoms as in this case only in around one-third of cases. Neurologic complications are usually the result of cerebral infarction, however in rare cases may progress to cerebral aneurysm and metastatic lesions. Embolic potential is higher in mobile masses and is less related to tumor size. Echocardiography is the modality of choice for initial detection of cardiac myxoma, however cardiac magnetic resonance imaging is more efficacious in differentiating myxoma from other intracardiac tumors or thrombi. Definitive management is surgical resection; medical management with anticoagulation alone has been demonstrated to be ineffective in preventing recurrent embolic events.

CONCLUSION: Atrial myxoma is a rare but important etiology of acute encephalopathy and ischemic stroke. Special consideration should be given to ruling out cardio-embolic causes of cerebrovascular events and repeat advanced head imaging should be considered for patients in whom alternate causes of encephalopathy have been clinically excluded.

CARDIAC Y SYNDROME: AN ENIGMATIC AND UNDERRECOGNIZED ANGIOGRAPHIC ENTITY

Junaid Ebrahim¹; Fadila Noor². ¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4064110)

CASE: A 62-year-old male with history of hyperlipidemia, diabetes, atrial fibrillation,sick sinus syndrome, active smoking and cocaine abuse, was initially evaluated at a different hospital for abdominal pain with work up negative but the course was complicated by sudden onset chest pain. EKG showed sinus rhythm without ST segment changes but troponin was elevated to 400’s. The patient was transferred to our hospital for final evaluation of NSTEMI. Further history revealed last cocaine use a few days prior to his onset of symptoms.Vitals and physical exam were normal. He was treated with aspirin, statin, beta blocker, heparin.Troponin levels were up trending on admission, but the chest pain resolved following the commencement of core measures.Echo showed EF >52%,without other abnormalities. He was taken for cardiac catherization,given the character of chest pain and risk factors. Coronary Angiogram showed right dominance and no atherosclerotic disease but revealed slow filling/opacification of the left anterior descending artery consistent coronary slow flow (cardiac Y syndrome). Post procedure diltiazem was started with resolution of symptoms and the patient was discharged home.

IMPACT/DISCUSSION: Cardiac Y syndrome, or coronary slow flow phenomenon (CSFP), is an angiographic entity characterized by delayed distal vessel opacification in the absence of obstructive coronary artery disease. It is frequently underrecognized, with a reported incidence of 1 to 7%, and often seen in male smokers and metabolic syndrome. It is associated with recurrent chest pain, arrhythmia, and sudden cardiac death. Diagnosis is made angiographically with either TIMI-2 flow or a TIMI frame count >27 and delayed distal vessel opacification. The pathophysiology is poorly understood but may be related to endothelial dysfunction in the coronary microcirculation. Studies have found increased endothelin-1 and decreased nitric oxide levels in the plasma concentration, which have a role in regulating vascular tone. Anatomically, CSFP patients have higher tortuosity and more distal branches of coronary arteries, which may lead to disturbed laminar flow and endothelial damage. Cocaine may cause coronary stenosis and increase vascular resistance; therefore, chronic cocaine abuse will lead to endothelial dysfunction. CSFP impairs quality of life due to relapsing anginal episodes. Management involves addressing the conditions contributing to microvascular dysfunction, and previous studies have shown the benefits of using dipyridamole. Statins may also be beneficial, possibly given anti-inflammatory properties. A randomized study found that oral diltiazem alleviated angina and improved TIMI frame count,exercise tolerance, and coronary blood flow velocity.

CONCLUSION: CSFP is an angiographically observed finding. The mechanism is unclear, but substance abuse may potentiate the symptoms. Further studies are needed to recognize and understand this clinically entity, given its relapsing nature and impact on quality of life.

CASE REPORT: A SEVERE CASE OF REFRACTORY PSEUDOACHALASIA AND DYSMOTILITY SECONDARY TO METASTATIC NON-SMALL CELL LUNG CANCER

Farha N. Ebadi^2,1; Christelle Nzugang³. ¹On Lok SeniorHealth Inc, San Francisco, CA; ²Internal Medicine, Kent Hospital, West Warwick, RI; ³Beth Israel Lahey Health, Cambridge, MA. (Control ID #4016055)

CASE: 78 years old female with a past medical history of metastatic NSCLC (with progression on pembrolizumab) complicated by cardiac tamponade s/p pericardial window on 2/9/21, pembrolizumab-induced thyroiditis, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (on 3 L NC), diabetes mellitus type 2, who presented to the hospital with current odynophagia. Patient had similar symptoms one month prior, for which she was treated with fluconazole and discharged however symptoms continued to worsen. She had pain with swallowing of both liquids and solids; she was started on IV fluconazole and esophagogastroduodenoscopy (EGD) demonstrated impacted food in the lower third of the esophagus with associated esophagitis. This was passed using an endoscope. Symptoms did not improve and repeat EGD again revealed a food bolus in the lower third of the esophagus that was gently advanced in the stomach with the scope; there was also a benign-appearing intrinsic moderate stenosis in the lower third of the esophagus. This was injected with 100 units Botox status post TTS dilation with a 15–16 0.5-18 mm balloon performed to 18 Miller. Biopsy of the esophagus demonstrated benign squamous mucosa with focal scattered intraepithelial lymphocytes concerning for pseudoachalasia.

IMPACT/DISCUSSION: Our patient presented with clinical and radiological features of achalasia. The diagnosis was further supported by her history of metastatic NSCLC and the propensity of cancers infiltrating this region. Pseudoachalasia accounts for 2 to 4% of all cases with manometric criteria of incomplete/absent relaxation of the lower esophageal sphincter. In a small portion of patients, there is no evidence of neoplastic involvement of the gastroesophageal junction. This reframing was also seen in the present case, however esophageal biopsy did not show histological evidence of malignancy. Furthermore, paraneoplastic gastrointestinal dysmotility is of most commonly associated with small cell lung cancer, however our patient was diagnosed with non-small cell lung cancer. Recent data has shown that pseudoachalasia is known to have positive anti-neuronal antibodies. Further evaluation of this will be useful as they are also hypothesized to be involved in the pathophysiology of paraneoplastic gastroparesis.

CONCLUSION: Pseudoachalasia is a term that describes obstruction in the gastroesophageal junction most commonly caused by a tumor. It is caused by either an invasion of the esophageal neural plexus directly by the tumor or through the release of humeral factors that disrupt esophageal function as part of a paraneoplastic syndrome. The most common tumors that cause this include esophageal carcinoma, carcinoma of the lung, lymphoma, and pancreatic carcinoma.

CASE REPORT: HYDRALAZINE-INDUCED LUPUS WITH ATYPICAL MANIFESTATIONS

Vivien Vivien, David J. Fink. Internal Medicine, MedStar Washington Hospital Center, Washington, DC. (Control ID #4060861)

CASE: A 75M patient with history of HTN, DM, ESRD(refused dialysis in the past), heart failure with preserved ejection fraction (EF 55-60%, grade 1 diastolic dysfunction), MGUS, and anemia presented to the hospital with dyspnea for 3 days. Initial vitals: HR 81, BP 138/73, T 36.4, SpO2 96% on room air. On exam, he was warm and volume overloaded with absent breath sounds in lower lung fields (R>L). Labs: WBC 7.12, Hgb 7.1, platelet 275, Na 139, K 3.7, CO2 25, BUN 109, SCr 5.02 (baseline 3.8), LDH 392, albumin 3.3, BNP 332. Chest x-ray showed pulmonary edema, pleural effusions, and cardiomegaly. Home medications included Hydralazine, Aspirin, Labetalol, Metolazone, Nifedipine, and Insulin. Past history of multiple hospitalizations in the preceding 12 months for uncontrolled hypertension and decompensated heart failure, significant for pleural effusions (often R>L) which never fully resolved. Diuresis improved symptoms and volume status. Thoracentesis revealed exudate (pleural fluid: LDH 443, cholesterol 64, albumin 1.9, protein 4). Infectious and cytological workup was negative and effusions were attributed to heart failure. On day 2 post thoracentesis, effusions reaccumulated, and echocardiogram showed a moderate-sized pericardial effusion. Due to lack of improvement despite diuresis, low likelihood of grade 1 diastolic heart failure being the culprit and negative cytology, autoimmune work-up was done. It showed ESR 119, CRP 172, ANA 1:2560, Histone antibody 3.9 (IgG 2037), ANCA IFA titer >1:1280 with p-ANCA pattern and Anti-MPO 30. Negative results included anti-ds DNA, RF, anti-CCP, Smith/RNP, SSA, SSB, Sm & anti-GBM. SPEP and UPEP showed no distinctive M spike. This pattern of lab results was highly suggestive of Hydralazine-induced lupus. History revealed symptoms first started a few weeks after initiation of hydralazine one year preceding this hospitalization.

Hydralazine was discontinued indefinitely. Refusing dialysis and future care plans, he opted for a palliative approach and passed away soon thereafter.

IMPACT/DISCUSSION: Hydralazine has been firmly linked to drug-induced lupus (DIL). Pleural and pericardial effusions are recognized but uncommon presentations of DIL. Our patient's effusions were attributed to underlying heart failure for over a year before considering any alternate etiology, despite his TTE showing minimal diastolic heart failure and normal systolic function. Considering DIL when a more common alternate diagnosis is available is difficult, but it is crucial to consider uncommon causes when issues are not resolving with adequate treatment regimens and patients are on long-term medications with possible drug induced complications.

CONCLUSION: This case highlights the impact of bias in diagnostic reasoning, particularly by scrutinizing how anchoring on previously assumed diagnoses can impede the timely identification of uncommon or atypical presentations. Iatrogenic causes should be considered and an impartial diagnostic approach is recommended.

CASE SERIES OF AORTITIS PANCREATITIS AND THYROIDITIS LEADING TO ONE DIAGNOSIS

Bipneet Singh²; Aakanksha Kapila²; Palak Grover²; Gurleen Kaur²; Zarqa Yasin¹; Jahnavi Ethakota¹; Mandeep Malik¹; Merritt Bern¹. ¹Internal Medicine, Henry Ford Allegiance Health, Jackson, MI; ²Dayanand Medical College and Hospital, Ludhiana, Punjab, India. (Control ID #4045643)

CASE: Case 1 - 48-year-old male patient with a complaint of 4 days of abdominal pain with associated diarrhea.Patient was afebrile, hemodynamically stable and lab work including lipase and LFTs were unremarkable except creatinine 1.6 with GFR 54. CT abdomen pelvis showed findings suggestive of acute/subacute infarcts within the anterior mid left kidney and anterior right kidney. There were also patchy areas of ischemia in different regions of gastrointestinal tract. Non-specific fat stranding in the distal aortocaval region and extending into the proximal right iliac region suggestive of inflammatory process versus retroperitoneal fibrosis or inflammatory aortitis/arteritis.CTA showed severe stenosis with wall thickening of the right renal artery, left renal artery, distal abdominal aorta, SMA and IMA regions.Rheumatology evaluated the patient, upon work-up, IgG levels were elevated. Patient was started on oral steroids for possible IgG4 related vasculitis which led to drastic improvement in symptoms.

Case 2- 69 years old female patient with recently diagnosed thyroid disease presented with complains of acute epigastric pain over the last few hours. Acute abdominal series showed large mass-like opacity at left med/lower lung zone. CT abdomen and pelvis with IV contrast showed acute interstitial pancreatitis. IgG 4 levels were elevated, patient's pancreatitis likely secondary to autoimmune pancreatitis. Patient started on prednisone 40 mg once daily with improvement in 2 days after initiation. Plan was made to to continue for 4-6 weeks followed by taper. Further thyroid and lung biopsies demonstrated abundance of plasma cells and storiform fibroblasts which consolidated the diagnosis of IgG4 related autoimmune diease with multi system involvement.

IMPACT/DISCUSSION: Myriad of ways IgG4 disease can present and adequate diagnosis for early treatment to reduce morbidity. In patients with idiopathic pancreatitis and aortitis, IgG4 should be suspected so that early treatment can be intiated to avoid complications like renal/intestinal infarcts, retroperitoneal fibrosis which can involve ureters and cause hydronephrosis

CONCLUSION: Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition that is capable of affecting multiple organs. Common forms of presentation include pancreatitis, sclerosing cholangitis, sclerosing sialdenitis in lacrimal, parotid and submandibular glands (Mikulicz disease), orbital disease, retroperitoneal fibrosis chronic aortitis often involving ureters and causing hydronephrosis.Histopathology findings are important to the diagnosis of IgG4-RD, such findings are never diagnostic alone of IgG4-RD. Pathology findings must always be interpreted in the context of clinical, serologic, and radiologic data. Early recognisition is important given early initiation of steroid based treatment if it is missed in the setting of alternative diagnosis and hence the treatments in cases like acute pancreatitis and renal infarcts

CATASTROPHE EVADED

Mahmoud Elmahi¹; Muna Osman²; Mazin Saadaldin³; Tanzina Afroze⁴. ¹Internal medicine, Texas Tech University Health Science Center, school of medicine, Amarillo, AMARILLO, TX; ²Internal medicine, Texas Tech University System, Lubbock, TX; ³internal medicine, TTUHSC, Amarillo, Texas, Amarillo, TX; ⁴Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX. (Control ID #4064900)

CASE: 35 y/o lady with no significant past medical history, c/o nausea, vomiting, weakness and syncope. She was febrile. No significant findings on physical exam. Initial labs low hemoglobin of 9.2, elevated bilirubin 2.4, CT of the abdomen and pelvis suspicion for pelvic inflammatory disease. CT of the head was normal. Echocardiogram was normal. She had an elevated alpha-1 antitrypsin. On day 3 she became confused, lethargic and delirious. A repeat CT of the brain showed no abnormality, Her mental status continued to worsen, and she was moved to the intensive care unit. MRI of the brain reported acute brain infarcts. The patient was comatose was intubated. She was on 2 pressors. On exam, she developed significant livedo reticularis spreading all over her body, and all her fingers and toes were very dark in color and cold, she had significant anasarca. New lab reported hemoglobin 4. Blood samples were very dark and has a water-like consistency, and clots almost immediately after collection. Other lab results lactic acid 20, PT 21, INR 1.9, D-dimer>35, bicarbonate 5, creatinine 1.5 AST and ALT 1000s, ferritin level >2000. Arterial blood gases pH 7 and CO2 of 14. Initial assessment in the ICU was Septic shock. She was on antibiotics. She received blood transfusions. The patient had hemodialysis.She was given IVIG, after which she improved. Possible CAPS, rheumatologist consulted. Labs low C3 and C4. She was given anticoagulation, pulsed glucocorticoids and plasmapheresis. She responded very well. She was discharged home. Discharge diagnosis SLE/APLAS with positive SSA and hypocomplementemia with a presentation of CAPS. She was discharged Prednisone and Coumadin.

IMPACT/DISCUSSION: Catastrophic antiphospholipid syndrome (CAPS) is a rare life-threatening variant of APS. CAPS accounts for less than 1% of APS cases, however mortality ranges from 37% to 50%. CAPS is characterized by the involvement of at least three organs within one week. It can be renal, cerebral, pulmonary, cardiac, hepatic, adrenal involvement, or peripheral gangrene. CAPS could be precipitated by infections, surgical interventions, drugs, or anticoagulation withdrawal.

Almost 50% of CAPS cases did not test positive for antiphospholipid antibodies (aPL) before, which makes CAPS their initial presentations. Due to the fatality and high morbidity and mortality associated with CAPS, if a clinical suspicion for a diagnosis of CAPS is present, early treatment is key, even in the absence of confirmatory (aPL) positivity.

CONCLUSION: CAPS is a life-threatening condition and early diagnosis is key to avoid mortality and morbidity. The absence of histories, positive diagnostic laboratory studies etc. doesn’t exclude the diagnosis of CAPS. There’s a thin line separating underdiagnosis and overdiagnosis, however that shouldn’t deter clinical judgment when faced with a challenging clinical presentation. Urgent critical care and rheumatological consultation should be considered when there’s clinical suspicion for CAPS

CAT GOT YOUR TONGUE?: AN UNUSUAL CAUSE OF ACUTE ONSET APHASIA

Sneha Rajendran¹; Lindsay Voltz²; Anna K. Donovan³. ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Neurology, UPMC, Pittsburgh, PA; ³Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4055346)

CASE: A 69-year-old man with a history of hypertension, hyperlipidemia, diabetes mellitus, and nephrolithiasis presented to the emergency room with dizziness and speech difficulties. He was in his usual state of health until 3 hours prior to presentation when he developed acute dizziness while showering. His wife then noticed that he had slurred speech prompting her to call EMS. En route to the hospital, the patient had flailing movements of all four extremities with disorientation. He had no incontinence or tongue biting. The patient’s wife reported that this episode was similar to the altered mentation he had during a recent hospitalization two weeks prior.

He had presented then with urinary incontinence and was found to have new left hydroureteronephrosis, radiographic evidence of pyelonephritis, and enterococcus faecalis bacteremia, for which he completed treatment. His hospital course was complicated by an episode of fevers, altered mentation, and rigors after urinary catheter removal. Workup was unrevealing and symptoms resolved spontaneously.

On physical exam, he had normal vital signs and was alert and oriented. Exam was notable for mixed aphasia, significant paraphasic errors, and inability to repeat words. He also had right visual field loss and mild right facial droop. Remainder of neurological exam was normal. Labs revealed a lactate of 4.1 mg/dL and CT imaging was unremarkable. The ED physician called a stroke code resulting in administration of Tenecteplase. A subsequent contrast-enhanced MRI brain revealed a large left occipital developmental venous anomaly with focal venous dilatation/varix. EEG showed left sided slowing. Levetiracetam was initiated and neurosurgery was consulted for management. They recommended outpatient diagnostic angiogram and follow-up to consider surgical resection or embolization.

IMPACT/DISCUSSION: This patient presented with acute onset aphasia, right sided facial droop, and right visual field cut. He was initially diagnosed with stroke based on clinical history and physical exam with NIH stroke scale 5, resulting in administration of thrombolytic medication. On MRI, the patient was found to have a venous malformation thought to be causing seizures, which explain his two prior witnessed episodes of altered mentation as well as the elevated lactate seen on admission. EEG obtained showed left sided slowing, which is consistent with the deficits that he experienced. This case highlights the importance of maintaining a broad differential diagnosis to avoid anchoring on classic presentations of common illnesses.

CONCLUSION: When a patient presents with an acute onset focal neurological deficit, seizure should be included in the differential diagnosis.

CEFAZOLIN INDUCED ACUTE INTERSTITIAL NEPHRITIS: A CASE REPORT

Sabbena Uppal, Anderson Ariaga, Mayura R. Kesara, Hector Ojeda-Martinez. Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4063242)

CASE: The patient is a 32-year-old female with a past medical history of polysubstance drug use disorder who presented to the emergency department with complaints of lower back pain, weakness, fatigue, pleuritic chest pain, and abdominal pain. On presentation, she was febrile, hypotensive, tachychardic and tachypneic. Her labs showed leukocytosis, anemia, and thrombocytopenia. Her creatinine at that time was 0.71mg/dL. CTA chest/abdomen/pelvis revealed scattered peripheral wedge-shaped lesions and cavitations consistent with hemorrhagic pulmonary infarcts. Patient was admitted to the ICU for sepsis secondary to acute infective endocarditis and was started on broad spectrum IV antibiotics. An echocardiogram revealed severe tricuspid regurgitation with tricuspid valvular vegetation. Blood cultures grew beta-lactam susceptible Staphylococcus Aureus, and IV vancomycin and ceftriaxone was switched to IV cefazolin. Due to persistent fevers, the Cefazolin dose was increased and IV ertapenem was added as the patient remained bacteremic. Repeat CT chest/abdomen/pelvis showed bilateral septic pulmonary emboli with enlarging cavitary lesions. The patient eventually underwent tricuspid valve repair and extraction of vegetations. Pathology report revealed findings consistent with infectious endocarditis. She continued on IV cefazolin and ertapenem following the procedure, given persistent MSSA bacteremia.

During hospital course, patient developed acute renal failure. Her creatinine increased from 0.85mg/dL to 1.68 mg/dL on day 24. Due to suspicion for cefazolin-induced AIN, urine eosinophil count was checked and returned positive. IV cefazolin was discontinued and IV vancomycin was restarted. Despite discontuing cefazolin, her creatinine rose to 2.16mg/dL. The patient was inititated on IV hydrocortisone 100mg daily from Day 28-30. A kidney biopsy was deferred given her acute illness. Her creatinine improved to normal range at the time of discharge.

IMPACT/DISCUSSION: A rare but significant adverse effect of Cefazolin use, AIN is a condition characterized by inflammation of the kidney interstitium leading to a decline in renal function. Although interstitial nephritis related to drug use is quite common, cases reported with cefazolin use are few and far in-between. Most cases of AIN are related to various drug exposures. In clinical practice, the diagnosis is made based on the temporal relationship between a decline in kidney function and medication use as well as other findings such as eosinophiluria, eosinophilia, and sterile pyuria.

CONCLUSION: Although the patient did not present with the classic symptoms, the index of suspicion was high given the temporal relationship between the drug exposure and worsening renal function. Although there is a known classic triad of fever, rash, and arthralgia, in actual clinical practice, the presenting symptoms of AIN are usually non-specific. It is advisable to monitor creatinine levels when introducing new medications that have been linked to AIN.

CELIAC DISEASE PRESENTING AS SEVERE VITAMIN B12 DEFICIENCY

Siddharth Gupta¹; Sachi Singhal²; Tammarah Sklarz²; Ashwin Chandar². ¹Internal Medicine, Baptist Memorial Hospital North Mississippi, Oxford, MS; ²Hematology/Oncology, Temple University Health System Inc, Philadelphia, PA. (Control ID #4063862)

CASE: A 27-year-old female with no significant past medical history presented to the ER with macrocytic anemia after evaluation by PCP for fatigue, bilateral foot numbness, and pain in soles ongoing for about 3 months. She also reported epigastric pain, nausea, and diarrhea with 15 lbs unintentional weight loss. She denied a personal history of anemia, prior surgical history, recent trauma, or illness. Her family history was unremarkable. She was on Depo-Provera but otherwise did not take any other medications/supplements. Vital signs were remarkable for sinus tachycardia. Physical exam was remarkable for pale conjunctivae with scleral icterus, epigastric tenderness with no organomegaly, and impaired first toe position sense bilaterally. Lab work showed macrocytic anemia with Hgb 4.6 mg/dl, MCV 123.8 fl. Other pertinent labs included total bilirubin 3.3 umol/ml with direct bilirubin 0.3 umol/ml, and Lactate Dehydrogenase 3067 units/L. Vitamin B12 was strikingly low at 201 pg/ml, along with low folate levels at 2.10 ng/ml. Iron studies were unremarkable with negative direct and indirect Coombs tests. The patient's blood smear revealed moderate anisocytosis, poikilocytosis with occasional teardrop cells, stomatocytes, and frequent hypersegmented granulocytes further corroborating significant vitamin B12 deficiency. Seeing this new onset macrocytic anemia with vitamin B12 deficiency in a young female, an autoimmune workup was obtained. Anti-IF and anti-parietal antibodies were negative ruling out pernicious anemia. Given her young age, celiac disease testing was sent despite normal iron levels revealing anti-tissue transglutaminase IgA (by ELISA) antibodies strongly positive at 172.5 units/ml. Endoscopy revealed scalloped mucosa in the duodenum clinching the diagnosis of Celiac Disease (CD). She was started on a gluten-free diet with IM vitamin B12 and IV folic acid repletion.

IMPACT/DISCUSSION: Neurological symptoms occur in up to 10% of patients with CD, and patients can present with ataxia and/or peripheral neuropathy for the first time. Classically CD is associated with iron deficiency anemia but vitamin B12 deficiency is prevalent in up to 12% of CD patients. Vitamin B12 deficiency may occasionally precede the diagnosis by years altogether. The cause of B12 deficiency is unknown but is postulated to be from bacterial overgrowth, concomitant autoimmune gastritis, or subtle dysfunction of the distal small intestine. Knowing vitamin B12 status is imperative before starting folate replacement, and unchecked vitamin B12 deficiency in these patients can lead to irreversible neurological damage.

CONCLUSION: New peripheral neuropathy and/or low vitamin B12 in a young adult should prompt evaluation for Celiac Disease

Peripheral neuropathy is an underreported initial manifestation of Celiac disease and warrants detailed workup

Symptomatic macrocytic anemia and low vitamin B12 levels may be the sole presenting feature of undiagnosed Celiac disease in young adults

CELL COUNTS FELL, LIVER SWELLED - WE NEED HELP! MULTIDISCIPLINARY PERSISTENCE DESPITE A NONDIAGNOSTIC WORKUP

Xinmiao Yang¹; Katherine M. Cooper¹; Chase Foster-Spence¹; Curtis Barry²; Sindha Madhav³; Laurie K. Pearson⁴. ¹Internal Medicine, UMass Memorial Health, Worcester, MA; ²Gastroenterology, UMass Memorial Health, Worcester, MA; ³Pathology, UMass Memorial Health, Worcester, MA; ⁴Hematology/Oncology, UMass Memorial Health, Worcester, MA. (Control ID #4064028)

CASE: A 52-year-old woman with fatigue and early satiety was found to have new pancytopenia (WBC 0.6, Hgb 8.8, Plt 167) from normal CBC 3 months prior. Metabolic profile revealed AST 211, ALT 352, ALP 193, and Tbili 2.4. She was repeatedly hospitalized for neutropenic fever. Differential diagnosis for concomitant pancytopenia and mixed liver injury included autoimmune, infectious, or drug/toxin-related hepatitis and bone marrow failure; infiltrative or depositional disorders such as iron- or copper-deposition disease, metastatic malignancy, or lymphoma; or separate etiologies such as myeloid malignancy in the bone marrow coincidentally occurring with gallbladder disease.

Iron and ceruloplasmin labs were not consistent with deposition disease. Hepatitis, HIV, VZV, HSV, CMV, EBV, parvovirus B19, and tick-borne panels were negative. CT abdomen revealed splenomegaly with infarction and possible cholecystitis, later excluded by MRCP and HIDA. Abdominal ultrasound was negative for thrombotic or congestive hepatopathy. She had a low-positive anti-smooth muscle antibody (1:40) and elevated serum immunoglobulins; thus autoimmune liver disease was considered. Liver biopsy revealed atypical lymphoid infiltration. Reticulocytes were 0%. Peripheral blood smear review was unremarkable and flow cytometry was negative for PNH, HCL, or abnormal B or T cell populations. Initial bone marrow biopsy showed trilineage hematopoiesis with no evidence of hematologic malignancy. Discussion between hematology, hepatology, and hematopathology continued to reveal concern for lymphoproliferative disorder. T cell clonality on the liver and bone marrow specimens showed T cell receptor gamma chain rearrangement which could have been consistent with T-LGL. However, given liver, splenic, and bone marrow involvement, a bone marrow biopsy was repeated and, in collaboration with the NIH, a diagnosis of hepatosplenic T cell lymphoma (HSTCL) was made.

IMPACT/DISCUSSION: HSTCL is rare, accounting for only 1.4% of T cell lymphomas (1,2) but is a unifying diagnosis for pancytopenia and transaminitis. We note the importance of provider persistence and multidisciplinary communication between specialties as biopsy can commonly be nondiagnostic. Identifying HSTCL is critical as the prognosis is poor, often related to delayed diagnosis, but multiagent chemotherapy followed by allogeneic stem cell transplant can improve survival (3).

CONCLUSION: 1. Concurrent pancytopenia and mild transaminitis is a classic presentation of HSTCL

2. HSTCL is a lymphoma with a poor prognosis.

3. Persistence and collaboration across disciplines and institutions led to a prognosis-changing diagnosis

CEREBRAL VASCULITIS, A RARE BUT LIFE-THREATENING COMPLICATION OF PNEUMOCOCCAL MENINGITIS

Daniel Matassa¹; Pooja Patel²; Jared Sapin³; Lisa Dever¹. ¹Medicine, New Jersey Medical School Department of Medicine, Newark, NJ; ²Neurology, Robert Wood Johnson University Hospital, New Brunswick, NJ; ³Medicine, New Jersey Medical School Department of Medicine, Newark, NJ. (Control ID #4042744)

CASE: A 65 year-old woman without significant medical history was brought in with one day of progressive confusion and fever. On arrival, she was febrile and obtunded with mild nuchal rigidity. Work-up revealed Streptococcus pneumoniae bacteremia and meningitis. Despite treatment, the patient experienced worsening left hemiplegia and altered mental status. MRI of the brain demonstrated fronto-parietal vasculitis. High-dose intravenous steroids led to a marked improvement in cognition, and she was discharged to complete a 3-week prednisone taper. One month later, the patient returned with progressive altered mental status for one week. The patient’s neurological condition had improved significantly with the above treatments, but after the steroid taper finished, she became lethargic again. On arrival, the patient was found to be non-verbal and unable to follow commands, with persistent left hemiplegia. Routine studies, CSF analysis, paraneoplastic testing, and an expanded autoimmune panel were all non-contributive. Repeat MRI of the brain demonstrated progressive cerebral vasculitis, and DSA findings were highly supportive of the diagnosis. The patient’s family declined leptomeningeal biopsy. Her clinical status improved markedly with high-dose steroids, and she was discharged with a 3-month prednisone taper. She remains in remission, is fully alert and oriented, and is now able to walk with a gait aid.

IMPACT/DISCUSSION: Literature guiding the management of cerebral vasculitis is quite limited, especially in the context of meningitis. Presentation can be quite variable, MRI findings may be inconsistent, CSF analyses are generally nonspecific, and DSA features can be mimicked by many other cerebrovascular disorders. Leptomeningeal biopsy has been considered the gold standard for diagnosis; however, it is invasive and has suboptimal sensitivity. Our patient’s successful outcome challenges recommendations that all patients with this suspected diagnosis should undergo brain biopsy. When there is a clear clinical course and supportive radiographic data, we propose that invasive brain biopsy may be foregone. There are no clinical studies identifying optimal steroid dosing/tapering, but our case supports the need for prolonged courses. Recommendations for immunosuppressive agents are based on evidence from other rheumatologic conditions, and their usage may not be necessary in cases such as this.

CONCLUSION: -Cerebral vasculitis is a rare, life-threatening complication of meningitis.

-Diagnosis requires specific MRI and angiographic findings, but need for brain biopsy should be individualized.

-Treatment requires prolonged steroid tapers and potential immunosuppressive agents.

CHASING A CASE OF CASTLEMAN DISEASE

Grace Patrice Anyetei-Anum¹; Nirosha D. Perera². ¹Medical Student, Mayo Clinic Alix School of Medicine, Rochester, MN; ²Dept. of Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4063816)

CASE: A 21-year-old female presented with dyspnea, 25 lb. weight gain in one month, fever, abdominal pain, and lower extremity edema. Outside hospitalization revealed diffuse indeterminate lymphadenopathy, splenomegaly, hepatomegaly, and laboratory derangements including thrombocytopenia (Plts 102 x10^9/L), elevated creatinine 1.86mg/dL (baseline <1mg/dL), hyperuricemia (15.8mg/dL), hyperphosphatemia (5.4mg/dL), elevated LFTs notably alkaline phosphatase in the 300s, and significantly elevated inflammatory markers (CRP 142.2mg/L and ESR 120mm/h). Differential diagnosis included lymphoma with tumor lysis syndrome, sarcoidosis, and disseminated histoplasmosis. She was admitted & treated with allopurinol, intravenous fluids, & lasix while further workup was pursued: PET CT skull to thigh FDG, CT-guided lymph node biopsy, leukemia-lymphoma phenotype peripheral smear, and broad infectious workup including EBV, CMV, HIV, Blastomycosis, Histoplasmosis, Tuberculosis, HHV-6, Syphilis and Lyme disease.

Infectious workup & peripheral smear returned negative. PET scan revealed mildly prominent and mildly FDG avid lymph nodes, mild splenomegaly and bilateral pleural effusion. Ultrasound-guided axillary lymph node fine needle biopsy was negative for malignancy. Bone marrow biopsy showed slightly hypercellular marrow without evidence of myelodysplastic syndrome or malignancy. Excisional biopsy of the right axillary lymph node was consistent with idiopathic, HHV-8 negative multicentric Castleman disease (MCD). The patient was treated with anti-interleukin 6 (IL-6) therapy resulting in improvement in all labs, with creatinine normalizing to 0.99 mg/dL. Kidney biopsy was considered but deferred given renal recovery. Altogether her presentation was suggestive of HHV-8 negative MCD with TAFRO syndrome (thrombocytopenia, anasarca (edema, pleural effusion, and ascites), fever, reticulin myelofibrosis (or renal insufficiency), and organomegaly (hepatosplenomegaly and lymphadenopathy)).

IMPACT/DISCUSSION: Castleman disease is a rare lymphoproliferative disorder that can affect the lymph nodes of any region of the body, imitating both benign and malignant conditions in the neck, chest, abdomen, and pelvis. There are three subtypes: HHV-8-associated CD, Idiopathic MCD, and POEMS-associated MCD. Castleman disease can be life-threatening if not treated and can increase the risk of developing lymphoma.

A relatively newer entity, TAFRO syndrome, is described as a related disorder of Castleman disease. Dysregulated production of IL-6 has been implicated in the pathogenesis of CD and may contribute to renal dysfunction; our patient with HHV-8 negative MCD with TAFRO has had complete remission with anti-IL-6 therapy and steroids.

CONCLUSION: Castleman disease is a rare lymphoproliferative disorder with a wide range of symptomatology. Although rare, maintain high clinical suspicion for MCD with TAFRO in patients with lymphadenopathy, organomegaly, renal insufficiency, and negative typical malignant & infectious workup.

CHOCOLATE COLORED BLOOD AND BLUE URINE FROM EXPIRED DAPSONE: A CASE REPORT OF ACQUIRED METHEMOGLOBINEMIA

Joane Titus^1,2; Fariha Mirza^1,2; Kristin Recker³; Vanthanh Ly². ¹Internal Medicine, University of Central Florida, Orlando, FL; ²Orlando VA Healthcare System, Orlando, FL; ³University of Central Florida, Orlando, FL. (Control ID #4055910)

CASE: Our patient is a 66-year-old male with a significant past medical history of asthma, hypertension, hyperlipidemia, paroxysmal supraventricular tachycardia, gastroesophageal reflux disease, and diabetes mellitus who presented to the emergency department with altered mental status. On physical examination, the patient was visibly distressed with labored breathing, nailbeds indicated cyanosis, oxygen saturation was 88% on 100% FiO2, respiratory rate was 29 breaths per minute, and heart rate was 116 beats per minute. Arterial blood gas analysis revealed a dark brown color, a PaO2 of 80 mmHg and a PaCO2 of 45mmHg, and pH of 7.29. He was emergently intubated and transferred directly to the Intensive Care Unit (ICU) from the Emergency Department. Co-oximetry analysis demonstrated a methemoglobin level of 26.6%. Based on the clinical presentation and laboratory findings, a diagnosis of methemoglobinemia (MetHb) was made. The patient was promptly treated with two doses of methylene blue 1mg/kg intravenously over two separate days, followed by observation. At this time, his urine then turned a light blue color secondary to the treatment. Within this timeframe oxygen saturation increased to 96%. Repeat co-oximetry analysis showed a significant reduction in methemoglobin levels to 11.5% then 4.7%.Following up with the patient post discharge and following recovery he was reported to have taken three days’ worth of expired Dapsone prior to admission for a respiratory illness without consulting with a physician. He reported being prescribed Dapsone one year prior for an unspecified reason.

IMPACT/DISCUSSION: (MetHb) is a rare condition caused by oxidizing agents and is characterized by the presence of methemoglobin, a non-functional form of hemoglobin with impaired oxygen-carrying capacity. In a recent review, dapsone accounted for 21% of acquired, or secondary, causes of methemoglobinemia. Dapsone causes MetHb by serving as an oxidizing agent. The pathophysiology occurs when iron in the ferrous state of Fe2+ is oxidized into Fe3+ the ferric state. Ferric iron cannot bind oxygen changing the configuration of hemoglobin and increases oxygen binding affinity preventing oxygen release to peripheral tissues.

To our knowledge, this is the first reported case of expired Dapsone resulting in MetHgb as it relates to expired dapsone.

CONCLUSION: This case report highlights the importance of considering methemoglobinemia as a potential diagnosis in patients presenting with cyanosis and respiratory distress. Prompt recognition of methemoglobinemia is crucial as delayed treatment can result in significant morbidity or mortality. Healthcare professionals should remain vigilant and educate patients regarding the potential risks associated with usage of expired medications.

CIPROFLOXACIN PROMPTED IMMOBILIZATION IN PERIPHERAL VASCULAR DISEASE PATIENT

Nazish Tarar, Dimple Ghassi. Department Internal Medicine, Albany Medical College, Albany, NY. (Control ID #4061456)

CASE: A 73-year-old male presented for hospital discharge follow up for left carotid post-surgical complications. He reported significant bilateral ankle pain and difficulty bearing weight since his discharge. Denied any fever, chills, warmth, redness, or history of trauma or gout . His past medical history was pertinent for history of peripheral vascular disease, coronary artery bypass graft, diabetes mellitus , stage 3 chronic kidney disease, hypertension, and hypothyroidism. Medications include amiodarone, aspirin, fexofenadine, furosemide, hydralazine, canagliflozin, levothyroxine, losartan, pantoprazole, pravastatin, ciprofloxacin and tamsulosin. Ciprofloxacin was a new medication started for post surgical wound infection. Physical exam found to have 1-2+ bilateral ankle edema, ecchymosis over the Achilles area adjacent to the left heel, and tenderness of bilateral Achilles tendons. Negative Thompson test. Range of motion was limited especially planter flexion due to pain. No evidence of cellulitis. Pedal pulses intact bilaterally with normal sensory and motor exams. Patient was noted to have difficulty bearing weight and taking steps due to intense pain with ambulation and needed wheelchair to ambulate. Pertinent labs including CBC, CMP, CPK and TSH were within limits except a hemoglobin of 9.5 g/dL and creatinine 1.89.

Due to concerns for achilles tendinopathy, patient was sent for urgent ultrasound evaluation that confirmed Tendinopathy of bilateral Achilles and advised to discontinue ciprofloxacin. He was recommended physical therapy and avoiding overuse. Post discontinuation patient reported improvement in his symptoms within a week.

IMPACT/DISCUSSION: Though the risk is rare (0.14-0.4%), this case demonstrates the serious risk for tendinopathy with fluoroquinolone treatment particularly in patients of advanced age, chronic kidney disease, transplant patients and steroid use. Symptoms can occur 2 hours to up to 6 months post first fluoroquinolone dose. Early diagnosis and treatment are key to prevent muscle rupture complicating treatment and recovery. Proposed mechanisms of injury are considered to be due to increased expression of matrix metalloproteinase-2 in tendon cells with concomitant degradation of type 1 collagen exacerbated by hypovascularity in PVD.

CONCLUSION: It is essential for clinicians to be aware of even very rare side effects of medications such as ciprofloxacin.

Empiric antibiotic use should be avoided in routine cases unless absolutely necessary.

CLEAR CELL RENAL CELL CARCINOMA PRESENTING IN A NOT SO CLEAR WAY

Omair Syed¹; George T. Kalapurakal²; Matthew R. O'Reilly¹; Yoonho Park¹; Ghassan Zalzaleh². ¹Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL; ²Internal Medicine, Advocate Aurora Health Inc, Milwaukee, WI. (Control ID #4054447)

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 Carcinoma (ccRCC) is the most common, accounting for over 80% of cases.

We present a case of metastatic ccRCC presenting as a scalp lesion.

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.

Physical examination of the right occipital scalp displayed a firm, immobile, painless mass measuring 1.7 centimeters (cm) x 1.4 centimeters (cm).

CT of the neck which demonstrated multiple subcentimeter lymph nodes scattered in the neck, none of which were pathologically enlarged or abnormally enhancing.

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.

PET Scan demonstrated physiologic uptake in the kidneys, no hypermetabolic activity was noted in the left kidney.

Pathology report of the scalp lesion returned as Clear Cell Neoplasm concerning for Renal Cell Carcinoma metastasis.

IMPACT/DISCUSSION: 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 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.

CONCLUSION: Given the high prevalence and malignant potential of ccRCC, it is important for clinicians to be aware of its variety of presentations.

Clear Cell Renal Carcinoma can be a difficult disease to recognize.

CLINICAL AND IMAGING CONSIDERATIONS FOR EARLY DIAGNOSIS IN A CASE OF FAT EMBOLISM SYNDROME

Sulaiman Karim¹; Austin D. Rodgers¹; Emily Rodenko⁴; Kathy Grove³; Barath Rangaswamy². ¹school of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ²internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ³Trauma Surgery, Texas Tech University Health Sciences Center, Lubbock, TX; ⁴Trinity University, San Antonio, TX. (Control ID #4064103)

CASE: A man in his early 20s is airlifted to our academic level-3 trauma center following a head-on collision with an eighteen-wheeler. On arrival, he was hemodynamically stable, with a Glasgow Coma Scale score of 15, and without a history of consciousness loss. His initial lactate level was notably elevated at 4.6 mmol/L. The CT Trauma-Scan Protocol revealed an aortic arch injury with pseudoaneurysm formation, along with multiple fractures including the left femur, tibia, radius and ulna, sternal body, left pubic rami, and left ribs 3, 5, 6, 7, and 8. His initial head CT showed no acute intracranial process.

However, 24 hours later, the patient deteriorated in both mental and respiratory status, necessitating intubation. Subsequent MRI, including diffusion-weighted images (DWI) and T2 weighted images (T2WI), revealed multiple hyperintense areas in the cerebral white matter and basal ganglia, in the centrum semiovale, subcortical white matter, and the thalamus/basal ganglia, consistent with fat embolism syndrome (FES). Repeated laboratory tests indicated a drop in platelets to 69,000 per μL, a decrease in hemoglobin to 7.0 g/dL, and an increase in bilirubin to 1.7 mg/dL, compared to initial values of 238,000 per μL, 13.4 g/dL, and 0.5 mg/dL, respectively. In light of his rapidly deteriorating clinical status, accompanied by the characteristic MRI findings, a diagnosis of FES was suspected. The patient started to improve with supportive treatment in the ICU, enteral feeding, and hydration.

IMPACT/DISCUSSION: Fat embolism syndrome is a clinical diagnosis with the classic triad of hypoxia, neurologic abnormalities, and occasionally a petechial rash, especially in the context of long bone fractures. However, this triad is often nonspecific, as evidenced by the petechial rash appearing in only about 50% of cases and its absence in our patient's case. In our case, the patient exhibited ancillary features such as thrombocytopenia, anemia, and jaundice, aligning with minor diagnostic criteria like Gurd’s Criteria, although these criteria lack broad clinical validation.

MRI plays a crucial role in the diagnosis of FES, with DWI revealing diffuse, punctate, or hyperintense lesions corresponding to neurological deficits. While suggestive of FES, these imaging patterns necessitate differentiation from other conditions that present with similar T2WI and DWI findings, such as diffuse axonal injury, vasogenic edema, and demyelinating diseases. CT scans are less sensitive for these subtle changes. Therefore, clinical judgment, in conjunction with imaging findings, is vital for accurate diagnosis and management of FES, especially given its nonspecific symptoms and the overlap with other neurological conditions.

CONCLUSION: For clinicians, effective management of traumatic FES relies on quick recognition and supportive care, as shown in our case, where diffusion-weighted MRI was crucial. Timely intervention led to the patient's recovery and regained mobility after months of dedicated rehabilitation.

CLINICAL DECISION MAKING AND MANAGEMENT APPLIED TO AN ATYPICAL CAUSE OF AN

UNCOMMON DISEASE

Michael E. Baumgartner¹; Anita Lee². ¹Medical School, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4063736)

CASE: A 33-year-old woman born in Mali presented with diarrhea, joint pain, and weight loss. She was in her usual state of health until 3 months ago, when she developed pain in her hips, neck, shoulders and wrists. Shortly after the joint pains began, she travelled back to Mali to visit family for a month. A week into her trip, she developed 8-10 episodes of profuse watery diarrhea and stomach pain. These symptoms persisted once she returned to the United States. With the abdominal symptoms and 10-pound weight loss, she presented to an outside hospital with an unrevealing evalulation. She presented to this hospital for the same symptoms. An extensive infectious workup, with particular focus on pathogens endemic to Mali, as well as consideration for autoimmune and GI conditions, was unrevealing. Colonoscopy and path were negative. While hospitalized, the patient developed worsening neck pain with numbness and tingling An MRI of her neck revealed diffuse bone marrow signal abnormalities. Flow cytometry and molecular testing revealed HTLV-associated adult T-cell leukemia/lymphoma (ATLL). Further history revealed that she had persistent mild left leg weakness since childhood, suggesting infection with HTLV1 in childhood and HTLV-associated myelopathy. She furthermore has a son born in the US who may have been exposed to HTLV1 during breastfeeding.

IMPACT/DISCUSSION: This unusual etiology for a common presentation highlights the importance of keeping a broad differential diagnosis for routine chief complaints. This vignette also highlights the diagnostic challenges associated with HTLV1 infection and ATLL. While HTLV1 is traditionally thought of as being endemic to Japan, West Africa, and the Caribbean, this retrovirus’ infection pattern resembles that of HIV, being a lifelong incurable infection that spreads via sexual contact and breast milk. Patients can therefore develop ATLL decades after leaving an endemic area and even if they never lived in such regions. This case also highlights the ethical dilemmas of testing for HTLV1 in the children of affected parents. Do the health benefits of clinical surveillance for HTLV1 associated complications and possibility of reducing risk of transmission warrant the emotional toll of a positive test result?

CONCLUSION: o ATLL is a rare aggressive T-cell malignancy caused by infection with the HTLV1 virus, which can develop

decades after infection and can be transmitted to children and sexual partners

o It can present uncommonly and may need persistence to diagnose.

o HTLV1 infection presents ethical dilemmas analogous to those of HIV infection, and no existing treatments are known for HTLV1. This case emphasizes moral discussions such as whether or not to test children and sexual partners

CLINICIANS MUST NOT HAVE A MENTAL BLOCK DIAGNOSING THIS BLOCKAGE: A CASE REPORT OF SVC SYNDROME

Jonathan Blackmon, Lindsey Blackmon, Nathan Douthit. Internal Medicine Residency, East Alabama Medical Center, Opelika, AL. (Control ID #4062340)

CASE: A forty-seven-year-old female presented with progressive dyspnea, dysphagia, and cough. She reported six months of malaise and sixty pounds of weight loss. She endorsed nausea, right chest pressure, and progressive cough for several weeks. Vital signs were within normal limits except an oxygen saturation of 88%. She had facial plethora, swelling of her neck, arms and hands, conjunctival suffusion, hoarseness, and distended chest vein collaterals. A CT chest revealed a 3.9 x 4.9 cm mass in the anterior mediastinum obliterating the left brachiocephalic vein at the SVC origin and the right internal jugular vein. There was extensive collateral flow through the chest and the azygos system. Biopsy revealed adenocarcinoma of the lung.

IMPACT/DISCUSSION: Superior vena cava (SVC) syndrome results from obstruction of blood flow through the SVC. The first case, described in 1757, was due to syphilitic aortitis. 15,000 cases occur per year in the United States. The SVC is formed by the union of the right and left brachiocephalic veins. The right internal jugular, also obliterated in our patient, empties into the right brachiocephalic vein and ultimately the superior vena cava. These vessels return blood from the head, neck, and extremities to the heart. Malignancy accounts for 60% to 85% of cases of SVC syndrome with the other 20% - 40% being due to intravascular devices leading to thrombosis. The most common malignancies include small cell bronchogenic carcinoma, non-Hodgkin's lymphoma, and metastatic tumors. With the increased use of pacemaker wires and semi-permanent intravascular catheters (for dialysis, long-term antibiotics, or chemotherapy) an increasing cause of SVC syndrome has been iatrogenic thrombus formation or SVC stenosis. Over time, venous wall inflammation, fibrosis, and eventual thrombus lead to stenosis. As was the case in our patient, symptoms often present over days to weeks. Collateral vascular networks form to divert blood to the lower body which is why there is an insidious onset of symptoms. The most common symptoms are nonspecific including cough and dyspnea. Our patient also had dysphagia. The physical exam is crucial to make this diagnosis. Common findings illustrated in our patient are facial plethora, upper extremity swelling, distended chest vein collaterals, conjunctival suffusion, and hoarseness. Other possible findings include orthopnea, stridor, pleural effusions, headache, nausea, syncope, visual changes, altered mental status, stupor, and coma. Initial evaluation includes ultrasound to look for a thrombus and CT. The presence of collateral vessels has a diagnostic sensitivity of 96% and a specificity of 92%. The gold standard is venography.

CONCLUSION: ● Recognizing common symptoms in the history and physical exam findings is critical to diagnose SVC Syndrome. If these are overlooked, a clinician may delay diagnosing a malignancy.

● Evaluation for the presence of SVC syndrome utilizes ultrasound and CT.

CMV ASSOCIATED SPLENIC INFARCTS IN A YOUNG IMMUNOCOMPETENT PATIENT

Shreya Bhatia, Sarah Jensen. Internal Medicine, Boston Medical Center, Boston, MA. (Control ID #4062550)

CASE: A 37 year old woman with obesity presented to the hospital with four days of progressively worsening abdominal pain, nausea, and vomiting. Vital signs were normal; however, she had diffuse tenderness to palpation of her left lower abdominal quadrant. Notable laboratory findings included thrombocytopenia of 135,000 and elevated AST 92 and ALT 98. Abdominal CT scan revealed splenomegaly and multiple areas of splenic hypoattenuation consistent with splenic infarcts. Relevant medication was a birth control implant. There was no personal or family history of blood clots or arrhythmias. She quit smoking 10 years prior. Denied other constitutional symptoms.

She was started on intravenous heparin due to concern for a thrombotic event. Broad hypercoagulable workup was negative. Transthoracic echo showed no signs of endocarditis or valvulopathy. No arrhythmias seen on telemetry. Infectious disease evaluation negative for HIV and EBV. Cytomegalovirus testing notable for positive CMV DNA PCR of 10,092. Positive CMV IgM antibody and negative IgG antibody suggested acute CMV infection. Symptoms improved within two days without intervention, and she was discharged on apixaban with close follow up.

IMPACT/DISCUSSION: Splenic infarction occurs when arterial or venous blood supply to the spleen is compromised. It presents most commonly as severe left sided abdominal pain, nausea, vomiting, fever, and splenomegaly. Splenic infarcts can also be asymptomatic and identified incidentally on imaging.

Thromboembolic and hematologic disease are the most common causes of splenic infarcts. Risk factors include atrial fibrillation, endocarditis, valvular heart disease as well as malignancy, sickle cell disease, antiphospholipid syndrome, and exogenous estrogen.

This case emphasizes the importance of considering additional etiologies of splenic infarction such as trauma or infection. About 19% of splenic infarcts appear to be triggered by infection, however splenic infarcts triggered by CMV are only noted in case reports.¹ In these reports, patients were predominantly febrile, whereas our patient remained afebrile.

While the pathophysiology remains unclear, studies suggest CMV-DNA damages endothelium inducing thrombus formation and increases inflammatory markers leading to hypercoagulability.^2,3 Viruses such as COVID-19 have been seen to lead to hypercoagulability as well. Further studies of systemic effects of CMV are warranted as more case reports emerge of CMV associated infarcts.

CONCLUSION: Cytomegalovirus and other infectious causes should be considered when assessing the etiology of splenic infarcts, even in afebrile and immunocompetent patients.

CMV COLITIS MASQUERADING AS ISOLATED WEIGHT LOSS

Corinne Zalomek¹; Eric Lorio². ¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²Gastroenterology, Tulane University School of Medicine, New Orleans, LA. (Control ID #4034620)

CASE: A 51-year-old male post-renal transplant and prolonged immunosuppression with steroids presented with 130 lbs weight loss in 12 months. The patient initially reported two daily watery stools with bloating, early satiety, and decreased appetite. CT scan showed diffuse decrease in bulk of skeletal muscle, colorectal thickening, and hypodense structures in the pancreatic head and tail. MRI confirmed a cystic lesion in the pancreatic head and a septate lesion in the tail, prompting workup for malignancy. Labs were significant for CA 19-9 of 49.8, CEA of 19.3, positive stool norovirus PCR, positive CMV PCR, elevated fecal fat, and low fecal elastase. He reported an increase to 10 episodes of diarrhea daily, with no improvement from pancreatic enzyme replacement.

Upper endoscopy revealed diffuse nodularity and circumferential, irregularly-bordered ulcerations without deep lesions in the distal esophagus near the GE junction. Biopsy of the distal esophagus, stomach, and duodenum were positive for CMV. Colonoscopy noted discrete perianal ulcerations and a superficial ulcer covering approximately 50% of the ileocecal valve circumference. Pathology from the terminal ileum and colonic mucosa were both positive for CMV.

Disseminated CMV was treated with ganciclovir then transitioned to valganciclovir. Eradication was determined by two negative serology PCRs one week apart. The patient has since had no more diarrhea and regained weight appropriately.

IMPACT/DISCUSSION: CMV is part of the double-stranded DNA Herpesviridae family. It spreads through fluids during the perinatal period or sexual contact, infecting 40%-100% of the general population. Symptomatic CMV usually results from reactivation. Immunocompromised individuals such as those with AIDS, solid organ transplant, or undergoing immunosuppressive therapy have the highest risk of active disease.

The most common GI sites of CMV involvement are the colon and esophagus. Diagnosis is based on symptoms, mucosal changes on endoscopy, and immunohistochemistry. CMV enterocolitis often presents with fever, diarrhea, and bloody stool. Endoscopically it typically appears as punched-out ulcerations, but variability may be observed. CMV esophagitis classically manifests as epigastric pain, dysphagia, or odynophagia with endoscopic findings of mucosal ulcerations, erythema, and erosions. Mucosal changes may cause poor nutrient absorption, and thus weight loss.

The nonspecific clinical presentations and variable endoscopic findings make the diagnosis challenging. Serologic tests do not strongly correlate to disease severity, but provide a tool for measuring treatment response. Immunohistochemical staining for the presence of virus within tissue and clinical presentation remains the diagnostic gold standard.

CONCLUSION: CMV can cause various mucosal changes along the entire GI tract, influencing the symptoms presented. It is essential to recognize atypical symptoms of malabsorption from CMV, such as isolated weight loss, to properly treat these patients.

CODE BROWN: CARDIAC ARREST IN A PATIENT PRESENTING WITH DIARRHEA

Eseoghene Kevu. Internal Medicine, Lankenau Medical Center, Wynnewood, PA. (Control ID #4057060)

CASE: The focal patient, a 91-year-old female with a medical history of hypertension, GI bleed, iron deficiency anemia, and rheumatoid arthritis, initially presented to the ED due to a 2-week bout of diarrhea. She described black, loose stools with decreased appetite, fatigue, and exertional shortness of breath during this period. Notably, there was no recent travel or exposure to sick contacts. The patient was afebrile, normotensive, with regular rate and rhythm.

Initial laboratory findings—K 3.4, Mg 1.7, Hb 12.3, WBC 5.8, lipase 14—were relatively unremarkable. A CT of the abdomen and pelvis revealed no acute inflammatory or obstructive processes. However, the situation took a dramatic turn when the patient experienced sudden ventricular fibrillation (VF) arrest in the ED. ROSC was achieved after 1 shock and 1 round of CPR. She was subsequently intubated and started on an amiodarone infusion.

Further assessment via EKG revealed 1st degree AV block and RBBB. A TTE in the ED uncovered severe LV dysfunction, abnormal wall motion consistent with the distribution of the left anterior descending artery, a patent foramen ovale exhibiting left-to-right shunting, and a sizable right atrial thrombus protruding into the RV. The RV was of normal size but with severely reduced function.

Heparin infusion was started followed by an urgent transfer to the cath lab for catheterization and mechanical thrombectomy. Findings were surprising, revealing mild non-obstructive coronary artery disease without evidence of thrombus in the heart or within the pulmonary arteries. Right heart catheterization, however, indicated elevated left and right filling pressures alongside reduced cardiac output and index, necessitating transfer to the ICU for the management of cardiogenic shock and VF.

IMPACT/DISCUSSION: Evaluation of VF includes review of family and cardiac history, assessment of medications for arrhythmogenic potential, EKG, analysis of pertinent laboratory parameters such as electrolytes, troponin, toxicology, BNP, and acid-base. The stabilization and comprehensive investigation of this patient demanded swift coordination among multiple specialties. This case underscored the unpredictability and inconclusiveness inherent in medicine. The abrupt deterioration of a seemingly stable patient with diarrhea was unforeseen. The discovery of a substantial thrombus in the right atrium was unexpected, and equally surprising was its absence during subsequent invasive procedures.

CONCLUSION: While the precise etiology of the patient's VF remained inconclusive, the leading hypothesis postulated the embolization of part of the clot to the pulmonary arterial tree, culminating in acute right heart strain and subsequent arrhythmia. It served as a reminder that in the realm of patient presentations, comprehensive answers may not always be forthcoming. As a physician, cultivating an open mind and preparing for the unexpected is not just essential but a fundamental approach to navigating complexities of patient care.

COLD AGGLUTININ HEMOLYTIC ANEMIA: A RARE AND SOCIALLY CHALLENGING DIAGNOSIS

Myriah Magaris¹; Shannon Barley¹; Jessica A. Schumann¹; Danielle Palaferro¹; Timothy Lindsay²; Chad Gunsolly¹. ¹Internal Medicine, Thomas Jefferson University, Philadelphia, PA; ²Tower Health, West Reading, PA. (Control ID #4057044)

CASE: A 72-year-old male initially presented complaining of worsening chronic back pain from a known compression fracture. He was found to have acute on chronic anemia with a decrease in hemoglobin from 6.6 to 4.9. Labs were consistent with hemolysis including hyperbilirubinemia, elevated lactate dehydrogenase, and undetectable haptoglobin. It was noted that the patient's blood clotted quickly after phlebotomy. Patient was evaluated by oncology, and he was transfused warmed packed red blood cells due to concern for cold-agglutinin hemolytic anemia.

Cold-agglutinin testing was positive with an elevated immunoglobulin M. There was concern for Waldenstrom's macroglobulinemia with cytometry notable for clonal B cell population. Bone marrow biopsy was hypercellular with monoclonal B lymphocytes and monoclonal plasma cells, consistent with malignant lymphoplasmacytic lymphoma. Patient's room was kept warm, and he remained on a Bair hugger throughout hospitalization. Blood transfusions were limited to symptomatic anemia. He was discharged when his hemoglobin stabilized, and he was initiated on rituximab and bendamustine treatment outpatient.

IMPACT/DISCUSSION: Literature: Cold agglutinin disease (CAD) has a prevalence of 5-20 per million and is defined as an autoimmune hemolytic anemia in which cold agglutinins cause clinical symptoms related to red blood cell agglutination and hemolysis when exposed to cold temperatures.(1) In this case presentation, our patient presented with CAD secondary to lymphoplasmacytic lymphoma.

Unique Aspects of this Case: This case highlights a rare disease that has significant impact on patients’ quality of life. Our patient was presented with many social challenges associated with his disease including transportation to outpatient appointments during the winter, keeping a consistent warm environment, and admission to facilities capable of caring for his needs.

CONCLUSION: In conclusion, CAD is a rare disease process that is associated with many challenges. Diagnostic specimens must be handled properly to assure results are not skewed, and clinicians must remain sensitive to the significant social impacts this disease presents.

COMPLICATIONS OF IMMUNE CHECKPOINT INHIBITORS: A CASE OF MYOCARDITIS AND ENCEPHALITIS IN ENDOMETRIAL CANCER TREATMENT.

John Fomeche, Maheen Zaidi, Ayara Ehinmisan, Alka popli, Hiren Mody, Forugh Homayounrooz. Medicine, Stamford Hospital, Stamford, CT. (Control ID #4064130)

CASE: A 66-year-old female presented to emergency department with acute exacerbation of dyspnea on exertion. Her medical history was notable for HTN, recurrent stage III C endometrial carcinosarcoma being treated with Lenvatinib and Pembrolizumab , prior Cerebrovascular accident , intracranial aneurism with no residual neurological deficits. Initial vitals were notable for T 36.5 C, BP 116/75, HR 106,RR 20, saturating comfortably on room air. Physical exam revealed decreased breath sounds bilaterally , 2+ symmetric lower extremity edema, and no focal neurological deficits. Chest XR revealed mild pulmonary, severe lung emphysema and interstitial disease, and CT angiogram of chest showed no evidence of pulmonary embolism. Labs showed WBC 9, Hgb 9.3, troponin I 129 ng/L (0-17), BNP 579 pg /mL (0-100). Initial EKG showed sinus tachycardia, and Transthoracic echocardiography showed left ventricular ejection fraction(LVEF) 20-25% with apical ballooning, with possible LV apical thrombus. Her hospital course was complicated by rising troponin levels (peaking at 1554 ng/L) and new diffuse T-wave inversions concerning myocarditis . Left Heart Catheterization for further evaluation revealed no significant ischemic disease. Her hospital course was further complicated by acute encephalopathy and worsening left-sided weakness for which brain MRI showed diffuse Dural enhancement and chronic infarct in the right frontal lobe and right basal ganglia. Lumbar puncture showed elevated protein and mild pleocytosis with negative paraneoplastic panel. Her acute encephalopathy, as well as myocarditis and heart failure were attributed to immunotherapy and Immune heck points Inhibitors (ICIs) were discontinued. She was started on guideline directed medical therapy for heart failure and treated with high-dose IV Methylprednisolone leading to significant improvement in neurological status and cardiac findings. Repeat echocardiogram prior to discharge showed LVEF 65% with previously noted regional wall motion abnormalities no longer apparent. Patient was discharged to acute rehabilitation facility for further recovery with close outpatient follow-up.

IMPACT/DISCUSSION: This case illustrates the severe, multi-system adverse reactions to immune checkpoint inhibitors, a critical concern in modern oncology. It emphasizes the importance of early recognition and tailored management of these complications. This experience contributes to the growing body of evidence regarding the safety profile of ICIs and underscores the need for continued vigilance and adaptation of treatment protocols in cancer immunotherapy.

CONCLUSION: Immune checkpoint inhibitors, though revolutionary in cancer treatment, can cause severe complications like myocarditis and encephalitis. Early recognition and management of these complications are crucial to minimize morbidity and improve patient outcomes.

CONCEPTION AND DISSECTION: AN UNUSUAL CASE OF VERTEBRAL DISSECTION IN A 24-YEAR-OLD MEDICAL STUDENT

Shane Vahjen¹; Ansley Wallace³; Christine E. Gough²; Mechelle J. Chen⁴; Theresa M. Rohr-Kirchgraber⁴. ¹Internal Medicine, Augusta University and University of Georgia Medical Partnership, Athens, GA; ²Internal Medicine, Augusta University, Augusta, GA; ³General, Augusta University, Augusta, GA; ⁴Medical College of Georgia, Augusta University, Augusta, GA. (Control ID #4060963)

CASE: A 24-year-old male medical student with no significant past medical or family history presented to the Emergency Department (ED) after experiencing two instances of “the worst headache of his life,” over four days. The first episode occurred during sexual intercourse four days prior to the date of presentation, and the other while weightlifting on the day of presentation. Despite the severity of his pain, the patient’s medical training caused him to initially downplay his symptoms, resulting in a delay in seeking care. Upon evaluation in the ED, the patient showed normal vital signs and an unremarkable physical exam with no focal neurological deficits. Due to the patient’s history of multiple intermittent instances of severe, pulsating headache, a subarachnoid hemorrhage arising from a cerebral aneurysm was suspected and a CT-A of the head and neck was ordered. Radiological imaging demonstrated a left-sided vertebral artery dissection in the V3 portion, without occlusion. The patient was given 325mg of aspirin and subsequently discharged. Follow-up imaging at six weeks showed resolution of the dissection.

IMPACT/DISCUSSION: Medical students sometimes experience a condition known as nosophobia; an anxiety-related illness referred to colloquially as “Medical Student Syndrome.” Nosophobia manifests as the somatization of life-threatening disease characteristics that are studied by students. This condition is thought to result in students receiving benign medical workups that reassure the absence of serious conditions, or in a delay in detection of true pathology due to belief by students that their symptoms are somatized. In recent studies, however, medical students were found to obtain the same scores on a nosophobic scale as non-medical students, and hypochondrial behavior was significantly higher in the non-medical student group (1). These findings imply that consideration of nosophobia may inaccurately guide clinical decisions, and more frequently, may result a delay of detecting true pathology rather than prompting unnecessary medical workups.

In this case, we demonstrate a situation in which the patient’s knowledge of more common etiologies delayed evaluation following multiple severe, headaches. In the setting of having recently studied serious neurological diseases such as subarachnoid hemorrhage and vertebral/carotid artery dissections, etiologies such as a sex headache or migraine were considered more probable due to the patient’s understanding of nosophobia. Knowledge of nosophobia may also pose a diagnostic challenge to the clinician when deciding to venture down diagnostic routes.

CONCLUSION: Vertebral artery dissection should be considered as a possible etiology in a young, previously healthy patient experiencing severe headache.

Nosophobia has not been found to have clear evidence and should not be considered when deciding upon course of treatment.

Medical students may be particularly at risk for delay in treatment due to a false understanding of nosophobia.

CONSTRICTIVE PERICARDITIS, PLEURAL AND PERICARDIAL EFFUSIONS AS AN UNUSUAL PRESENTATION OF RHEUMATOID ARTHRITIS.

Jason Penrod, Sara Walden. Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4028072)

CASE: A 66 yo F presented to the ED with nonproductive cough, DOE, fever, and pleuritic chest pain, gradually worsening over two weeks. In the ED she was found to be febrile, with new afib with RVR, tachypnea, and leukocytosis. She was initially treated for A-fib with RVR and SIRS with empiric antibiotics and was admitted to the Medicine service.

Her PMH included RA,. She had been on MTX from 2009 to 2010 for symptomatic hand erosive synovitis. Her articular symptoms abated despite stopping MTX, and she was not actively treated for RA after 2010 other than prn NSAIDs.

Labs at admission:

Procalcitonin, troponin, CMP, normal

WBC 31, HCT 37, Plt 509

RF 174

CCP 174

ESR 45

Extensive ID testing including Tb, fungal/viral cx, blood/fluid cultures-all negative

VS

BP 118/82

HR 181

SpO2 94%

RR 29

T 38.2

After admission, echo, CT of the chest, abd/pelvis were unremarkable. She remained febrile, with persistent leukocytosis. Antibiotics were dc'd as she had no overt source of infection.

On day 7 she was found to have a moderate pericardial effusion and small pleural effusions. Leukocytosis persisted. She was diagnosed with pericarditis and started on colchicine and ibuprofen. She was discharged home but returned to the ED 3 days later with dyspnea; she was diagnosed with a large pericardial effusion with tamponade physiology. She also had a left sided pleural effusion found to be exudative, both sources had cytology with no malignant cells or organisms.

She was diagnosed with effusive-constrictive pericarditis by cardiac MRI with LV flattening and septal shift with inspiration, consistent with constrictive pericarditis.

Rheumatology and ID were consulted. Rheumatology initially felt her pericardial and pleural effusions could be related to RA, but still presumed an occult infectious process given her high fevers. However, as her fevers and leukocytosis improved on colchicine and NSAIDs, Rheumatology and ID consultants believed the pericarditis was an extra-articular manifestation of uncontrolled RA. She was discharged on a prednisone taper and colchicine. Two weeks after discharge, she was feeling clinically well.

IMPACT/DISCUSSION: This case demonstrates the difficulty in arriving at RA without significant synovitis as the underlying etiology of symptomatic constrictive pericarditis with rapid progression of pericardial and pleural effusions. The constellation of fever, leukocytosis, and SIRS physiology initially suggested an infectious etiology. Only after an exhaustive negative infectious evaluation, supportive strongly positive autoimmune labs, plus her historical diagnosis of RA, was the diagnosis of pericarditis as an extra-articular RA manifestation made.

This case serves as an example of an heuristic “anchoring” cognitive bias.

CONCLUSION: This case constitutes an unusual manifestation of rheumatoid arthritis with extra-articular manifestations. Be aware to avoid anchoring bias with diagnostic reasoning.

Early constrictive pericarditis may be managed medically with colchicine and corticosteroids or NSAID.

CO-OCCURRENCE OF HEART FAILURE AND NEPHROTIC SYNDROME

Divya Satishchandra. Internal Medicine, Boston Medical Center, Boston, MA. (Control ID #4063150)

CASE: A 52 year old male with a past medical history significant for hypertension, hyperlipidemia, type 2 diabetes mellitus presented to a New England academic medical center for subacute onset shortness of breath and bilateral lower extremity edema. Prior to presentation, his long-standing chronic conditions were well controlled. His physical exam was notable for an S3 audible at the left upper sternal border, right lung basilar crackles, and pitting lower extremity edema. Bedside ultrasound of the heart suggested reduced systolic function, and the patient was diuresed with intravenous furosemide. EKG was notable for sinus tachycardia and left ventricular hypertrophy, and troponins were not elevated. Admission CBC and CMP were notable for elevated creatinine. Ultrasound of the liver was normal. Echocardiogram showed an ejection fraction of 35% with isolated, moderate global hypokinesis of the left ventricle. Urine protein and urine creatinine revealed nephrotic range proteinuria. HIV, hepatitis panel, trypanosoma cruzi, and syphilis testing were negative. Additionally, serum/urine protein electrophoresis, complement levels, and anti-nuclear antibody were within normal range. On hospital day 2, the patient underwent a renal biopsy. He subsequently received cardiac MRI and coronary CT scan, which were negative for myocardial infiltration, inflammation, or coronary atherosclerosis. The patient was started on Guideline Directed Medical Therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) and was discharged. Renal biopsy ultimately revealed diabetic nephropathy; however, the etiology of his cardimyopathy has thus far been unidentified.

IMPACT/DISCUSSION: This case illustrates the importance of conducting a broad evaluation for the initial presentation of volume overload. Here, there was early suspicion for heart failure; however, the urine studies revealed co-occurring nephrotic syndrome. Though the prospect of unifying these entities under one diagnosis such as systemic lupus erythematosus or amyloidosis–was exciting, it was imperative to consider these problems as separate, each with its own diagnostic algorithm. First, renal biopsy was required to understand the cause of nephrotic syndrome with unremarkable laboratory findings, and secondly, evaluation for coronary artery disease and infiltrative pathology began the patient’s evaluation of cardiomyopathy.

CONCLUSION: - Undifferentiated volume overload should include evaluation of cardiac, hepatic and renal etiologies.

- Co-occurring HFrEF and nephrotic syndrome encompasses a narrow range of diagnoses, so it is important to consider these as separate entities in patients with common risk factors.

COPPER DEFICIENCY ANEMIA AND NEUTROPENIA DUE TO ZINC EXCESS

Jasmine Shrestha¹; Victoria Schrock⁴; Asis Shrestha²; Runa Shrestha^1,3. ¹Internal Medicine, Mercy Hospital Fort Smith, Fort Smith, AR; ²University of Arkansas for Medical Sciences, Little Rock, AR; ³Arkansas College of Osteopathic Medicine, Fort Smith, AR; ⁴Arkansas College of Osteopathic Medicine, Fort Smith, AR. (Control ID #4016690)

CASE: We present a case of an 84-year-old female with history of hypertension and asthma, who was referred to hematology clinic for evaluation of anemia and neutropenia. Her chief complaint was fatigue. Her recent cancer screening with mammogram and colonoscopy were normal. Her family history was relevant for leukemia in brother during his 80’s. Laboratory investigation showed worsening macrocytic anemia(Hemoglobin 9.3 from 12.2g/dl in one year with MCV 98.5fl), worsening leukopenia(WBC 2.5 from 6.1X10^3/ul) and neutropenia (ANC 793 cells/uL). Her other anemia workup including bilirubin, vitamin B12, folate, iron panel, ferritin, haptoglobin, LDH were within normal limits. Vitamin D and celiac serology were normal. As basic anemia workup showed no obvious etiology, copper level was tested and resulted extremely low (< 10 mcg/dl). On further investigation, she reported taking almost 9 to 10 tablets of zinc tablets per day(50 mg each) for the last two years since the COVID pandemic. She was advised to stop zinc supplement. The zinc level was 101 mcg/dl but was checked 10 days after discontinuing the supplement. She was started on copper gluconate 2mg daily. Repeat CBC in two months showed normalization of blood counts with resolution of symptoms. Copper level improved to 110 mcg/dl.

IMPACT/DISCUSSION: Copper and zinc are crucial micronutrients for our body. Copper functions as an enzymatic cofactor in metabolic processes such as hemoglobin synthesis, iron oxidation, neurotransmitter, cellular respiration, antioxidant and in formation of pigments and connective tissue. Zinc is involved in DNA expression, membrane stabilization and vitamin A metabolism.

Daily recommended intake of zinc is 8 mg/ day for women, 11 mg/day for men and the tolerable upper intake level for adults is 40 mg/day. Excessive zinc stimulates erythrocytes to produce intracellular heavy metal-binding protein called metallothionein. The metallothionein then binds to zinc and promotes its excretion. However, copper also has high affinity towards metallothionein and will be excreted in the process. Thus, excess zinc could lead to copper deficiency. Anemia and neutropenia are common hematological abnormalities associated with copper deficiency. Typically, copper deficiency due to excessive zinc resolves with removal of zinc but may require copper supplementation in symptomatic patients.

CONCLUSION: Dietary supplements are quite common in the general population. Copper deficiency could present with bicytopenia without neurological symptoms and should be considered as a part of anemia workup after basic workup is unrevealing. Excess zinc supplementation should be ruled out when copper deficiency is revealed.

CRITICAL CROSSROADS: NAVIGATING THROMBOTIC MICROANGIOPATHY AND DIC

Jesse E. Doyle¹; Anthony El Khouri¹; Roger Johnson². ¹Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; ²Pulmonary/Critical Care Medicine, Ascension St Vincent, Evansville, IN. (Control ID #4064823)

CASE: A 39-year-old male post-splenectomy due to hereditary spherocytosis presented with syncope, fatigue, fever and dark urine. He had associated tachycardia and fever. Physical exam was unremarkable. Labs showed an elevated lactate, creatinine, bilirubin, transaminases, and markedly elevated D-dimer. CBC was normal. He received IV fluid resuscitation and IV Rocephin. Patient subsequently desaturated and received empiric IV heparin for suspected pulmonary embolism. PT, PTT, and INR were prolonged. Lactic acid continued to rise, and renal function deteriorated. CRP was elevated but ESR was normal. Blood cultures grew Streptococcus pneumoniae. He developed mottling throughout the extremities with associated pain. Patient then developed severe thrombocytopenia and low fibrinogen. He received fresh frozen plasma and protein C (PC) concentrate. Hemodialysis was initiated for anuria and he suffered multiple necrotic digits from worsening purpura fulminans (PF). Blood smear revealed schistocytes. Antithrombin III and PC activity were low. On day three, his D-dimer continued to rise. LDH was elevated with a normal reticulocyte count. Hematology recommended urgent transfer to our facility for emergent therapeutic plasma exchange (TPE). Patient improved markedly after initial TPE. ADAMTS13 activity ruled out thrombotic thrombocytopenic purpura (TTP). Sepsis-related disseminated intravascular coagulation (DIC) was diagnosed. He received five TPE cycles in total.

IMPACT/DISCUSSION: This case highlights the potential challenge distinguishing between thrombotic microangiopathies (TMAs) and DIC. Although initial TTP suspicion was ruled out, the patient’s TPE response implied a broader diagnosis beyond sepsis-related DIC with PF. Prompt recognition and targeted interventions, including TPE, are essential in such cases. Prompt diagnosis of TMAs, particularly TTP, remains crucial in cases of severe thrombocytopenia and hemolytic anemia. The PLASMIC score aids in early identification, and TPE is a pivotal intervention, removing autoantibodies and large von Willebrand factor multimers. In the context of DIC, heparin may be considered. Studies suggest TPE's efficacy in sepsis-associated DIC, possibly through removal of inflammatory cytokines and restoration of endothelial function. PF, associated with DIC, is a life-threatening syndrome, and our case's occurrence following S. pneumoniae infection aligns with known infectious etiologies. TPE was chosen in our case as an urgent intervention due to the patient’s rapidly deteriorating condition, clinical suspicion of TMA, and the need for quick removal of potential pathogenic factors. Timely TPE was pivotal in reversing clinical decline and underscores its significance.

CONCLUSION: Distinguishing between TMA and DIC may pose diagnostic and therapeutic challenges in critically ill patients. Timely recognition and targeted interventions, specifically TPE, can be pivotal in reversing rapid clinical decline.

CRYOGLOBULINEMIC GLOMERULONEPHRITIS IN A PATIENT WITH A HISTORY OF PERIPHERAL T-CELL LYMPHOMA IN REMISSION

Jacob Dubner, Jeffrey Arace, Amy Song, Lyle Dershowitz, Maria H. de Miguel. Medicine, Columbia University Irving Medical Center, New York, NY. (Control ID #4053752)

CASE: An 80-year-old male with a history of HFrEF and stage II peripheral T-cell lymphoma (PTCL)— diagnosed in 2016, treated with CHOP, in remission as of 2017—presents to the ED with dyspnea. Three weeks prior, he developed a purpuric rash on his legs and trunk that was diagnosed as leukocytoclastic vasculitis via outpatient punch biopsy. In the ED, he was found to have an AKI (Cr 1.77 mg/dL; baseline Cr 0.9 mg/dL) with low C3, undetectable C4, and a urinalysis notable for hematuria, proteinuria, and pyuria without bacteriuria. ANCA was mildly positive (1:80), RF was normal, and anti-nuclear, PLA2R, SSA/SSB, and dsDNA antibodies were negative. SPEP was negative, serum κ/λ ratio was normal, and UPEP detected kappa Bence-Jones proteins. Testing for HBV, HCV, and HIV was negative. Renal US showed kidneys normal in size and echogenicity without hydronephrosis or nephrolithiasis. The patient was admitted to a medical service with nephrology consulted.

The patient underwent diuresis for a suspected HFrEF exacerbation with an improvement in dyspnea. Diuresis was stopped on hospital day (HD) 5 due to a worsening AKI with a peak Cr of 4.31 mg/dL on HD10. Given concern for cryoglobulinemic glomerulonephritis (GN) linked to a possible recurrence of PTCL, the patient was started on a 3-day course of pulse steroids with improvement in Cr to 3.10 mg/dL by HD15. The patient later tested positive for type III serum cryoglobulinemia with kidney biopsy showing IgG-dominant immune complex mediated diffuse endocapillary proliferative GN, confirming the diagnosis of cryoglobulinemic GN. The patient was discharged on high-dose prednisone and biweekly rituximab infusions and was referred to oncology to be evaluated for PTCL recurrence. Follow-up PET imaging was negative for PTCL. At 3-months, Cr had partially recovered to 2.64 mg/dL.

IMPACT/DISCUSSION: Mixed cryoglobulinemia (MC) is a cryoglobulinemic small-to-medium vessel vasculitis associated with C4-predominant hypocomplementemia that can present with purpura, weakness, and arthralgia as well as GN and peripheral neuropathy. MC is most often associated with chronic infections such as HCV, but it can also be seen in lymphoproliferative disorders and autoimmune conditions. This case highlights the importance of including MC in the differential diagnosis for GN in the absence of chronic infection. Prior case reports have described MC as a presenting sign of undiagnosed PTCL, but this is the first case to discuss MC as a sign of PTCL recurrence requiring referral to oncology. Although this patient’s PET imaging was negative for PTCL, he is appropriate for continued monitoring for PTCL given early subclinical recurrence remains possible and other etiologies of MC are considered unlikely.

CONCLUSION: Patients with a history of lymphoproliferative malignancy who present with MC in the absence of chronic infection should be referred for additional evaluation to enable early detection and treatment of malignancy in the event of recurrence.

CULTURE NEGATIVE SPINAL EPIDURAL ABSCESS IN THE SETTING OF CHLAMYDIA INFECTION: COULD IT BE DISSEMINATED GONORRHEA?

Gabrielle J. Gundermann¹; Elizabeth Trandel^1,2; Anandi Sheth⁴; Jung M. Park³. ¹Internal Medicine, Emory University, Atlanta, GA; ²Division of General Internal Medicine, Harborview Medical Center, Seattle, WA; ³Division of Hospital Medicine, Emory University, Atlanta, GA; ⁴Division of Infectious Diseases, Emory University, Atlanta, GA. (Control ID #4056843)

CASE: A 34-year-old male with history of methamphetamine use presented with 1 week of neck, shoulder, and wrist pain; intermittent fevers, myalgias, and arthralgias; and 1 day of confusion. He was afebrile and tachycardic; physical exam was notable for nuchal rigidity, cervical spinal tenderness, and upper extremity weakness. His left wrist and bilateral ankles were swollen, erythematous, warm, and tender. Arthrocentesis of the left wrist and ankle showed 47,000 and 275 WBCs, respectively. MRI demonstrated a cervical spinal fluid collection suggestive of spinal epidural abscess (SEA). He underwent emergent cervical laminectomy with washout. Blood, urine, synovial, and epidural fluid bacterial, mycobacterial, and fungal cultures were negative. In the setting of oligoarticular arthritis, urine chlamydia (CT) and gonorrhea (GC) by nucleic acid amplification testing (NAAT) were obtained with a positive CT. Subsequent oral and rectal testing for GC/CT were negative. A diagnosis of culture-negative SEA with concomitant urogenital CT infection was made. CT and GC present as coinfections approximately 10-40% of the time, and thus, a concurrent disseminated gonococcal infection (DGI) was the most likely etiology of the culture-negative SEA and the patient was treated with ceftriaxone and doxycycline.

IMPACT/DISCUSSION: SEA is a rare (2-3 cases/10,000 admissions) surgical emergency that is often detected by internists as it mimics diagnoses like meningitis and encephalitis. The most common causative organism is S. aureus, but approximately one third of patients with SEA have no identifiable etiology. The differential diagnosis of culture-negative SEA includes bacterial infection with cultures sterilized by antibiotics or, rarely, disseminated gonococcal infection (DGI). Though sensitivity for NAAT for GC is high (>90%) for urine/oral/rectal specimens, gram stain of body fluid culture is only positive approximately 50% of the time in the setting of DGI, making it an under-recognized cause of SEA. In cases of culture-negative SEA, it is important to pursue genital and extragenital testing for GC/CT. In this case, had we pursued GC/CT testing sooner, we may have been able to definitively diagnose this patient with DGI and tailor antibiotic therapy further.

CONCLUSION: - GC is likely under-recognized and challenging to diagnose as a potential etiology for culture-negative abscess syndromes.

- This case highlights that clinical suspicion for DGI should be high in the setting of culture-negative abscesses especially with another concomitant sexually transmitted infection.

DEFECT AND EFFECT: A DEFECT IN TEGMEN MASTOIDEUM LEADING TO GROUP A STREPTOCOCCAL MENINGITIS AND VENTRICULITIS

Asma Mohammadi¹; Mohamed Yassin³; Gerritt Lagemann². ¹Internal Medicine, UPMC Mercy, Pittsburgh, PA; ²Radiology, UPMC, Pittsburgh, PA; ³Infecious disease, UPMC, Pittsburgh, PA. (Control ID #4016276)

CASE: A previously healthy 35-year-old woman presented due to a two-week duration of a sore throat, a right ear infection, and a two-day decline in mental status. Despite a previous visit to urgent care where she received topical antibiotics, her symptoms persisted. She had a fever, elevated white blood cell count 26.1 K, and lactate levels 2.6. On examination, right ear purulent drainage, left eye swelling, restricted lateral eye movement bilaterally, and a right facial droop were noted indicating bilateral sixth cranial nerve palsies, and right seventh nerve palsy. Imaging disclosed left posterior scleritis, optic peri-neuritis, as well as right-sided mastoiditis and otitis media. The infection that initially spread to the left retro-bulbar side subsequently extended to the right. MRI orbit showed left pre-septal cellulitis, ventriculitis of occipital horn, right-sided meningitis, and skull base osteomyelitis—no cerebritis or cerebral abscess. The infection spread through a defect in her tegmen mastoideum to her meninges and ventricles. ENT specialists performed myringotomy, mastoidectomy, and tube placement. Treatment involved Ciprofloxacin and Brimonidine. CSF analysis indicated bacterial meningitis but with 2000 WBC. Vancomycin, cefepime, and steroids were started. Cultures returned positive for GAS. The patient was discharged on Ceftriaxone for skull base osteomyelitis. Post-discharge, she complained of dizziness and gait instability and a repeat MRI showed an extension of infection to right labyrinth.

IMPACT/DISCUSSION: Group A Streptococci (GAS), or Streptococcus pyogenes, is a Gram-positive beta-hemolytic bacterium historically linked to acute pharyngitis, rheumatic fever, and skin and soft tissue infections. Recent studies reveal rising cases of GAS infections such as mastoiditis, pneumonia, and osteomyelitis. Here, we present a case of a young woman displaying right oto-mastoiditis, left sided peri-neuritis, sixth and seventh cranial nerve palsies, meningitis, and ventriculitis due to GAS infection.

CONCLUSION: GAS continues to be a challenging organism with significant morbidity and mortality. GAS is a rare cause of acute bacterial meningitis (<0.2% of bacterial meningitis cases). This combination of sixth and seventh cranial nerve involvement secondary to meningitis related to complicated ear infection is extremely unusual. Our patient did not display any meningeal signs, however, despite treatment her infection progressed from mastoiditis to ventriculitis to labyrinthitis. The reasons for our patient’s complications could be postulated to be undertreatment prior to hospital admission and delayed diagnosis and treatment given the fact that GAS meningitis is uncommon. Ear infections have to be treated aggressively, especially if there is any mastoid involvement to avoid potential CNS complications. This case underscores considering GAS as a potential cause of optic neuritis, meningitis, and ventriculitis.

DEFYING THE ODDS - A UNIQUE PRESENTATION OF COLPOCEPHALY IN AN ADULT WITHOUT NEUROLOGICAL IMPAIRMENTS

Jacky V. Tran²; Julia Liang¹; Ajay Breen¹. ¹Internal Medicine, Legacy Health System, Portland, OR; ²Kansas City University, Kansas City, KS. (Control ID #4064220)

CASE: 53 yo F with PMH of T1DM, CKD, depression, HTN, HLD with prior imaging showing ventriculomegaly presents with recurrent falls and altered mental status, found to have hydrocephalus and diagnosed with colpocephaly. She presented with change in mentation on day of admission that was new from her baseline. She had been having recurrent falls 2 years prior for which she had an MRI that showed chronic appearing ventriculomegaly but was not issued a formal diagnosis by her neurologist. Patient reported that she forgot what happened in the morning but her daughter found her in the bedroom with vomit over her. She had been adherent to her medications including insulin, citalopram, lisinopril/HCTZ and lovastatin. Denied recent illness or sick contacts but had poor PO intake. Worked as a department store clerk for decades. Physical exam notable for amputation to left greater toe, diminished sensation to distal left foot, and normal strength in BUE and BLE with trace dysmetria on finger to nose testing. Lab workup only notable for an elevated creatinine, and negative for leukocytosis/troponin elevation/ethanol/drugs/TSH, B12 or ammonia derangements. Her urinalysis was negative for infection. Prior workup showed normal vitamin B12, B6, folate and copper, with a slightly low vitamin D and slightly elevated GAD antibody. No arrhythmia was noted on telemetry. Repeat MRI showed no acute hydrocephalus but chronically enlarged occipital horns, suggestive of congenital abnormality vs. prenatal insult with hyperdynamic flow of CSF. Neurosurgery evaluated patient and felt patient's imaging and physical exam was most consistent with colpocephaly. Patient improved with supportive treatment including oral intake and IV fluids. She was ultimately discharged with home health referral to help optimize her living situation and encouraged to follow-up with her neurologist in regards to ongoing options for colpocephaly.

IMPACT/DISCUSSION: Colpocephaly is a rare congenital brain anomaly that is characterized by selective enlargement of the posterior horn of the lateral ventricles relative to the other parts of the lateral ventricles. Colpocephaly is usually diagnosed in infancy when a patient presents with intellectual disability or seizures, and is rarely diagnosed in adulthood, often incidentally. We report an unusual case of 53 yo female who experienced no neurological or psychiatric deficits for much of her life until she presented to the hospital with acute encephalopathy in the setting of recurrent falls and an AKI. Her imaging findings and clinical picture was thought to be most consistent with colpocephaly rather than NPH and she improved with supportive care without invasive measures such as shunting. She was discharged with home health and recommended close follow-up by neurology.

CONCLUSION: Colpocephaly is a rare congenital brain anomaly that should be recognized as a distinct entity from NPH as it can be treated supportively without shunt placement.

DERMATOMYOSITIS WITH ANTI-TRANSCRIPTION INTERMEDIARY FACTOR 1-γ ANTIBODIES MASKING UNDERLYING DIFFUSE LARGE B-CELL LYMPHOMA

Takuya Otsuki^1,6; Kosuke Ishizuka²; Hiromitsu Eto³; Hiroyasu Nakano⁴; Yo Kato⁵; Hiroshi Sudo⁴; Iori Motohashi^1,6; Kenya Ie^1,6; Yoshiyuki Ohira⁶; Chiaki Okuse^1,6. ¹Department of General Internal Medicine, Kawasaki Shiritsu Tama Byoin, Kawasaki, Kanagawa, Japan; ²Department of General Medicine, Yokohama Shiritsu Daigaku Fuzoku Byoin, Yokohama, Kanagawa, Japan; ³Department of Dermatology, Ofuna Chuo Byoin, Kamakura, 神奈川, Japan; ⁴Department of Internal Medicine, Ofuna Chuo Byoin, Kamakura, Kanagawa, Japan; ⁵Department of Pathology, Ofuna Chuo Byoin, Kamakura, 神奈川, Japan; ⁶Department of General Internal Medicine, Sei Marianna Ika Daigaku, Kawasaki, Kanagawa, Japan. (Control ID #4061398)

CASE: A 69-year-old man presented with a rash, limb pain, and dysphagia. Physical examination revealed a heliotrope rash, Gottron's and V-neck signs, and proximal muscle tenderness and weakness in the limbs. Blood chemistry showed elevated muscle enzymes and immunological tests showed positive for anti-transcription intermediary factor 1-γ (anti-TIF1-γ) antibodies. Contrast-enhanced chest-abdominal computerized tomography (CT) revealed a 20-mm enlarged para-aortic lymph node, with no other signs of malignancy. Thigh magnetic resonance imaging showed bilateral inflammatory changes suggestive of myositis. The patient was diagnosed with anti-TIF-1γ antibody-positive dermatomyositis. His dysphagia, muscle weakness, and myositis did not respond to steroid pulse therapy or high-dose intravenous immunoglobulin and azathioprine treatment. Bone marrow biopsy showed no sign of malignancy but worsening anemia and atypical lymphocytes were noted in the peripheral blood 6 weeks later. The patient developed a fever of 38°C during week 8 of hospitalization, and CT revealed para-aortic lymphadenopathy up to 30 mm in diameter. A lymph node biopsy was not performed due to the patient’s poor physical condition. The bone marrow biopsy and steroid therapy were repeated during week 10 owing to persistent fever and elevated lactate dehydrogenase (LDH) levels. The bone marrow biopsy revealed diffuse large B-cell lymphoma (DLBCL). The patient died due to disease progression before treatment could be initiated.

IMPACT/DISCUSSION: Dermatomyositis is associated with malignancies, but cases of anti-TIF-1γ antibody-positive dermatomyositis with DLBCL are rare. Dermatomyositis often improves following the treatment of associated malignancies; however, diagnosis and treatment can be challenging. The patient had fever, lymphadenopathy, and elevated LDH levels, but these were attributed to dermatomyositis. The initial bone marrow biopsy was negative and lymph node biopsy was not feasible due to the surgical risks. When initial malignancy screening is inconclusive, steroid treatment for dermatomyositis may mask hematologic malignancies, such as lymphoma. In this case, DLBCL was diagnosed after the second bone marrow biopsy, and may initially have been masked by steroid treatment.

CONCLUSION: In patients with anti-TIF-1γ antibody-positive dermatomyositis, comprehensive malignancy screening is advisable before administering steroids because of the high prevalence of coexisting malignancies.

DIAGNOSIS OF CALCIPHYLAXIS IN A YOUNG FEMALE WITH ESRD

Sarita Sooklal¹; Joseph Lieber². ¹Internal Medicine, Mount Sinai Health System, New York, NY; ²Internal Medicine, NYC Health and Hospitals Elmhurst, Queens, NY. (Control ID #4056444)

CASE: The patient is a 43 year old female with type 2 diabetes, lupus, end stage renal disease on dialysis, peripheral vascular disease complicated by poorly healed wounds, and prior splenic vein thrombosis (on Eliquis), who was admitted for management of purulent drainage from chronic lower extremity wounds. On review of systems, she denied fevers, chills, shortness of breath, or chest pain but reported severe lower leg pain. On exam, she was afebrile and vitals were unremarkable. She had numerous eschars and ulcers draining purulent fluid and dry gangrene on both lower legs. Her labs showed WBC 15.5, Hgb 7.8, Ca 8.9, phos 2.7, and PTH 567. X-Rays of the tibia and fibula showed extensive calcification of arterial vessels. She was started on antibiotics for presumed skin and soft tissue infection and underwent wound debridement in the OR. Biopsies were obtained per dermatology, as there was concern for calciphylaxis given the exam and XR findings. Renal recommended empiric treatment with cinacalcet and sodium thiosulfate. The biopsy results were consistent with a diagnosis of calciphylaxis. The patient’s pain was managed with IV Dilaudid. She is status post L AKA with concern for new RUE gangrenous changes.

IMPACT/DISCUSSION: Calciphylaxis is a rapidly progressive disease with extremely high mortality rates within the first year (50-80%). Therefore, appropriate identification and treatment is critical. The disease is most prevalent in ESRD patients due to abnormalities within the bone mineral pathway, including elevated phosphorus and elevated parathyroid hormone. They stimulate transformation of vascular smooth muscle cells into osteoblast-like cells. Similarly, chronic inflammation, autoimmune disease and low Vitamin K (patients on warfarin), decrease inhibitors of vascular calcification, such as Fetuin A and MGP. The result is increased calcium deposition in arteriole walls that progresses to fibrosis and thrombosis, causing the distinctive eschars and tissue necrosis seen on exam. Diagnosis can be made based on physical exam findings alone, thus tissue biopsy is not required. If calciphylaxis is suspected, it is crucial to start empiric therapy with cinacalcet, to decrease PTH levels, and sodium thiosulfate, to vasodilate the arteries and remove calcium from vessel walls (calcium chelator). Patients’ pain should be treated with IV medications and wound dressings should be changed regularly to prevent infection.

CONCLUSION: ESRD, AI disease, Vitamin K inhibition, elevated PTH, obesity, diabetes and female sex are risk factors for calciphylaxis.

Keep calciphylaxis on the differential in ESRD patients with painful ulcers, eschars and necrosis.

Vigilant wound care, pain control, cinacalcet and sodium thiosulfate are the mainstays of treatment for calciphylaxis.

DIAGNOSTIC DILEMMA: ENDOMETRIOSIS MIMICKING IBD IN THE SETTING OF TERMINAL ILEITIS AND SMALL BOWEL OBSTRUCTION

Rushnan Islam¹; Rohan Goyal^3,1; Scott J Schafler^2,1. ¹Medicine, Albert Einstein College of Medicine, Bronx, NY; ²Montefiore Medical Center, New York, NY; ³Internal Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4060605)

CASE: 35 year old female with history of dysmenorrhea, infertility, and recent terminal ileitis, presented with 3 months of RLQ pain. Two weeks prior, she was treated conservatively for terminal ileitis with small bowel obstruction (SBO). The pain recurred along with no bowel movement or flatus for 2 days. Transvaginal ultrasound revealed enlarged ovaries and hemorrhagic cysts. CT indicated distended distal ileal loops with bowel wall thickening. Colonoscopy revealed erythematous, eroded and ulcerated mucosa in the terminal ileum, raising suspicion for Crohn's. Biopsies showed benign lymphoid hyperplasia. Despite initial improvement, she experienced worsening abdominal pain and recurrent SBO. Conservative management was re-initiated along with PPN. MR enterography demonstrated deep infiltrating endometriosis with bilateral endometriomas in ovaries, sigmoid colon and uterine serosa, along with adherence of terminal ileum to right ovarian endometrioma. Leuprorelin and norethindrone were initiated. Patient underwent bilateral salpingectomy, ovarian cystectomy, small bowel resection and ileocecectomy with primary anastomosis. Pathology confirmed diagnosis of endometriosis involving terminal ileum and appendix, with transmural necrosis and ileal perforation.

IMPACT/DISCUSSION: Initially chronic abdominal pain, recurrent SBO and elevated ESR/CRP led to a thorough evaluation of gastrointestinal etiologies. Despite colonoscopy findings resembling IBD, biopsy played a crucial role in redirecting our differential. Our approach was then guided by clinical suspicion for bowel endometriosis due to the fluctuating nature of pain, history of dysmenorrhea and infertility, and imaging results.

Endometriosis, characterized by the presence of ectopic endometrial tissue outside the uterine cavity, is a cause of chronic abdominal pain in pre-menopausal women. However, SBO and ileal perforation are a rare presentation for it, which might have delayed our diagnosis. This highlights a common diagnostic pitfall of anchoring and pattern recognition among clinicians. Surgical intervention is definite for diagnosis and treatment of endometriosis, yet MR enterography, with 77-94% sensitivity, offered vital peri-operative insights. Hormone suppression was initiated to reduce disease activity.

Recurrent SBOs and the extensive diagnostic studies delayed surgery by weeks and prolonged PPN exposure, raising the question of whether in the setting of high index of suspicion could diagnostic approach be narrowed? Earlier MR enterography and multidisciplinary collaboration might have expedited surgical intervention. We also sought to ask what is the ideal duration of hormonal suppression to optimize patients for surgery? Balancing diagnostic accuracy with timely intervention is crucial, especially for acutely ill patients.

CONCLUSION: In pre-menopausal women with terminal ileitis and acute SBO, a high clinical suspicion for endometriosis is crucial considering the clinical context, for timely diagnosis and treatment.

DIAGNOSTIC LESSONS FROM RECURRENT DISTRIBUTIVE SHOCK

Katherine Miotke¹; Christina Morse². ¹Internal Medicine Residency, Washington State University, Pullman, WA; ²Providence Regional Medical Center Everett, Everett, WA. (Control ID #4061168)

CASE: 77 y.o. male with a history of CAD, HTN, and DLBCL (diagnosed 10 yrs ago, treated w/ 3 cycles of CHOP with CSF recurrence 5 yrs later).

Over the past month, he’s had three admissions for hypotension, intermittent fevers, and shock physiology requiring vasopressor support. He has had persistently elevated ferritin at 2300, procalcitonin > 50, CRP >5, anemia, and thrombocytopenia. Over each hospitalization, he was started on broad spectrum antibiotics, but no source of infection was clearly found on CXR, UA, CT C/A/P, or LP. Bone marrow biopsy and PET-CT was unrevealing and did not show hemophagocytic activity or a recurrence of his DLBCL. He was seen by ID and Oncology that only uncovered an autoimmune hemolytic anemia and noted splenomegaly, for which he was started on prednisone.

Now, he returned from SNF after being found altered, and again has shock physiology. At this time, a soluble IL-2 receptor level resulted as elevated, although NK activity was normal. Additionally, repeat peripheral smear on this admission with malignant cells concerning for a recurrence of his lymphoma with a repeat bone marrow biopsy and flow cytometry pending.

IMPACT/DISCUSSION: This case highlights the challenging task of diagnosing both a recurrence of DLBCL and HLH. This patient showed none of the obvious signs of DLBCL, such as an enlarging lymphoma or lymphadenopathy but did have some non-specific B symptoms. This clearly highlights the importance of having a high threshold of suspicion for relapse with unexplained B-symptoms or inflammatory findings, even in the presence of a normal PET-CT and bone marrow biopsy.

This case also highlights the difficulty in accurately diagnosing HLH, as the patient meets some but not all of the diagnostic criteria for HLH, exhibiting only recurrent fever, splenomegaly, persistently elevated ferritin, elevated soluble IL-2 receptor, and bicytopenia but no hypertriglyceridemia, lower NK cell activity, or hemophagocytosis on bone marrow biopsy. No single diagnostic test can be used as a gold standard for diagnosing HLH and the findings can often overlap with other clinical conditions. This is further complicated by the fact that HLH can be triggered by other conditions, such as a recurrence of DLBCL, and thus diagnosis of an underlying condition cannot rule out HLH altogether

The biggest learning point to take away from this case is that it highlights the importance of not overly relying on diagnostic testing. All tests could return as a false negative and repeat testing should be considered, particularly if no alternative diagnosis is found. Taking a careful history can be crucial in these cases and can both guide your threshold for repeat testing as well as the likelihood of alternative diagnoses.

CONCLUSION: No test has a sensitivity of 100%, so consider retesting if no alternative diagnosis is found

DLBCL recurrence is a diagnostic challenge and can both mimic HLH and trigger it.

DILTIAZEM DILEMMA: A CASE REPORT OF DILTIAZEM-INDUCED LACTIC ACIDOSIS AND AKI IN A PATIENT WITH ACUTE DECOMPENSATED HFREF

John P. Kundrick, Morgan Ferrell, Louis Leff. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4063498)

CASE: A 60-year-old man with a history of HFrEF (LVEF 40%) and atrial fibrillation (AF) presented with acute onset dyspnea in the setting of not taking his prescribed medications for one week. In the emergency room, findings were consistent with acute decompensated heart failure, as BNP was elevated, chest x-ray demonstrated pulmonary edema, and he appeared volume-overloaded on exam. Notably, his lactate level was 2.5 mMol/L. He was also found to be in AF with rapid ventricular response (RVR), for which he was given an intravenous bolus of diltiazem, followed by an oral dose, which successfully controlled his rate. Soon after admission, and six hours after the diltiazem administration, a repeat lactate level was drawn and was noted to be increased to 8.2 mMol/L. In addition, CMP demonstrated a rise in creatinine of 0.3 mg/dL, consistent with an AKI. Diltiazem was discontinued and he was monitored closely overnight with trends in his lactate level. Fortunately, he remained hemodynamically stable, his lactate trended down, and his AKI self-resolved. An alternative agent was used for ongoing rate control and no further incidents arose.

IMPACT/DISCUSSION: Diltiazem’s negative inotropic effects are well documented and its use in patients with HFrEF is rightfully cautioned by various sources. Moreover, it is generally recommended to avoid negative inotropes altogether in patients with acute decompensated HF. However, there is still some debate and conflicting evidence on whether diltiazem’s use for rate control produces more adverse events than alternatives in patients with AF with RVR and HFrEF. Some sources caution that it may precipitate HF symptoms, AKI, and even cardiogenic shock, while others have found no difference in safety outcomes between its use with alternatives. Generally, these studies are small and have mixed results or extrapolate data from chronic diltiazem use in HFrEF. This is a case of a significant lactic acidosis and AKI precipitated in a patient with acute decompensated HFrEF who received diltiazem for rate control. Other agents without negative inotropic effects, such as amiodarone and digoxin, may have a better overall safety profile in these instances. Fortunately, the lactic acidosis and AKI spontaneously resolved without further incident once diltiazem was discontinued.

CONCLUSION: Diltiazem should be used judiciously for rate control in patients with HFrEF, especially during acute decompensation. Further research is needed to determine the efficacy and safety differences of diltiazem versus other treatment options for AF with RVR in patients with HFrEF with or without acute decompensation.

DISSEMINATED INTRAVASCULAR COAGULATION (DIC) COMBINED WITH ACUTE BILATERAL RETINAL HEMORRHAGE AS INITIALLY CLINIC PRESENTATION IN NEW ONSET ACUTE PROMYELOCYTIC LEUKEMIA (APL)

Roop S. Parlapalli¹; Syed Muhammad Hussain Zaidi²; QI SHI³. ¹Hospital Medicine, Geisinger Health, Danville, PA; ²Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ³internal medicine, Geisinger Community Medical Center, Scranton, PA. (Control ID #4053900)

CASE: A 32-year-old male with past medical history of atopic asthma, allergic rhinitis who presents to the emergency department with chief complaints of worsening right eye blurry vision for the past 2 days associated with headache, dizziness, and fevers. Patient also has intermittent easy bruising, epistaxis, earache, sore throat, and for the past 2 months. Physical examination: temperature was 101.3 F, respiratory rate was 14 times/min SpO2 was 100% on room air, blood pressure was 140/120 mmHg and pulse was 110 per minute multiple bruising sports over abdomen, chest, lower and upper extremities. Fundus examination in ED found right eye macular edema, possible retinal hemorrhage. Laboratory tests showed hemoglobin 6.4, WBC 25.77, platelets 7, immature reticulocyte fraction 39.0, Coagulation profile showed Disseminated Intravascular Coagulation including elevated INR was 1.5, prothrombin time was 18.5, and fibrinogen was 156, and D-dimer was more than 20. Uric acid 7.5. Rest of metabolic panel was normal. Patient received urgent 2 units of PRBC and 1 unit of platelets. CT of head showed unremarkable for intracranial pathology, The flow cytometry of peripheral blood demonstrates that populations of myeloblasts, consistent acute myeloid leukemia with features suggestive of acute promyelocytic leukemia. Cytogenetics: showed 46, XY, PML-RARA long fusion transcript associated with t (15;17) (q22; q21), detected (92.5%). PML: RARA fusion associated translocation. Peripheral blood tested AML (90% blasts) and Auer rods present, Bone Marrow biopsy showed AML with morphology and immunophenotypes suspicious for APL. The patient was promptly started on Hydroxyurea, Cytarabine, Tretinoin, and one dose of Gemtuzumab and Arsenic Trioxide. During treatment patient developed differentiation syndrome that resolved with systemic steroids. Allopurinol and rasburicase were given for considering Tumor lysis syndrome. Patient was discharged after about 3 weeks and followed up with Hematology/Oncology.

IMPACT/DISCUSSION: Acute promyelocytic leukemia, unique form of acute leukemia, catastrophic unless treated early with specific agents. it predominantly presents with hemorrhagic manifestations at the time of initial presentation usually in the central nervous system with devastating consequences. There were only limited cases presented with initial retinal hemorrhages for Acute Promyelocytic Leukemia. Prompt identification and initiation of specific target chemotherapy reversed and averted bad clinical outcome. During tretment patient also developed differntiation syndrome which is noticed during the initial acute phase treatment of leukemia, which was treated effectively with systemic steroids and also treatment for tumor lysis syndrome.

CONCLUSION: Our case highlights the importance of early identification of specific form of leukemia where prompt identification and treatment is required. Patient had undergone successful treatment with good clinical response.

DISSEMINATED VZV SEIZURE IN AN IMMUNOCOMPETENT YOUNG MALE WITH UNCONTROLLED DIABETES

Kathleen Young¹; Rooshan Arshad¹; Angela Ishak²; Abeselom Geletu²; Mohamad Beidoun². ¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #4054047)

CASE: A 39-year-old male with a history of untreated schizophrenia and bipolar disorder presented with a witnessed seizure, characterized by extremity shaking, unresponsiveness, and vomiting, lasting 10 minutes. He reports a prior seizure-like episode one year ago but was never medically evaluated. Upon arrival at the emergency department, he exhibited sinus tachycardia, elevated troponins peaking at 54, and hyperglycemia at 418 mg/dL. HIV testing was negative, and the patient had no recent illnesses or trauma. Labs were pertinent for an increased lactate of 3.9, anion gap metabolic acidosis, elevated CPK at 456, and leukocytosis of 19.7. Physical exam was notable for a single dermatome vesicular rash on the right thoracic spine. Given the clinical picture concerning for meningitis, a lumbar puncture (LP) was performed, and the patient was empirically initiated on vancomycin, acyclovir, and ceftriaxone. Further workup revealed A1C of 15.0. EEG and MRI were unremarkable at the time for epileptic or ischemic changes respectively. A diagnostic LP demonstrated pleocytosis, lymphocytosis and confirmed Varicella-Zoster Virus (VZV). Treatment with IV acyclovir resulted in clinical improvement, and he was discharged following a 7-day course with neutral protamine Hagedorn (NPH) insulin (4 units twice per day) and 7 days of oral valacyclovir.

IMPACT/DISCUSSION: This case challenges the conventional understanding of disseminated (VZV), typically observed in immunocompromised individuals. The patient is a young male with no apparent risk factors, presenting with a seizure and vesicular lesions across only a single dermatome as manifestations of disseminated zoster. Notably, there exists a few cases that link disseminated VZV and diabetes and only one involving one single dermatome in an immunocompetent diabetic patient, involving the abdomen in that case. In this patient, the possibility of meningeal involvement is significant, despite limited dermatomal spread. This may potentially be explained by untreated hyperglycemia resulting in compromised immunity. However other case reports highlighted this association in patients with well controlled diabetes. Patients with diabetes are thought to be at an increased risk as studies has show lower cell-mediated immunity in these patients against VZV. Given the necessity for airborne precautions in disseminated zoster, it is crucial to promptly identify criteria for disseminated zoster as early recognition may improve infection control.

CONCLUSION: A high suspicion of disseminated herpes zoster in patients with diabetes should be considered. It is crucial to promptly identify visceral involvement as disseminated zoster, even in cases with limited cutaneous manifestation, in order to limit risk of infectious transmission. Recognize the criteria for disseminated varicella zoster virus (VZV) infection, emphasizing that visceral involvement should be considered, even in cases with limited dermatome manifestation.

DON'T OVERLOOK URINARY TRACT INFECTIONS IN ANURIC DIALYSIS PATIENTS: UNMASKING PYOCYSTIS

Saki Takeda¹; Akihito Yoshida¹; Takaaki Kobayashi²; Kazuya Oshima¹; Takahiro Fukushima¹. ¹general internal medicine, Kameda Medical Center, Kamogawa, Chiba, Japan; ²University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #4058476)

CASE: An 84-year-old woman with chronic renal failure due to diabetic nephropathy on maintenance hemodialysis (HD) and right-sided hemiparesis due to a previous stroke presented with abdominal pain and general body ache. She has been anuric for the last two years and has been undergoing HD three times a week. She developed mild fever and appetite loss 1.5 months ago. Vital signs were unremarkable without fever. Physical examination revealed non-reproducible tenderness in the abdomen and general joints. Laboratory workup revealed a white blood cell count of 6,900/μL. Urinalysis was not performed due to the history of anuria. Blood cultures were negative. A contrast-enhanced computed tomography revealed a low-attenuation area in the bladder distinct from urine. A urinary catheter was inserted, and pus-like fluid (40 mL) was drained, leading to a diagnosis of pyocystis. Urine culture subsequently grew ESBL-positive Klebsiella pneumoniae, and she received cefmetazole for two weeks. Bladder irrigation with sterile saline was also performed twice a week along with systemic antibiotics.

IMPACT/DISCUSSION: Pyocystis is a severe form of lower urinary tract infection resulting from the collection of purulent debris within the bladder. It is referred to as 'empyema cystis' and 'vesical empyema' in the literature, often occurring in patients with bladder dysfunction. The cause is believed to be the accumulation of shed bladder epithelium and microorganisms, leading to urinary tract infections. Clinical symptoms vary from lower abdominal discomfort to sepsis-like symptoms. However, in patients with neurological disease, associated sensory deficits may make the presence of local symptoms inconsistent. In addition to systemic antibiotic treatment, bladder irrigation with sterile saline or an antibiotic-containing solution of gentamicin or neomycin is recommended. Growing evidence suggests that cefmetazole has clinical and bacteriological effectiveness comparable to carbapenem against invasive urinary tract infections due to ESBL-producing Enterobacteriaceae (ESBLECs) and is considered a potential candidate for carbapenem-sparing therapy. In this case, the diagnosis of pyocystis was delayed due to the history of anuria and unclear localization of symptoms. It is crucial to consider pyocystis in the differential diagnosis when there is fluid retention in the bladder, even in anuric dialysis patients.

CONCLUSION: Pyocystis is an important yet overlooked rare complication of a non-functioning urinary bladder and can even affect anuric patients. In addition to antibiotic administration, bladder irrigation should be considered to prevent the re-accumulation of infected debris and to assist in clearing the initial collection.

DON’T WORRY, IT JUST LOOKS LIKE TAMPONADE ON THE ECHO

Bronson R. Kunzler¹; Nicholas S. Faraci¹; Aiyedun Uzamere³; Aimee N. Pickering². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ³University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4064860)

CASE: An 81-year-old female with past medical history of hypertension and hypothyroidism presents with a 2-week history of lower extremity edema, dyspnea, and difficulty ambulating found to be in new onset congestive heart failure.

Upon presentation, the patient was afebrile, HR 110’s, BP 136/110, RR 27, saturating 95% on 3L nasal cannula. The physical exam was notable for significant Jugular Venous Distention (JVD), bibasilar rales, normal heart sounds without murmur, and 4+ pitting edema to the knees. Labs were notable for WBC 13.0, Na 132, K 5.1, Cr 2.1 (baseline 1.2), Ca 11.6, INR 1.4, high-sensitivity troponin 2330, BNP 2927 and lactate 2.2. Her EKG was only notable for tachycardia, CXR showed bilateral effusions, POCUS showed thickened LV with reduced function and evidence pericardial effusion. Transthoracic Echocardiogram was significant for severe LVH with LVEF estimated at 20-25%, Pulmonary Artery Pressure of 39 mmHg, and a moderate to large circumferential pericardial effusion with diastolic RA collapse and >25% respiratory variation of the mitral E wave consistent with increased pericardial pressure. These findings were communicated to the primary service with the guidance to “correlate clinically”.

On reassessment the patient remained hemodynamically stable, pulsus paradoxus was negative, her heart sounds were easily appreciated on auscultation, and she continued to have significant JVD. Urgent intervention was deemed unnecessary. The following day right heart catheterization revealed normal cardiac pressures and no evidence of tamponade.

IMPACT/DISCUSSION: Even with convincing echocardiographic findings, tamponade is a clinical diagnosis classically presenting with Beck’s triad of hypotension, JVD, and muffled heart sounds. The most sensitive findings for tamponade are dyspnea (87%-89%), tachycardia (77%; 95% confidence interval [CI], 69%-85%), pulsus paradoxus (82%; 95% CI, 72%-92%), JVD (76%; 95% CI, 62%-90%), and cardiomegaly on CXR (89%; 95% CI, 73%-100%). Precise physical exam can help internists raise or lower their suspicion of hemodynamically significant tamponade. In this case, though significant dyspnea, tachycardia, and JVD were present, the patient had easily appreciable heart sounds, normotension, and no evidence of pulsus paradoxus on exam. The absence of pulsus paradoxus alone lowers the likelihood ratio to .03 (vs. a likelihood ratio of 3.3 in a patient with positive pulsus paradoxus) effectively ruling out the diagnosis of tamponade.

CONCLUSION: Thoughtful and complete physical examination provides the information needed for internists to rule out the diagnosis of cardiac tamponade, even if echocardiographic evidence is suggestive of tamponade physiology.

DOUBLE TROUBLE A COMPLEX CASE OF RECURRENT ULCERS AND SKIN LESIONS

Yonathan Daniel¹; Sarah Freeman¹; Noor Tell¹; Gabrielle Knauer². ¹Medicine, Brown University Warren Alpert Medical School, Providence, RI; ²Lewis Katz School of Medicine at Temple University, Philadelphia, PA. (Control ID #4042289)

CASE: A young African-American male with a history of recurrent oral and genital sores and uveitis presented with severe mouth sores, dysphagia, odynophagia, and targetoid skin lesions. His medical history included sporadic steroid use, no consistent primary care, no sexual history, and daily marijuana use. Tachycardic at presentation, he had erythematous oral mucosa with thrush, lip ulcers, hyperpigmented genital lesions, and painful lesions on his palms and feet. Labs showed hyponatremia, elevated CRP and ESR, normal liver enzymes, and an unremarkable neck CT. A skin biopsy indicated erythema multiforme; HSV testing was negative. He initially received Valtrex, Nystatin, PPI, multivitamins, Tylenol, and IV Morphine for presumed erythema multiforme and thrush, but swallowing difficulties persisted. EGD revealed friable esophageal ulcers, leading to a switch to IV medications. On day 2, with worsening symptoms and repeat HSV testing negative, a multidisciplinary team initiated 80mg IV Solumedrol for a suspected flare of Behçet’s disease. Dramatic improvement followed, and oral mucosa biopsies post-discharge confirmed BD.

IMPACT/DISCUSSION: This may represent the first known instance of concurrent Behçet's Disease (BD) and Erythema Multiforme (EM). In a departure from prior literature that involves misdiagnoses between the two, this patient received a unique dual diagnosis confirmed by both Dermatology and Rheumatology.

Crucially, the diagnostic process was informed by the distinct criteria and clinical findings associated with BD and EM. Biopsy findings alone were insufficient for a diagnosis. For BD, the diagnosis was supported by clinical criteria, particularly the presence of recurrent oral ulcers, a hallmark of the disease, and chronic involvement of multiple organ systems, including the eyes and genitalia. On the other hand, the diagnosis of EM was primarily driven by its characteristic target or "bullseye" skin lesions, which are emblematic of EM and not BD. EM's pathology is often a reaction to infections or medications and is self-limiting in nature.

This concurrent presentation of BD and EM in the same patient underscores the diagnostic complexity when the two syndromes co-occur. It highlights the importance of thorough and multi-disciplinary diagnostic approaches, especially in cases where overlapping symptoms might lead to an initial misdiagnosis. The unique combination of BD's chronic, systemic involvement and EM's acute, reactional nature in this patient posed a significant diagnostic challenge, effectively managed through the collaboration of different specialties and integrating both clinical and histopathological evidence.

CONCLUSION: This case report underscores key learnings in diagnosing and managing Behçet's Disease (BD) and Erythema Multiforme (EM).

-It cautions against early diagnostic conclusions; biopsy findings can be misleading.

-Provides a robust discussion of the diagnostic criteria for BD and EM.

-Highlights the importance of a multidisciplinary team approach

DRESS FOR SUCCESS: SUCCESSFUL TREATMENT OF DRESS SYNDROME WITH SEVERE LIVER INVOLVEMENT

Muhammad Ahmed Khan, Natalya Maharaj, Riffat Sabir. Internal Medicine, Baystate Medical Center, Springfield, MA. (Control ID #4063912)

CASE: A 54-year-old female with history of hyperlipidemia, asthma, and generalized anxiety disorder presented to the hospital due to fevers, sore throat, and a non-pruritic maculopapular rash that progressed from her legs to face, neck, and arms over the past week. On presentation, she was febrile and tachycardic with an unremarkable physical exam except for rash. Initial work-up showed an eosinophilia of 9.5%, atypical lymphocytosis of 25%, and deranged liver enzymes: aspartate transaminase (AST) 545 units/L, alanine transaminase (ALT) 511 units/L, and alkaline phosphatase (ALP) 622 units/L. She denied recent travel, tick bites, or intravenous drug use. Further work-up included an abdominal ultrasound, blood cultures, as well as testing for mononucleosis, tick-borne illnesses, human immunodeficiency virus, cytomegalovirus, and viral hepatitis which were all unremarkable. Further history revealaed that the patient started Lamotrigine for anxiety a month ago which she stopped a week ago. She was started on Doxycycline for presumed tick-borne illnesses; however, her negative work-up raised suspicion for a drug-induced hypersensitivity reaction which prompted initiation of Methylprednisolone 60 mg daily. Her AST and ALT gradually improved to 288 units/L and 388 units/L, respectively; however, they quickly increased to AST 606 units/L and ALT 676 units/L by hospital day four. Her RegiSCAR score was consistent with possible DRESS syndrome due to Lamotrigine exposure. Literature review was scarce on using systemic steroids for DRESS syndrome with isolated, severe liver involvement. However, given worsening liver enzymes and unimproved rash, intravenous Methylprednisolone 250 mg daily was started for 4 days. Subsequently, her liver enzymes and rash showed remarkable improvement. She was discharged on weight-based daily Prednisone and Bactrim for Pneumocystis pneumonia prophylaxis. In the outpatient setting, her liver enzymes continued to improve and she was monitored for reactivation of Herpesviridae viruses and autoimmune diseases, common sequelae of DRESS syndrome.

IMPACT/DISCUSSION: Liver injury is the most common visceral manifestation of DRESS syndrome, occurring in over 50% of cases, and can range from mild transaminitis to acute liver failure. Despite this occurence, the role of systemic steroids to treat DRESS syndrome with isolated, severe liver involvement has not been well-established to date. This case provides novel insights for such presentations by showing their efficacy in this population.

CONCLUSION: Given its clinical complexity, a high suspicion is required for timely diagnosis of DRESS syndrome. As depicted, DRESS syndrome with severe liver involvement is a complex clinical scenerio where stopping the offending drug does not hault worsening transaminitis. This case depicts the efficacy of pulse intravenous steroids in this scenerio. It also shows how timely treatment can circumvent acute liver failure which needs referral for prompt liver transplantation.

DRUG-INDUCED LIVER INJURY SECONDARY TO IMMUNOTHERAPY WITH PEMBROLIZUMAB: A RARELY FATAL COMPLICATION

George G. Kidess¹; Jasdeep S. Bathla²; Kenan Abou Chaer²; Ayman Salem³; Dana Kabbani⁴. ¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Detroit Medical Center, Detroit, MI; ³internal medicine, Detroit Medical Center, Detroit, MI; ⁴Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4061212)

CASE: A 62-year-old male with a history of relapsed Hodgkin’s lymphoma on salvage chemotherapy was transferred to our facility for acute liver injury noted by transaminitis, hyperbilirubinemia, and coagulopathy. His last dose of pembrolizumab was roughly one month prior to presentation and acute causes of liver failure such as autoimmune, viral, or infection had returned negative. Given the risk of drug-induced liver toxicity, he was started on steroids promptly. Due to worsening of liver enzymes, hyperbilirubinemia, and progression to grade IV hepatotoxicity, mycophenolate mofetil was added with steroid dose reduced due to possible steroid-induced cholestasis. Liver ultrasound showed cirrhotic morphology suspected from steatohepatitis and subsequent MRCP showed acute vs chronic cholecystitis, cirrhotic liver, and non-dilated biliary tree. He ultimately underwent liver biopsy which showed portal and lobular inflammation consisting of mostly lymphocytes with some plasma cells and few neutrophils and macrophages along with hepatocyte injury with occasional acidophil bodies and hepatocellular cholestasis, overall consistent with moderate hepatitis supporting a diagnosis of checkpoint inhibitor treatment induced liver injury. Ultimately, despite appropriate treatment, his liver failure progressed to multiorgan involvement and he was then terminally weaned in the ICU per family’s wishes.

IMPACT/DISCUSSION: Immune checkpoint inhibitors (ICI’s) are a novel class of chemotherapy medications that include cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors and programmed cell death protein 1 (PD-1) inhibitors. Commonly used for immunotherapy in a variety of advanced stage malignancies, CTLA-4 inhibitors are more associated with drug-induced liver injury (DILI). Here, we present a rare occurrence of severe DILI secondary to a commonly used PD-1 inhibitor, pembrolizumab, ultimately leading to a fatal outcome. Cases of DILI secondary to PD-1 inhibitor use are a rare occurrence and fatal outcomes occur in less than 1% of scenarios. Oftentimes, cessation of ICI use or appropriate therapy with steroids is sufficient for resolution of symptoms, however as presented above, patients can often decompensate quickly despite therapy. Some theories regarding DILI secondary to ICI use include predisposition with a history of steatohepatitis as well as an autoimmune process against hepatocytes due to inhibition of T-cell negative regulators.

CONCLUSION: With rising use of ICI’s due to their utility as an oncological chemotherapy, clinicians must remain vigilant to diagnose potential serious adverse effects and complications early and initiate treatment. Further studies and clinical trials on the development of these drugs must be done to evaluate associations between ICI use and DILI.

DRUG INDUCED LUPUS ERYTHEMATOUS

Keaton Wieschhaus, Garrett Cotter, Matthew Schirtzinger, Charles F. Hawk. Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4060889)

CASE: A 74-year-old Female with a history of rheumatoid arthritis, resistant hypertension, and CKD stage 2 presented with 8 weeks of progressing, photo-distributed rash. The rash was associated with oral mucositis, myalgias, arthralgias, and a 15 pound weight loss. Previously, the patient was prescribed a course of Doxycycline and prednisone with no improvement. Prior to arrival she had a biopsy, while on prednisone, that revealed no clear etiology. Upon presentation, physical exam revealed erythematous plaques with overlaying collarettes of scale and hemorrhagic crust in a photo-distributed pattern sparing the nasolabial folds.

Lab work revealed an elevated CRP, ESR, hypotonic hyponatremia, acute-on-chronic normocytic anemia, and proteinuria on Urinalysis. At this time a broad differential included DILE, phototoxic drug eruption, porphyria cutanea tarda, dermatomyositis, and polymyositis. Lab work-up revealed a positive ANA, chromatin antibody, SM/RNP antibody, smith antibody, and myositis panel was positive for Anti-U1-RNP, moderately positive for Anti-U2-RNP. The CK, Anti-histone antibody, serum porphyrins, and ENA all resulted negative. There was no significant proteinuria on 24 hour urine collection. Left thigh punch biopsy revealed vacuolar interface changes with dyskeratosis including necrotic keratinocytes scattered throughout the stratum spinosum. The dermis contained a superficial perivascular lymphocytic infiltrate.

The patient’s medication list included hydralazine, PPI, and CCB. She was taken of adalimumab 6 weeks prior to admission. The CCB was the only medication continued at time of discharge, at which time her rash had improved. Patient was started on daily hydroxychloroquine. She was diagnosed with Acute Cutaneous Lupus Erythematous and subacute cutaneous lupus overlap syndrome with improvement following drug cessation and hydroxychloroquine initiation.

IMPACT/DISCUSSION: Drug-induced Lupus erythematous (DILE) is an uncommon but morbid condition with proper treatment relying on early identification and cessation of frequently vital medications. The most common medication classes involved are chemotherapies, proton pump inhibitors, and cardiac agents such as procainamide and hydralazine. Due to the high morbidity associated with the condition, and the importance of many of the culprit agents, an early and confident diagnosis is necessary. This is effectively done through awareness of the common offending agents. This case highlights the importance of a broad differential and a high clinical suspicion for DILE as the diagnostic and therapeutic process requires time and multiple treatment steps.

CONCLUSION: Although DILE presenting with a cutaneous rash is rare, it must be considered early so that offending agents can be identified and discontinued.

DYSPNEA IN DIABETIC KETOACIDOSIS AND SEVERE AORTIC STENOSIS: A CASE OF MYOCARDITIS DIAGNOSED BY CARDIAC MAGNETIC RESONANCE IMAGING

Zhiyu Liu. Internal Medicine, University of South Florida, Tampa, FL. (Control ID #4064279)

CASE: A 57-year-old female with a medical history of type 1 diabetes mellitus presented to the hospital due to elevated blood glucose and dyspnea. She has severe aortic stenosis, hypertension, and hyperlipidemia. Labs showed blood glucose 767 mg/dL, potassium 6.4 mEq/L, creatinine 1.7 mg/dL, and venous blood pH 7.01 with anion gap 29 mEq/L. A prior echocardiogram showed Ejection Fraction (EF) of 70-75% and severe aortic stenosis with a valve area of 0.88 cm2 and a peak velocity of 425 cm/s. She had a recent coronary angiography which revealed non-obstructive coronary artery disease. Subjectively, she denied any chest pain or any upper respiratory infection symptoms. However, due to worsening dyspnea and left shoulder pain, serial high-sensitivity troponin tests were ordered, 14 (0-14) ng/L at admission, followed by 299 ng/L, with the peak level above 60,000 ng/L. The diabetic ketoacidosis was treated with an insulin drip, then transitioned to an appropriate insulin regimen and it gradually resolved. Repeat echocardiogram showed EF 45-50% and apical hypokinesis. The respiratory viral panel was negative. The cardiac MRI (cMRI) showed diffuse late gadolinium enhancement of the left ventricle, which suggests myocarditis. The patient was managed conservatively and followed in the cardiology clinic to continue surgical planning of valve replacement.

IMPACT/DISCUSSION: Myocarditis can be caused by many medical conditions, with viral infections being the most commonly identified etiology. Stressful strain, like diabetic ketoacidosis, particularly in a highly demanding heart condition, severe aortic stenosis, may precipitate myocarditis presenting with unspecific complaints. Troponin might be a valuable diagnostic tool in patients with severe aortic stenosis in the setting of an acute systemic illness complaining of worsening dyspnea without chest pain, especially ordered and followed consecutively as known as "delta-troponin". With cardiac MRI, timely identification and diagnosis of myocarditis facilitates medical management and formulation of a comprehensive intervention plan.

CONCLUSION: Cardiac biomarkers with the "delta-troponin" pattern may be useful in detecting myocarditis in patients with unspecific chief complaints underlying acute illnesses who have preexisting structural abnormalities of the heart.

ELUCIDATING PULMONARY BLEBS AS THE ETIOLOGY OF A PERSISTING PRIMARY SPONTANEOUS PNEUMOTHORAX

Idil Askar¹; Daniel Murphy². ¹Internal Medicine, The Jewish Hospital - Mercy Health, Cincinnati, OH; ²pulmonary and critical care, Bon Secours Mercy Health, Cincinnati, OH. (Control ID #4064809)

CASE: We present a 19-year-old male with no past medical or surgical history who was not taking any prescribed medications or recreational drugs. He initially presented with a chief complaint of acute chest pain. At presentation, he reported that his symptoms began at work with an acute onset of left-sided chest tightness with subsequent shortness of breath. He denied any symptoms prior or any similar experiences in the past. His vitals at presentation were remarkable of sinus tachycardia and he was saturating on room air. Chest x-ray was conducted revealing a large left-sided spontaneous pneumothorax and an 8 french chest tube was placed at presentation with repeat chest x-ray confirming placement and resolving pneumothorax. He was admitted to the hospital for further management. He was seen by thoracic surgery in addition to pulmonology. During hospitalization, his pneumothorax expanded, and his initial symptoms returned while the chest tube was set on water seal. The chest tube setting was then changed to suction. CT imaging of the chest was conducted revealing small apical blebs bilaterally which were more widespread on the left. His pneumothorax persisted and concern was made regarding the contribution of the elucidated pulmonary blebs to his persisting pneumothorax. Left video assisted thoracoscopic surgery (VATS) was conducted with two blebs visualized at the left lung apex. A wedge resection was performed with two staples and mechanical pleurodesis was performed.

IMPACT/DISCUSSION: This case highlights the importance of establishing the etiology of each primary spontaneous pneumothorax even at initial presentation. The investigation of the underlying cause of a primary spontaneous pneumothorax is typically addressed when there is a recurrence of symptoms. Our patient was managed for his large spontaneous pneumothorax with a chest tube but it was by further investigation through imaging that his pulmonary blebs were elucidated as the inciting factor. Through evaluating the underlying cause of his primary spontaneous pneumothorax, definitive management through VATS procedure was conducted prior to any further reoccurrence of symptoms upon hospital discharge. Our case also highlights the challenges that may be faced if a spontaneous pneumothorax is refractory to management in addition to the subsequent consideration of active factors behind the persistence of symptoms. This case contributes to the literature by encouraging the diagnosis of primary spontaneous pneumothorax and swiftly managing its underlying cause to improve outcomes and prevent recurrence of disease.

CONCLUSION: -Primary spontaneous pneumothorax requires immediate management to alleviate symptoms typically through chest tube insertion.

-Typically, management of the underlying etiology of a primary spontaneous pneumothorax occurs after disease recurrence.

-Recognizing the underlying cause of disease at initial presentation will allow for swift definitive management and therefore improve outcomes.

ENCEPHALOPATHY SECONDARY TO HYPERVISCOSITY SYNDROME (HVS): AN UNUSUAL INITIAL PRESENTATION OF MULTIPLE MYELOMA (MM)

Anna Kaiser¹; Maria Sanes Guevara¹; Alyssa Kelder¹; Sarah B. Merriam². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh , PA. (Control ID #4063961)

CASE: A previously highly functional 82-year-old Veteran with history of COPD, OHS, HTN, HLD and splenomegaly initially presented with 2 weeks of progressive encephalopathy. On admission, the patient was unable to recognize family or answer orientation questions. Per his wife, outside of a few days of mild abdominal and rib pain, review of symptoms was negative. Vital signs were notable for O2 saturation of 86% on RA, and neurologic examination was limited but non-focal. Initial labs were significant for Hb 7.1, WBC 6.1, Cr 1.8, Ca 10.4, protein 15.0, albumin 3.1. Infectious evaluation included a negative urinalysis and CT findings suspicious for aspiration. CT head was unremarkable. Taken together, the new neurologic symptoms, markedly elevated total protein level and protein gap, hypercalcemia, and AKI were concerning for MM complicated by HVS. Further workup revealed a serum viscosity of 5.2, an M spike of 6.5% in the gamma region with gamma fraction of 6.7%, kappa/lambda ratio of 0.01, and IgG level 9203. The patient was urgently transferred to the ICU for initiation of plasmapheresis in conjunction with hematology consultation. Bone marrow biopsy ultimately revealed hypercellular marrow with extensive IgG lambda plasma cell involvement. The patient’s final diagnosis was FISH positive for t(4,14) IgG lambda MM, indicative of high-risk disease.

IMPACT/DISCUSSION: HVS, an unusual hematologic emergency resulting from excess serum protein, is typically associated with Waldenström’s macroglobulinemia (90% of cases). However, this syndrome can also manifest in individuals with MM, leukemia, and polycythemia.

The hallmark manifestations result from increased serum viscosity, leading to relative hypoperfusion, platelet aggregation, and ultimately end-organ dysfunction, manifested as the classic triad of mucosal bleeding, visual, and neurologic abnormalities. Because most cases present with just one of these signs/symptoms, a high degree of clinical suspicion is critical, as is rapid initiation of therapy. Measurement of viscosity is not necessary to initiate therapy. Patients exhibiting neurologic, hemorrhagic, or thrombotic signs/symptoms in the right clinical context should undergo plasma exchange as the preferred treatment. If plasmapheresis is delayed or unavailable, temporizing measures include phlebotomy and intravenous fluids. In asymptomatic patients with high serum viscosity, chemotherapy initiation proves rapidly effective. Given this patient did not previously carry a diagnosis of MM, this case underlines the necessity for high index of suspicion in the setting of encephalopathy, and the urgency of prompt hematologic evaluation.

CONCLUSION: MM is an uncommon cause of HVS, which itself is a rare etiology of encephalopathy. Clinical suspicion is key for prompt initiation of plasma exchange in symptomatic patients with neurological deficits or hematologic complications.

ENDOCARDITIS AND SEPTIC EMBOLI, BALANCING THE RISK OF ANTICOAGULATION

Katarina Fabre¹; Alan Hu¹; Anna Svatikova². ¹Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Cardiovascular disease, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4058265)

CASE: A 70-year-old male presented with fevers, chills, nausea, vomiting and dyspnea one day after cardioversion for atrial fibrillation. Medical comorbidities included atrial fibrillation (on warfarin), heart failure with mid-range ejection fraction of 45%, hypertension, severe mitral regurgitation, moderate-severe tricuspid regurgitation, coronary artery disease with history of STEMI (ST Elevation Myocardial Infarction) status post drug eluding stent to the left main coronary artery. His surgical history included coronary artery bypass grafting to the right coronary artery, prior aortic valve replacement with On-X mechanical valve and composite root with ascending aortic graft. 24 hours post cardioversion, the patient appeared febrile, diaphoretic with nausea and vomiting. His exam was unremarkable outside of a baseline murmur and normal neurological exam. Laboratory evaluation yielded: WBC 17.6 x10 9 /L (normal 3.4 to 9.6 ×109/L), lactic acidosis 12.9 mm/L (normal 0.5-2.2 mmol/L). Blood cultures were positive for methicillin sensitive staphylococcal aureus, and he underwent transesophageal echocardiogram which revealed mechanical aortic valve and tricuspid valve vegetations, suggestive of endocarditis. He was initiated on oxacillin. Despite his diagnosis of endocarditis, anticoagulation was carefully continued given recent cardioversion and normal neurological exam. An MRI (Magnetic Resonance Imaging) brain was obtained upon transfer to assess for evidence of septic emboli which noted multiple areas of septic emboli and the patient’s anticoagulation was discontinued.

IMPACT/DISCUSSION: This patient’s indication for anticoagulation was recent cardioversion and mechanical valve. In the acute period after cardioversion, there is an increased risk of thromboembolic events (up to 7%). This increased risk has been attributed to atrial stunning, which is transient dysfunction of the left atrium and left atrial appendage. In a patient with newly diagnosed endocarditis and a clear indication for anticoagulation, this becomes a complex risk-benefit medical decision. In one large multicenter retrospective analysis, anticoagulant therapy at infective endocarditis diagnosis had a hazard ratio of 1.31 for development of neurological complications, and hazard ratio of 2.71 for cerebral hemorrhage. In this case, given the presence of multiple septic emboli, anticoagulation was discontinued. There is now some evidence that discontinuation of anticoagulation after 10-14 days could be possible and safe, but it is an area needing further investigation.

CONCLUSION: This case illustrates a difficult scenario of weighing the risk and benefit of anticoagulation with clear indications post cardioversion, mechanical aortic valve, atrial fibrillation against newly diagnosed endocarditis. Anticoagulation in this setting is controversial, particularly in patients who with pre-existing indication for it.

EPIDURAL BLOOD PATCH FOR THE TREATMENT OF LATERAL RECTUS PALSY IN THE SETTING OF INTRACRANIAL HYPOTENSION IN JEHOVAH’S WITNESS

Muhammad U. Javed, Lauren G. Stogner, maymona Dulli, Sami G. Tahhan. Internal Medicine, Eastern Virginia Medical School, Norfolk, VA. (Control ID #4032620)

CASE: A 36-year-old G9P9 Jehovah’s Witness female with no significant past medical history, presented to the emergency department with a 2-week history of postural headaches and double vision. Neurological examination was normal except for left abducens nerve palsy. CTA of the head was unremarkable, but an MRI of the head revealed diffuse smooth dural thickening with enhancement suggestive of intracranial hypotension. The patient reported a history of nine live births, with seven involving epidurals. A CSF leak was suspected as the cause of the intracranial hypotension. MRI of the whole spine showed diffuse smooth dural thickening with enhancement and extradural collections, however, no single point of leakage was identified. Based on her history and imaging, abducens nerve palsy was believed to be secondary to intracranial hypotension leading to brain displacement and traction on the left abducens nerve.

Conservative treatment modalities including Caffeine and salt tablets did not result in significant clinical improvement. The treatment team felt an epidural blood patch was the next treatment option but we had to make sure it did not go against the patient’s religious beliefs. The patient consulted with the Elders of her Jehovah’s Witness community, and they felt that an autologous epidural blood patch procedure was in alignment with her beliefs as a Jehovah’s Witness. She reported significant improvement in her headache and mild improvement in her double vision after two blood patches were applied. She was discharged home thereafter.

IMPACT/DISCUSSION: The etiology of the left lateral rectus palsy and headaches in this patient with a history of multiple epidural anesthesia procedures, is most likely due to spontaneous intracranial hypotension. Intracranial hypotension is often caused by a CSF leak which can be associated with trauma or can occur spontaneously after sudden movements. The common presentation is orthostatic headaches, worsening with sitting up or standing and improving with lying down. Typically associated with intracranial hypertension rather than hypotension, abducens palsy is the most common cranial nerve palsy in intracranial hypotension. MRI head imaging can help diagnose intracranial hypotension with dural thickening and enhancement potentially suggestive of hypotension. While spinal MRIs for our patient were negative for CSF leak, other imaging studies such as CT/MR myelography are generally more effective at identifying a leak and may be used instead.

While most cases of intracranial hypotension due to suspected CSF leaks resolve with conservative measures, CSF blood patches are used when symptoms persist. Contrary to popular belief, CSF blood patches can be used in Jehovah's Witness patients.

CONCLUSION: While spontaneous intracranial hypotension is a rare cause of lateral rectus palsy, it should be considered. Blood patches are used in refractory cases, and they can be used in Jehovah's witness patients.

EPISODIC HYPOTHERMIA, BRADYCARDIA, AND ENCEPHALOPATHY IN A YOUNG TRANSGENDER WOMAN

Sharon Abada, Molly A. Kantor. Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4054850)

CASE: A 36-year-old transgender woman was admitted to an inpatient medicine service with encephalopathy and ataxia. Her symptoms began suddenly with no provoking trauma or trigger. She denied fevers, headache, or vision changes. She denied recent alcohol use, drug use, or environmental exposures. She had no known family history of neurologic disease.

At presentation, physical examination showed hypothermia (34.2°C), bradycardia (44 BPM), hypotension (90s/60s), limb ataxia, and orientation only to self. Laboratory tests were notable for thrombocytopenia (platelets 31), an unremarkable blood smear, and normal creatinine and liver function tests. Serum ethanol was negative, and urine toxicology was only positive for THC. Evaluation for infection (hepatitis, HIV, RPR, blood and urine cultures), nutrient deficiencies (B12, folate), endocrine disease (hypothyroidism, adrenal insufficiency) and heavy metals (lead, mercury) was unrevealing. Lumbar puncture showed normal opening pressure and unremarkable cell counts; CSF HSV, VZV, IgG index, and oligoclonal bands were negative/normal. CTA head/neck and MRI brain were negative for stroke or structural abnormalities.

While hospitalized, she had recurrent episodes of hypothermia, bradycardia, and encephalopathy. Her platelet count slowly normalized. Further history revealed numerous similar hospitalizations and the onset of similar episodic symptoms at age 12. Through discussion with consultant neurologists, her presentation was determined to be consistent with a diagnosis of congenital non-structural periodic hypothermia. She was started on clonidine with improvement.

IMPACT/DISCUSSION: Hypothermia, bradycardia, and encephalopathy are common in hospitalized patients due to environmental exposures, toxins, or infections, and resolve upon treatment of the underlying disorder. However, our patient presented without a known trigger and experienced recurrent episodes while hospitalized, raising suspicion for abnormal central thermoregulation. “Periodic hypothermia” (PH) is a very rare condition of episodic hypothermia often associated with encephalopathy, bradycardia, diaphoresis, and/or thrombocytopenia. PH may be congenital or acquired. Congenital PH is usually associated with structural brain lesions such as agenesis of the corpus callosum, though non-structural cases have been described in pediatric case reports. Acquired PH may be associated with traumatic brain injury, intracranial hemorrhage, multiple sclerosis, or hypothalamic tumors. Treatment of PH has only been described in case reports; medications include clonidine and cyproheptadine. This patient’s episodic symptoms since childhood provided supportive evidence for a diagnosis of congenital non-structural PH.

CONCLUSION: Periodic hypothermia is a rare diagnosis of exclusion that should be considered in patients presenting with recurrrent, spontaneous episodes of otherwise unexplained hypothermia, bradycardia, and encephalopathy.

ESOPHAGEAL PERFORATION DUE TO TUBERCULOUS MEDIASTINAL LYMPHADENITIS WITH INITIALLY SUSPECTED ESOPHAGEAL MALIGNANCY

Iori Motohashi^1,2; Kenya Ie^1,2; Chiaki Okuse^1,2; Yoshiyuki Ohira². ¹Department of General Internal Medicine, Kawasaki Shiritsu Tama Byoin, Kawasaki, Kanagawa, Japan; ²Department of General Internal Medicine, Sei Marianna Ika Daigaku, Kawasaki, Kanagawa, Japan. (Control ID #4050696)

CASE: An 80 year-old, previously healthy woman, presented with anorexia including 3 kg weight loss in one month. On physical examination, vital signs were normal except for a high fever of 39.8°C (103.6°F), and a 3-cm, immobile, elastic-hard mass was found in the right supraclavicular fossa. Laboratory data showed an elevated inflammatory response. Contrast-enhanced computed tomography (CT) indicated irregular wall thickening in the mid esophagus, mediastinal emphysema and multiple enlarged lymph nodes in the right supraclavicular fossa and mediastinum. Advanced esophageal carcinoma or malignant lymphoma and associated esophageal perforation were suspected, and a biopsy of a lymph node in the right supraclavicular fossa was scheduled. Follow-up CT, after hospitalization, revealed new multiple small granular shadows in the lungs. Initially, the imaging findings were considered to be indicative of miliary metastasis of a malignant tumor; however, miliary tuberculosis could not be ruled out. Gastric aspirates and sputum were examined and both were positive for acid-fast bacilli and Mycobacterium tuberculosis (TB) PCR, thus a diagnosis of miliary TB. The patient was isolated in a negative pressure room for infection control. Fluoroscopic upper gastrointestinal endoscopy showed a protruding lesion with a central depression in the mid esophagus and contrast spillage into the mediastinum. Biopsy indicated no evidence of malignancy, and the patient was finally diagnosed as esophageal perforation due to tuberculous mediastinal lymphadenitis, and anti-tuberculous treatment was initiated. Follow-up upper gastrointestinal endoscopy confirmed spontaneous closure of the esophageal perforation. The patient eventually recovered and was discharged.

IMPACT/DISCUSSION: Esophageal TB is a rare extrapulmonary TB and the esophageal mucosa is rarely the primary site of the disease, which is often secondary to tuberculous lymphadenitis of the mediastinum. There are no specific endoscopic or imaging findings, and it is important to distinguish it from cytomegalovirus infection, Crohn's disease, gastrointestinal stromal tumor, and malignant lymphoma or esophageal cancer. Most esophageal TB is curable by treatment with antituberculosis drugs. It has been reported that some patients diagnosed as having malignant tumors at one cancer center in the United States had extrapulmonary TB that was misdiagnosed. Even if malignancy is strongly suspected on imaging studies, histopathological and bacteriological examinations should be performed if the possibility of tuberculosis cannot be ruled out.

CONCLUSION: Esophageal TB is a rare extrapulmonary TB and can mimic a malignancy. Even severe esophageal TB with perforation of the esophagus can be cured with antituberculosis drugs.

ESSENTIAL THROMBOCYTOSIS: HOW A MIDDLE-AGED MALE LOST HIS SPLEEN

Tyler Wark¹; William Ghaul¹; Andres Zirlinger². ¹Internal Medicine, Lehigh Valley Hospital - Cedar Crest, Allentown, PA; ²Pulmonary and Critical Care, Lehigh Valley Health Network, Allentown, PA. (Control ID #4064470)

CASE: A 45 year old male with history of ventral hernia repair presented with complaints of left sided abdominal pain, decreased appetite and nausea for four weeks. Patient had family history of maternal grandfather with chronic lymphoblastic leukemia. Examination showed tenderness to palpation in the epigastric region and left upper quadrant. Lab work was consistent with a platelet count 508k call, CRP 76.6, ESR 32, alk phos 262, AST 45. CT abdomen pelvis with IV contrast show splenomegaly 22cm with upper abdominal and mesenteric varices with suspicion of thrombus of the main portal and splenic veins. MRI abdomen found main right and left portal, SMV thrombosis with multiple splenic infarctions. Heme/onc started patient on anti-coagulation with Lovenox. Lab work continued to worsen with platelets to 1548k, Cr 3.78 (baseline 0.7), hgb 8.1 (baseline 13). Hemodynamics became unstable requiring surgical evaluation. Repeat CT showed large hemorrhagic ascites. Trauma surgery performed exploratory laparotomy with 5000cc's old blood evacuated and splenectomy due to splenic rupture and performed multiple washouts over 1 week. Patient was continued on a heparin drip and transitioned to Eliquis prior to discharge. Further genetic testing was positive for Jak2 V617F mutation.

IMPACT/DISCUSSION: Essential thrombocythemia this genetic condition that can lead to both thrombosis and hemorrhage. Incidence rates have been reported between 0.59 to 2.53 per 100,000 people. Major vascular occlusive events can occur including the cerebrum, coronaries, and the peripheral circulation. Patients can experience life threatening occlusions in the areas of the hepatic and portal veins. As platelets become unavailable due to clotting, severe hemorrhagic events can occur including hematomas, epistaxis or internal bleeding.² Current therapy in the outpatient is to prevent thrombotic events with either dual antiplatelet or using less studied areas with anti-coagulation.

CONCLUSION: If patient’s exhibit persistent thrombocytosis over 450,000 for more than two months then suspect primary causes including the essential thrombocythemia.

Essential thrombocytosis can cause both thrombotic and hemorrhagic complications. Physicians should have suspicions of bleeding if patient’s hemodynamics, hemoglobin and symptoms worsen.

EXTENSIVE SKIN ERUPTION FOLLOWING MOMELOTINIB USE

Jiahua Zhang¹; Jansynn Radford²; Preston Mundhenke¹. ¹Internal Medicine, Mercy Hospital St Louis Area, Saint Louis, MO; ²Kansas City University, Kansas City, MO. (Control ID #4064878)

CASE: A 73-year-old male presented with an extensive skin eruption. He has a past medical history of myelofibrosis (MF) that had previously been stabilized with ruxolitinib, with the exception of persistent chronic anemia. 39 days before this admission, the patient’s ruxolitinib was switched to momelotinib due to its benefit on chronic anemia in patients with MF. After taking momelotinib for 30 days, he developed a fever of 103 F and painful hive-like, blotchy, raised welts from head to toe. He was first treated with high-dose prednisone, but his rash continued to progress. He then presented to the hospital for further evaluation.

At presentation, the patient was found to have macular rashes and blisters involving over 20% of the body surface area, including face, trunk, extremities, and genital area. No mucosal lesions were seen. The initial lab was only significant for a positive wound and blood culture, both positive for Group B Streptococcus. Oncology, Plastic Surgery, Infectious Disease, and Dermatology were consulted. Differential diagnoses included Stevens-Johnson syndrome (SJS), paraneoplastic pemphigoid, and erythema multiforme. 3% Bismuth Tribromophenate dressing was applied to open areas on the skin, and petrolatum ointment was used on dry, healed areas. Due to concern of SJS, the patient was treated with intravenous methylprednisolone, as well as 2 doses of etanercept 50 mg subcutaneously on hospitalization day 3 and day 7. Vancomycin was used for 10 days for his bacteremia. On hospitalization day 9 the punch biopsy resulted, showing mixed inflammation in the superficial dermis without classic features of SJS. The patient was diagnosed with drug eruption secondary to momelotinib. His steroid was tapered down on hospitalization day 4 due to the improvement of his lesions and he was discharged to a skilled nursing facility on hospital day 11.

IMPACT/DISCUSSION: Myelofibrosis (MF) is caused by the overactivation of JAK/STAT signaling pathway, resulting in bone marrow fibrosis. Momelotinib is a JAK 1/2 inhibitor that not only suppresses the JAK/STAT pathway but also increases iron availability for erythropoiesis. In SIMPLIFY-1/2 and MOMENTUM trials, it demonstrated a decreased transfusion-dependent rate when compared to other therapies. Therefore, it was approved by FDA in September 2023 to be used in MF patients with anemia. In the above trials, only 1 toxic skin eruption case was reported. In our case, the patient developed diffuse skin eruption after one month of momelotinib use. We hope that this case can add more data to the registry to help providers take care of patients who are going to start taking this newly approved medication.

CONCLUSION: 1. Momelotinib is a newly FDA-approved medication for myelofibrosis patients with anemia. Patients who started momelotinib should be monitored for skin changes for at least 1-2 months.

2. Early identification, multidisciplinary teamwork, and meticulous wound care are crucial to patients with severe skin eruptions.

EXTREME REACTIVE THROMBOCYTOSIS SECONDARY TO IRON DEFICIENCY ANEMIA COMPLICATED BY ACUTE PULMONARY EMBOLISM IN A 49-YEAR OLD WOMAN

Maria E. Fierro¹; Iqra Kazi¹; Wiley Perkins². ¹Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ²Hospital Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4035456)

CASE: A 49 year old female with no PMH presented the ED with multiple non-specific symptoms. Labwork in the ED was notable for WBC 25, Hb 4.6, and platelets (plts) 1,437,000, iron 6, ferritin 2, and percent transferrin saturation 2%. Hematology was consulted and had concern for a myeloproliferative process. Hydroxyurea was initiated on Day 2 of admission for cytoreduction. From Day 3-7, she was given IV iron and received a total of 6 units pRBCs during her hospital course. On Day 4, her plts and WBCs began to downtrend. On Day 6, she had a bone marrow biopsy that showed no evidence of malignancy. On Day 10, hydroxyurea was stopped due to leukopenia and a drug eruption rash. On Day 19, she developed an acute pulmonary embolism (PE). She had an EGD on Day 22 that revealed a non-bleeding gastric ulcer. Biopsy of the ulcer was negative for malignancy. Throughout her admission, she had an extensive hematologic and rheumatologic workup that was entirely negative aside from identification of iron deficiency anemia (IDA) and the gastric ulcer. She was discharged on Day 34 with a CBC showing WBC 14, Hb 10.4, and plts 625,000.

IMPACT/DISCUSSION: We present a case of extreme thrombocytosis of up to 1.6 million plts in a 49 year old woman. Her presentation raised concern for a myeloproliferative process but she was ultimately found to have a reactive thrombocytosis secondary to IDA. Her hospital course was further complicated by an acute PE as well as leukopenia, MSSA bacteremia, and a drug eruption rash related to treatment with hydroxyurea.

Thrombocytosis is common but extreme thrombocytosis > 1 million is rare (J Intern Med PMID 2045755). The differential diagnosis for thrombocytosis is broad but is first categorized into primary (clonal) versus secondary (reactive) thrombocytosis. Reactive thrombocytosis is much more common than clonal thrombocytosis, even in cases of extreme thrombocytosis as we see in this case (Thrombosis PMID 22084665).

Identifying and treating the underlying cause of thrombocytosis is clinically relevant because thrombocytosis is associated with thrombosis and hemorrhage. The risk for thrombosis and hemorrhage is higher in those patients who have clonal thrombocytosis (Curr Hematol Malig Rep PMID 32399765). However, as we see in this patient, there are rare cases of reactive thrombocytosis, especially those related to iron deficiency, in which thrombosis has occurred (Clin Appl Thromb Hemost PMID 15497026).

CONCLUSION: Thrombocytosis is common; however, extreme thrombocytosis > 1 million is rare. Thrombocytosis is associated with thrombosis and hemorrhage, more commonly in the setting of a clonal process. However, as seen in this clinical case, thrombosis can still occur in the setting of reactive thrombocytosis. Given the association between thrombocytosis and thrombosis, it is clinically relevant to identify the etiology of thrombocytosis and provide targeted treatment to prevent thrombosis.

FAHR’S SYNDROME A UNIQUE CAUSE OF REFRACTORY HYPOCALCEMIA

Elizabeth Soladoye^1,2; Raheem Robertson^2,1; Stefan Gafoor^1,2; Njika Atemnkeng². ¹Internal Medicine, Piedmont Athens Regional Internal Medicine Residency Program, Athens, GA; ²Graduate Medical Education, Piedmont Athens Regional Internal Medicine Residency Program, Athens, GA. (Control ID #4064026)

CASE: Fahr’s syndrome is a rare neurologic disease characterized by symmetrical and abnormal calcifications involving the basal ganglia primarily but also may affect the thalamus, hippocampus, dentate nucleus, cerebral cortex and cerebellar subcortical white matter. Typically manifesting in middle aged adults, it may occur sporadically despite an autosomal dominant pattern.

We present a case of a 46 year old male with idiopathic hypoparathyroidism, hypertension and chronic kidney disease who presented in a postictal state with generalized, spasms, tetany and seizures. Despite lack of pertinent family history he exhibited severe hypocalcemia 6.8mg/dl, ionized calcium 0.93mmol/L, serum parathyroid hormone 6.60pg/ml, hypomagnesemia 1.2 mg/dl, phosphorus 3.90mg/dl, Alkaline phosphatase 56 UL, prolonged QT interval on EKG and extensive calcifications of the brain on computed tomography and magnetic resonance imaging consistent with Fahr’s syndrome. He has had recurrent symptomatic hypocalcemia necessitating multiple hospitalizations and treatment with calcium infusions to maintain a target calcium level of 10 mg/dl.

IMPACT/DISCUSSION: The diagnostic criteria for Fahr’s syndrome include progressive neurologic symptoms involving movement disorder primarily, or other neuropsychiatric manifestations, bilateral calcification of the basal ganglia on neuroimaging, absence of biochemical abnormalities suggestive of mitochondrial or metabolic disease and exclusion of infectious, toxic or traumatic causes. The age of onset typically ranges between 40-60 years. Molecularly, various gene loci are associated with Fahr’s syndrome including: SLC20A2 that codes for a type 3 sodium dependent phosphate transporter 2 on chromosome 8, XPR1 gene that codes for retroviral receptor with phosphate export function on chromosome 1q, platelet-derived growth factor family-gene (PDGFRB) on chromosome 5q, and PDGFRB on chromosome 22q. Genetic testing is a valuable tool for definitive diagnosis and counseling, however it was not pursued due to financial constraints. This case aligns with existing literature emphasizing the common association between Fahr’s syndrome and endocrine disorders, particularly idiopathic hypoparathyroidism which was found in 23.3% of cases. Treatment is mainly symptomatic, treating associated neuropsychiatric features and hypocalcemia associated with endocrine pathologies. Symptoms are recurrent and can be debilitating, as such more studies are required to minimize loss of function associated with the disease.

CONCLUSION: Fahr’s syndrome is a rare neurological disorder that occurs primarily in an autosomal dominant pattern however sporadic cases have been identified. The diagnosis is challenging and requires keen work up, including genetic testing which is not readily available to rule out other diseases. There are no specific treatments for this disease, only symptomatic management, as such more research is needed to understand this disease.

FASCIA ON FIRE: A CASE OF PERIORBITAL NECROTIZING FASCIITIS

Katsiaryna Murashka, Laura Rivera Boadla, Violetta Laskova. Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4064889)

CASE: Patient is a 54-year-old male with alcohol use disorder, HIV on antiretroviral therapy, and no history of diabetes, who initially presented to an outside hospital with acute onset of progressive pain and swelling of the left (L) upper and lower eyelids 1 day earlier. Patient denied fevers, chills, tooth pain, recent dental work, or facial trauma. He was diagnosed with L preseptal cellulitis based on CT imaging, was started on ceftriaxone and vancomycin and transferred to our institution for ophthalmology evaluation and continued IV antibiotics.

In ED, BP was 100/61 HR 101, Temp 37 C, RR 16 SpO2 96%. L upper and lower eyelids were swollen and tender. The overlying skin was erythematous, ecchymotic, with superficial blisters. No crepitus was noted. WBC 80,000 k/ul, lactate 4mmol/L, CRP 96 mg/L, ESR 92mg/L, CD4 270 /cu mm, HIV viral load -- undetectable. Repeat CT orbits confirmed non-specific L periorbital subcutaneous soft tissue swelling suggesting preseptal cellulitis. Despite continued treatment, the swelling worsened over the following 24 hours. Overlying skin became duskier and started to slough off. Necrotizing fasciitis was strongly suspected at that time. Orbital CT was repeated yet again, however, it only showed further progression of the soft tissue swelling without signs of gas or fascial fluid collections. Despite the non-specific imaging findings, clinical suspicion for necrotizing infection remained high due to rapid disease progression and signs of skin necrosis. Ophthalmology and Infectious disease teams were urgently consulted. Patient’s wound was debrided, and the diagnosis of periorbital necrotizing fasciitis was confirmed. Antibiotics were broadened to vancomycin, piperacillin-tazobactam, and clindamycin for toxin suppression. Eventually, deep wound cultures grew penicillin-susceptible S. pyogenes and methicillin-resistant S. aureus. Patient completed a 7-day course of IV vancomycin and received more than 20 wound debridements prior to being discharged on a 2-week course of oral linezolid. He continued to follow up with the ophthalmology team for additional debridements prior to complete resolution of infection. Eventually, patient had a reconstruction surgery with skin grafting, and his vision was preserved.

IMPACT/DISCUSSION: Periorbital necrotizing fasciitis is a devastating infection that carries a risk of cosmetic disfigurement, vision loss, meningitis, and death. Early diagnosis is essential for effective management, yet it is challenging due to its resemblance to cellulitis in its early stages.

While orbital CT is the modality of choice for diagnosis of periorbital necrotizing fasciitis, it lacks sensitivity in diagnosing early disease as soft tissue gas or fluid collections may not have reached levels detectible by CT.

CONCLUSION: This case emphasizes the role of clinical suspicion in timely diagnosis of periorbital necrotizing fasciitis.

Absence of soft tissue gas or fascial fluid collections on orbital CT does not rule out early necrotizing fasciitis.

FAST RESULTS: DIAGNOSING DISSEMINATED MYCOBACTERIUM INFECTION WITH METAGENOMIC NEXT GENERATION SEQUENCING

Harrison Tran¹; Daniel Minter². ¹School of Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ²Infectious Diseases, University of California San Francisco Department of Medicine, San Francisco, CA. (Control ID #4063925)

CASE: A 60-year-old woman with a history of deceased donor renal transplant in 2005 with re-transplant in 2020 presented with 4 weeks of progressive fatigue, dyspnea on exertion, weight loss of 15lbs over 6 months, hematochezia, and left upper quadrant pain. Upon presentation, she was taking tacrolimus, mycophenolate mofetil, and prednisone. She was febrile to 38.1C and had tender splenomegaly. She initially had a hemoglobin of 8.6 but became progressively pancytopenic requiring transfusion. She underwent colonoscopy which demonstrated acid-fast bacilli on biopsies without any growth on culture. CT demonstrated massive splenomegaly and retroperitoneal lymphadenopathy. There was a concern for tuberculosis (MTB) for which respiratory, gastrointestinal (GI), and blood samples were sent in addition to starting empiric MTB therapy.

Serum metagenomic next generation sequencing (mNGS) sent on admission returned positive for Mycobacterium genavense. Subsequent ribosomal DNA PCR of the biopsy sites also showed M. genavense. Diagnostic testing for MTB was negative, and her antimycobacterial therapy was switched to Azithromycin, Ethambutol, Rifabutin, and Levofloxacin. Of note, her course was also complicated by hyperammonemic encephalopathy thought to be due to urease activity of M. genavense as has been previously reported. In the outpatient setting, she continues her inpatient antibiotic regimen apart from Levofloxacin.

IMPACT/DISCUSSION: Non-tuberculous mycobacteria (NTM) are commonly found in the environment and can lead to disseminated infection in immunocompromised patients (ICP). Patients can present with constitutional symptoms, hematologic abnormalities (cytopenias), gastrointestinal symptoms, and lymphatic manifestations (splenomegaly and lymphadenopathy).

Mycobacterium genavense is a rare NTM that has been associated with disseminated disease in ICP. Gastrointestinal disease, as was seen in our case, has been reported with M. genavense and can cause vomiting, abdominal pain, hematochezia.

Mycobacteria are characterized by their acid-fast properties and fastidious growth. M. genavense, in particular, can be difficult to diagnose due to its limited ability to grow in standard mycobacterial cultures which can take weeks if any growth occurs.

Metagenomic next generation sequencing is an emerging diagnostic modality that refers to sequencing all DNA material in a collected sample then using analytics to produce DNA sequences from potential pathogens to explain a patients’ presentation. We were able to use mNGS to establish our patient’s diagnosis within 1 week and changed her antibiotic regimen as a result. To our knowledge, this is the first-reported case of M. genavense diagnosis via mNGS.

CONCLUSION: Clinicians should be aware of disseminated non-tuberculous mycobacteria infections in patients with immunocompromise. While definitive identification was a slow and difficult process in the past, metagenomic next generation sequencing can lead to rapid diagnosis and treatment.

FEBRILE TO 109: A HYPERTHERMIA STORM

Brianna Graham²; Carly E. Sokach¹. ¹Internal Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA; ²Internal Medicine, Temple University Hospital, Philadelphia, PA. (Control ID #4064815)

CASE: 35-year-old female with history of PCOS, hypertension, and obesity presented with two weeks of worsening epigastric pain, decreased appetite, and acute encephalopathy. On admission, she was hemodynamically stable and afebrile, with labs notable for a mild leukocytosis, elevated lipase, elevated total bilirubin and low potassium. CT head and MRI of the brain were unremarkable. CT of the abdomen revealed an 8.6 cm pancreatic head mass. Follow up abdominal MRI revealed the mass was partially encasing the SMV and showed innumerable liver lesions. A few days into her admission, she became hypoxic, tachycardic and hypotensive, with worsening encephalopathy requiring transfer to the ICU. She became febrile to 101°F, progressively hypotensive, and encephalopathic requiring pressors as well as intubation for airway protection. Despite empiric treatment for sepsis with broad-spectrum antibiotics and fluids, her clinical status continued to worsen. Her temperature increased throughout the day, remaining steadily at 105°F for two hours before rapidly increasing to a maximum temperature of 109°F. In-depth review of her medications did not reveal any use of common agents associated with hyperthermia. Stress dose steroids were initiated for persistent shock and concern for an acute endocrinologic process. She unfortunately suffered a cardiac arrest and was pronounced deceased after several rounds of ACLS. Autopsy report determined the cause of death as complications of a well-differentiated pancreatic neuroendocrine tumor with numerous liver metastasis and superimposed acute pancreatitis.

IMPACT/DISCUSSION: Although fevers are common in an inpatient setting, true persistent hyperthermia is seen much less frequently. Defined as a dangerously uncontrolled increase of body temperature, greater than 104°F, hyperthermia can quickly become life threatening. The differential diagnosis for hyperthermia is broad and should include infectious, inflammatory, neurologic, toxic, environmental, and endocrinologic etiologies. This case highlights the profound hyperthermia that can be caused by cytokine storm. Cytokine storm can cause multisystem organ failure through massive systemic inflammation. Fever is a hallmark of cytokine storm, induced through interleukins 1 and 6, and TNF. The inflammatory pancreatitis in this patient super-imposed on the neuroendocrine tumor likely resulted in cytokine storm leading to profound hyperthermia, shock, and ultimately - fatality.

CONCLUSION: Hyperthermia is defined as a temperature greater than 104 F and can occur rapidly.

Fever is a hallmark symptom of cytokine storm which can lead to multisystem organ failure.

When evaluating hyperthermia, it is essential to consider multifactorial and superimposed etiologies.

FEELING HEAVY-HEARTED AFTER KYPHOPLASTY

Rachel A. Motechin¹; Akhil A. Chandra¹; Harsh Jain¹; Vidish Pandya¹; Benjamin T. Galen². ¹Internal Medicine, Montefiore Medical Center, New York, NY; ²Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, NY. (Control ID #4061054)

CASE: A 54-year-old woman with end-stage renal disease on peritoneal dialysis underwent kyphoplasty for refractory back pain. Several days later, routine imaging incidentally revealed a nonmobile mass in the RA consistent with cement embolism. A multidisciplinary decision was made not to evacuate the mass due to a high risk of procedural complications. The patient was started on anticoagulation given the thrombogenic nature of this material but was unable to tolerate it because of recurrent anemia requiring transfusion.

Several months later, she was readmitted with shock, altered mental status, and recurrent anemia. She was volume resuscitated and re-started on antibiotics. MRI of her spine was negative for osteomyelitis or epidural abscess. Echocardiography redemonstrated the known RA mass with a new mobile mass attached to it, as well as a small mass on the mitral valve, initially suspicious for bacterial vegetations. Multiple blood cultures returned without growth, though peritoneal fluid cultures did grow E. faecium. The patient eventually succumbed to the burden of her disease. Autopsy identified the masses as a blood clot intermixed with cement attached to the tricuspid valve and a blood clot on the mitral valve.

IMPACT/DISCUSSION: Percutaneous kyphoplasty is a common minimally invasive surgical technique utilized to treat osteoporotic vertebral compression fractures; cement embolization due to inadvertent cannulization of vertebral vessels is a known complication, with a rate as high as 3.5-23%. While some cement emboli are asymptomatic, other patients can present with devastating symptoms of cardiac perforation, pulmonary embolism, or pneumothorax. The management of cardiopulmonary cement embolisms is not well defined, but anticoagulation is typically recommended. Surgical or percutaneous extraction of cement emboli has been utilized as well, but it is not clear when this is most beneficial. Some suggest it may be first line for symptomatic intracardiac embolism.

In a multidisciplinary meeting with the interventional cardiology and cardiothoracic surgery services, it was determined that this patient was too high-risk a surgical candidate given her multiple comorbidities and critical illness. Furthermore, the anatomic location of the cement embolism rendered her at high risk for myocardial perforation, valvular damage, and/or further embolization causing neurologic damage were invasive treatments to be performed. Surgical management was therefore not pursued. Unfortunately, this patient could not tolerate anticoagulation as well and therefore developed worsening thrombosis.

CONCLUSION: Cardiopulmonary cement embolism should be considered in patients who present with chest pain, dyspnea, or hypoxemia after kyphoplasty. In patients with cardiac embolization of acrylic cement, early surgical management would likely provide the most benefit while anticoagulation alone may be considered on a case-by-case basis.

FEVER OF UNKNOWN ORIGIN WITH SEVERE HEPATOSPLENOMEGALY IN AN IMMUNOCOMPETENT FEMALE

Wei Tang, Vihanga Perera, Pritika Sharma, Arushika Yedla, Christopher Nabors. Medicine, Westchester Medical Center, Valhalla, NY. (Control ID #4045077)

CASE: A 46-year-old female with diabetes mellitus who lives in the New England area was admitted for influenza pneumonia. She had a prolonged hospital course complicated by 8 weeks of recurrent fever (100 to 103 °F) despite continuous, uninterrupted broad-spectrum antibiotics coverage including Piperacillin-Tazobactam, Vancomycin, and Linezolid. She is HIV negative; multiple blood, respiratory, and urine cultures as well as repeat gastrointestinal multiplex and respiratory infection panels were consistently negative.

Physical examination was unremarkable except for mild pallor. Laboratory findings included normocytic anemia (Hb 8.7 g/dL) with normal white blood cell and platelet count. Her liver and kidney function tests were also normal.

CT abdomen and pelvis revealed severe hepatosplenomegaly (HSM) with no focal lesions. CT thorax with contrast showed left lower lobe and upper lobe bronchial inflammation, and reactive mediastinal lymphadenopathy but no evidence of pulmonary emboli.

Rheumatological workup was only notable for high-titer antinuclear antibody (1:160) in speckled pattern without any other positive autoimmune markers.

A bone marrow biopsy was pursued and showed normocellular marrow with trilineage hematopoiesis without acute leukemia or lymphoma; the corresponding flow cytometry showed no evidence of lymphoproliferative disorders.

Additionally, a liver biopsy was performed to investigate HSM and found a grossly normal liver with only mild steatosis.

Further infectious disease investigation excluded viral hepatitis, EBV or CMV infection, and tick-borne illness. The Fungitell assay was negative. Interestingly, the urine histoplasmosis antigen returned strongly positive while the serum histoplasmosis antigen and antibody were negative.

Disseminated histoplasmosis was diagnosed based on positive urine antigen and exclusion of other causes. The patient was started on liposomal amphotericin B and her fever resolved within 3 days of treatment. She was switched to oral itraconazole therapy after 2 weeks and there has been no recurrence of fever.

A retrospective history review identified a recent endemic outbreak of histoplasmosis in her living area due to construction activities.

IMPACT/DISCUSSION: We presented an extremely rare case of disseminated histoplasmosis characterized by fever of unknown origin and HSM without significant pulmonary involvement.

Our case also featured the discordance between serum and urine histoplasmosis antigen, which accounts for only 2% of cases reported in the literature. Urine Histoplasma antigen has a high sensitivity of 94%.

Activities that disturb the soil and bird droppings is the major environmental risk factor in patients from non-endemic areas.

CONCLUSION: HSM is found in nearly 50% of patients with disseminated histoplasmosis and gives an early clue for diagnosis.

Clinicians should have high suspicion for histoplasmosis in patients with both fever of unknown origin and HSM.

Thorough history-taking should include exposure to soil and bird droppings.

FEVERS, RASH, ARTHRALGIAS, AND MORE

Perrin Fugo¹; Maurice Facey²; Debra S. Leizman³. ¹School of Medicine, Case Western Reserve University, Cleveland, OH; ²Internal Medicine, University Hospitals, Cleveland, OH; ³medicine, University Hospitals, Cleveland, OH. (Control ID #4062928)

CASE: A 68 year old women with Gilbert’s disease and penicillin allergy (rash) presented to the ED with two weeks of pharyngitis, non-pruritic macular rash, migratory arthralgias, polyuria, fatigue, and two days of altered mental status and neck pain.

She was found to have mildly elevated transaminases, leukocytosis, elevated CRP, negative ASO titers, and hyperferrtinemia (>9000). She was treated empirically for meningitis/encephalitis which was discontinued after no evidence of CNS infection was identified. Infectious work up was positive for EBV and UA showed bacteriuria/pyuria. She was treated with ceftriaxone and then sulfamethoxazole/trimethoprim for her UTI and discharged home after four days with improvement in her mental status, rash, and transaminases.

Six days later, she returned to the ED with new onset pruritic rash and fever. She was tachycardic without leukocytosis. Her AST, ALT, and alkaline phosphatase were elevated above levels at discharge, ferritin >9000, and she had mild anemia. She was admitted and started on empiric vancomycin/cefepime for sepsis. One of four bacterial cultures grew Methicillin Susceptible Staphylococcus aureus. However, no source for infection was identified.

Despite several days of antibiotics, she remained febrile with worsening rash and transaminases. CMV DNA, EBV DNA, hepatitis labs, HSV, and HIV were all negative as were Anti-DNA, Anti-SM and AMA antibodies. Notably, CT showed mediastinal lymphadenopathy and PET scan showed hypermetabolic activity in lymph nodes, the spleen, and bone marrow.

On hospital day 6, she developed thrombocytopenia. She remained febrile, ALT= 787, and AST=1958. With 3/8 of the 2004 criteria for HLH met, a bone marrow biopsy was ordered. The next day, she developed hypofibrinogenemia and bone marrow biopsy showed hemophagocytoic macrophages. With 5/8 criteria, she was diagnosed with HLH and started on dexamethasone.

Liver enzymes improved, but her hospital course was complicated by hemorrhagic shock, ATN, and acute hypoxic respiratory failure. Ultimately, cervical lymph node biopsy showed findings consistent with peripheral T cell lymphoma which likely triggered HLH.

IMPACT/DISCUSSION: This case illustrates the difficulty in diagnosing HLH. Findings used in the 2004 HLH diagnostic criteria evolve over days all while, as in this case, a patient’s condition deteriorates. In 2022 the European Alliance of Associations for Rheumatology and American College of Rheumatology convened to address the need for guidance during the early stage when there is suspicion for HLH but diagnostic criteria are not yet met. The EULAR/ACR guidelines present “points to consider” and support starting immunomodulatory therapy while testing is ongoing. This guideline should be widely circulated and shared in an effort to improve clinical outcomes.

CONCLUSION: High clinical suspicion is needed to diagnose HLH as diagnostic criteria overlap with other systemic inflammatory states like sepsis.

FEVERS, TREMORS, AND TACHYCARDIA OH MY!

Edward Woods¹; Michelle Bach¹; Tracey Henry²; Nicole Guynn³. ¹Internal medicine, Emory University, Atlanta, GA; ²Medicine, Emory, Powder Spgs, GA; ³internal medicine, Emory University, Atlanta, GA. (Control ID #4047775)

CASE: A 46 yo man with PMH of AUD presented with tremors, emesis, and diarrhea. He endorsed drinking 5-6 cocktails/day and cut down over the past week. He denied seizures and hallucinations. He was febrile, tachycardic, with tongue fasciculations, and tremors on exam. He was placed on CIWA protocol and Ativan for alcohol withdrawal (AW). His course was complicated by ICU transfer for acute encephalopathy, and hallucinations. He was transitioned to a phenobarbital taper with some improvement in mental status but had worsening tachycardia, and fevers. An initial infectious workup revealed infiltrates on CXR in the setting of a cough. He was started on antibiotics for pneumonia. Despite ongoing phenobarbital taper, his tachycardia, diaphoresis and fevers persisted. Over the next few days, he continued to have intermittent fevers and remained tremulous. A fever of unknown origin workup with ID consultation was pursued. CT abdomen/pelvis revealed an extensive ileocaval DVT centered on a previously unknown IVC filter. He underwent venous thrombectomy, thrombolysis, and was started on apixiban. His high-grade fevers were thought to be too high to attribute to DVT alone and given his persistent encephalopathy an LP was obtained. The LP showed pleocytosis, elevated protein, and was positive for West Nile. He received supportive management and ultimately had resolution of symptoms.

IMPACT/DISCUSSION: AUD has a prevalence of 13.9% and up to 50% of patients who cut back will experience withdrawal symptoms. Risk factors for developing AW include heavy alcohol use, prolonged duration, history of withdrawal, concurrent substance use, and increased age. While patients do not always progress linearly through AW, symptoms usually begin with anxiety, nausea, fevers, and tachycardia, progressing to delirium by 12-24 hours, seizures at 24-48 hours and finally delirium tremens with severe confusion by 2-4 days. Scoring models such as CIWA are used to gauge severity and ascertain treatment response. Even with prompt treatment, there have been cases in the literature showing refractory withdrawal lasting up to 28 days. In these cases, it is important to avoid anchoring bias and consider alternative diagnoses. Symptoms of neuroinvasive WNV include a course tremor, ataxia, confusion, and can present with fever and tachycardia. For this patient, prolonged AW was mimicked by an inflammatory and an unusual infectious etiology, underscoring the importance of adapting to treatment failures and dislodging anchoring bias.

CONCLUSION: Alcohol withdrawals have high morbidity and mortality but with prompt treatment, usually show rapid improvement. When withdrawal symptoms do not abate, it is imperative to check anchoring bias and consider alternate etiologies to explain persisting symptoms.

FROM BACTEREMIA TO ARTHRITIS: NAVIGATING A COMPLEX CASE OF ACUTE INFLAMMATORY POLYARTHRITIS

Nicholas Han¹; Katherine Oakden². ¹Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Hospital Medicine, Penn Medicine, Philadelphia, PA. (Control ID #4016324)

CASE: An 18 year old male with a history of recently resected anal condyloma 2 weeks prior presented with 4 days of fever, diarrhea, chest rash, and polyarthralgia. He denied prior upper respiratory infection. On initial evaluation, he was hypotensive and tachycardic with a lactatemia (3.6) and leukocytosis (17.6). CT chest demonstrated septic emboli, and TEE demonstrated a prominent chiari network, the suspected etiology of emboli. He was admitted to the ICU and Vanc/Zosyn were started empirically. Blood cultures grew Group A Strep and antibiotics were ultimately narrowed to Ceftriaxone. Vital signs stabilized, and he was transferred to floor on hospital day #3 with persistent fevers and worsening polyarthritis refractory to NSAIDs. Arthrocentesis was pursued given persistent R knee effusion and was notable for WBC 48,993 with neutrophilic predominance and negative gram stain/cultures. Synovial fluid cultures were thought to be negative due to prior antibiotic exposure and a diagnosis of septic arthritis was favored. Throughout hospital course, his right knee effusion continued to reaccumulate prompting repeat arthrocentesis and drain placement. Waxing and waning involvement of his PIP, MCP, wrist, elbow, and hip joints was also noted. Severe arthritic pain persisted four weeks into hospitalization despite high dose opioids and antibiotics, and arthritis differential was broadened to include rheumatologic etiologies. Given his migratory polyarthritis, persistent fevers >101.3F, and elevated ESR/CRP, diagnosis of ARF was ultimately favored. At the end of hospitalization, IV Ketorolac was restarted and arthralgia resolved.

IMPACT/DISCUSSION: While Acute Rheumatic Fever typically presents 2-3 weeks following GAS pharyngitis, hospitalists should recognize the potential atypical presentations of ARF as described in this case. ARF is typically diagnosed with the jones criteria, requiring either 2 major or 1 major/2 minor criteria. Major criteria include polyarthritis, carditis, subcutaneous nodules, erythema marginatum, and chorea. Minor criteria include arthralgia, fever, elevated ESR/CRP, and prolonged PR interval. While our patient met ARF criteria early in hospitalization with polyarthritis, carditis, and fever, diagnosis was delayed given the atypical time course and the team’s early anchoring to septic arthritis. A rheumatologic diagnosis was further confounded by leukocytic synovial fluid in the septic arthritis range, worsening polyarthralgia despite NSAIDs, and lack of preceding pharyngitis. While septic arthritis is a can’t-miss diagnosis in inflammatory arthritis during infection, reactive arthritis and ARF should also be considered.

CONCLUSION: - While ARF typically follows GAS pharyngitis, other infections, including bacteremia, may also precipitate ARF

- Early nonresponse to NSAIDs does not preclude future response after precipitating infection has cleared

- Anchoring biases can delay diagnoses of less commonly seen conditions especially if presentation is atypical

FROM COMPLEXITY TO CLARITY: NAVIGATING DIFFERENTIATION SYNDROME IN ACUTE PROMYELOCYTIC LEUKEMIA - AN EDUCATIONAL ABSTRACT

Farah Yassine¹; Rashelle Ripa¹; Mahija Cheekati¹; Mohamad Cherry²; Megha Chiruvella¹. ¹Internal Medicine, Morristown Medical Center, Morristown, NJ; ²Hematology-Oncology, Morristown Medical Center, Morristown, NJ. (Control ID #4064755)

CASE: A 28-year-old man with autism and hypothyroidism presented with easy bruising and bleeding gums. Workup revealed significant anemia and thrombocytopenia. Subsequent hematological workup, including a bone marrow biopsy, was diagnostic of acute promyelocytic leukemia (APML) with t(15;17) chromosomal translocation detected in 90% of bone marrow. Given intermediate risk classification (WBC <10,000 and Platelets <40,000), all-trans retinoic acid (ATRA) was initiated. Within 1 week of treatment, the clinical course was complicated by disseminated intravascular coagulation (DIC), differentiation syndrome (DS) and pulmonary alveolar hemorrhage, requiring intensive care. Bone marrow biopsy and fluorescence in situ hybridization (FISH) after the first month were negative for PML/RARA fusion gene suggestive of remission. Consolidation therapy with ATRA and arsenic trioxide (ATO) was then resumed for an additional month along with Gemtuzumab Ozogamicin (Mylotarg). Consolidation therapy was complicated again by DS requiring intensive care and high dose steroids. He eventually responded well and made a successful recovery.

IMPACT/DISCUSSION: APML is a subtype of acute myeloid leukemia (AML) characterized by t(15;17) chromosomal translocation, leading to accumulation of promyelocytes in the bone marrow. It accounts for 10-15% of adult AML. With the advent of novel therapies, APML transformed from the most fatal to most curable acute leukemia in adults. The mainstay of APML treatment is ATRA and ATO, similar to our case. One of the common treatment complications encountered by hospitalists is DS, consisting of a constellation of generalized symptoms (fever, weight gain, peripheral edema, dyspnea with interstitial pulmonary infiltrates, pleuro-pericardial effusion, hypotension, and acute renal failure), sometimes warranting intensive care. DS is caused by maturation of leukemic blasts resulting in cytokine expression, systemic inflammatory response with capillary leakage, endothelial damage and tissue infiltration. It can be difficult to identify due to vague symptomatology. We present an algorithm to provide a systematic thought process to rule out other diagnoses on the differential and successfully identify DS when clinically suspected to initiate appropriate treatment strategy.

CONCLUSION: Early identification and management of DS are key for survival. We aim that this educational abstract and systematic algorithm are a useful tool for hospitalists to navigate the diagnostic work-up and management of DS in APML.

FROM NEURON TO NEPHRON: A COMPLICATED COURSE OF HERPES ZOSTER OPHTHALMICUS AND ENCEPHALITIS

Nathan L. Kindja²; Sai Talluru¹; Valerie Gobao¹. ¹Internal Medicine, UPMC, Pittsburgh, PA; ²University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4064811)

CASE: An 84-year-old woman presented with a week of painful left periorbital rash and confusion. Exam was notable for vesicular rash along the left V1 distribution and conjunctival injection. She was agitated and unable to follow two-step commands. Neurology, ophthalmology, and infectious disease were consulted. MRI brain and labs were unremarkable. Lumbar puncture showed elevated protein at 55 mg/dL and positive varicella zoster virus (VZV) PCR.

She was diagnosed with herpes zoster ophthalmicus (HZO) complicated by VZV encephalitis, admitted to an isolation room, and started on high-dose IV acyclovir. We gave daily 1 L fluid boluses in lieu of continuous fluids, as patient’s agitation worsened with prolonged connection to an IV pole. Her creatinine rose from a baseline of 0.7 mg/dL to 1.4 mg/dL on day 5. By this point, agitation had improved. Maintenance fluids at 120 cc/hr were started with 500 cc boluses before and after acyclovir administration. Her creatinine steadily normalized, though she then became delirious. Mentation improved with stringent delirium precautions and extra effort from floor staff and medical team to engage patient. After 14 days, she was discharged home with mental status at baseline, vision intact, and facial rash healing well.

IMPACT/DISCUSSION: VZV reactivation is common in adults over 60. HZO is seen in up to 20% of cases and results in severe morbidity including blindness. VZV encephalitis is rarer with high rates of mortality. Encephalitis should be suspected in cases of VZV with altered mental status and focal neurologic deficits. It is diagnosed by positive CSF VZV PCR.

VZV encephalitis is treated with IV acyclovir at a dose of 10 mg/kg three times a day for 10 to 14 days. This puts patients at risk for crystal-induced AKI, necessitating prophylactic IV fluid administration titrated to a urine output of 75 cc/hr. Prolonged hospitalization in isolation precautions with continuous IV attachment puts elderly patients at risk for delirium.

Our case demonstrates the challenges of managing VZV encephalitis. Inadequate fluids led to acute kidney injury from acyclovir. She then developed iatrogenic delirium after being isolated for days with movement limited by an IV pole. Interdisciplinary communication with floor staff and consultants was essential to prevent and correct iatrogenic complications.

CONCLUSION: VZV encephalitis is an uncommon but deadly presentation of herpes zoster reactivation. Suspect VZV encephalitis in patients with VZV and altered mental status or focal neurologic deficits.

Interdisciplinary communication is essential to prevent and treat iatrogenic complications of VZV encephalitis including crystalline nephropathy and delirium.

FROM SILENT COMPANION TO FIERCE ADVERSARY: PLASMA CELL LEUKEMIA ARISING FROM MGUS

Athar Eysa, Farah Yassine, Michael Scola. Internal Medicine, Morristown Medical Center, Morristown, NJ. (Control ID #4065034)

CASE: A 76-year-old woman with osteopenia and IgG lambda monoclonal gammopathy presented with worsening fatigue and new onset low back pain. CBC showed worsening leukocytosis, anemia, and thrombocytopenia. Laboratory studies showed elevated creatinine, hypercalcemia, high lactate dehydrogenase, uric acid, and worsening beta-2 microglobulin. Protein electrophoresis revealed monoclonal protein (5g/dl) and lambda light chain (203mg/L) with a kappa/lambda ratio of 0.03. A blood smear revealed circulating plasma cells. The findings were concerning for primary plasma cell leukemia. Bone marrow biopsy confirmed the diagnosis of plasma cell leukemia with extensive replacement (greater than 90%), (11;14) translocation, 14q translocation, and 13q deletion. Imaging studies revealed bone marrow replacement and L1 partial compression fracture. Treatment with transfusions and steroid was started. She received myeloma-directed therapy with daratumumab, lenalidomide, bortezomib, and dexamethasone (dara-RVd). Follow-up lab studies showed favorable resolution of the leukemic component. She was not a transplant candidate due to the aggressive nature of her disease. She then had disease progression, requiring second-line therapy with carfilzomib, pomalidomide, and dexamethasone, followed by third-line venetoclax, daratumumab, and dexamethasone. She continues to benefit from the third-line therapy with a favorable reduction in immunoglobulin.

IMPACT/DISCUSSION: IgG MGUS is the most common type of heavy chain MGUS. It is characterized by the absence of CRAB symptoms (hypercalcemia, anemia, renal failure, and bone pain/lytic bone lesions) and a level of M protein spike <3 g/dl. MGUS has a yearly risk of 1% for progression to MM. Typically, IgG and IgA MGUS progress to multiple myeloma (MM), compared to IgM MGUS, which has a high risk of developing non-Hodgkin lymphoma. Plasma cell leukemia (PCL) is the rarest and most aggressive form of plasma cell disorder. The exact percentage of MGUS progression to PCL is unknown.

Given the rarity of PCL, treatment is inferred from MM studies. Our patient was ineligible for a bone marrow transplant, so treatment with dara-RVd was initiated. Given this patient's presence of t (11;14), venetoclax was presumed beneficial. The patient achieved a favorable response after the venetoclax regimen was started. Venetoclax has shown good response as a single agent or in combination in relapsing MM trials. No studies on Venetoclax and PCL have been performed.

CONCLUSION: MGUS is a common condition requiring frequent monitoring for fear of complications. While IgG MGUS is likely to progress to multiple myeloma, progression to plasma cell leukemia should also be considered. Early recognition is essential, given that PCL is highly aggressive. There are no clinical trials directed towards the treatment of PCL. However, case reports of PCL show a higher response to venetoclax, which could be due to the high expression of t(11:14) in PCL. Further trials studying PCL are needed.

FROM THE FOREST TO THE ICU: A RARE CASE OF WEIL’S SYNDROME WITH A LEUKEMOID REACTION IN A NON ENDEMIC AREA.

Chef Stan Macaraeg. Internal Medicine, UConn Health, Farmington, CT. (Control ID #4064857)

CASE: Our patient is a 53-year-old male from Connecticut, who spends time in the forest, presented with a five-day history of malaise and myalgia. Despite denying other symptoms or trauma, he exhibited elevated creatinine kinase (1589mg/dl), leukocytosis (12.1K/uL), and thrombocytopenia (77K/uL) upon admission, with acceptable hemodynamics and no fever. As his stay progressed, his creatinine worsened to 4.9mg/dl, bilirubinemia increased to 10.1mg/dl, and thrombocytopenia worsened to 6K/uL. Prednisone was started for concerns of thrombotic thrombocytopenic purpura, but a blood smear and bone marrow biopsy were unrevealing. Empiric antibiotics were started to address potential tick-borne infections. His azotemia escalated necessitating hemodialysis. Further tests, including ADAMTS13, tick-borne disease workup, and autoimmune tests, were unrevealing. On the eighth day, a Leptospira IgM test returned positive, prompting a seven-day course of ceftriaxone and apparent improvement. On the tenth day, he experienced acute hypotension needing vasopressors, accompanied by a precipitous increase in leukocytosis to 87.7K/uL with 90% neutrophils. His total bilirubin surged to 52.4mg/dl, with direct bilirubin exceeding 30mg/dl, while liver transaminases remained near normal. His condition eventually stabilized and took three days to wean off vasopressors. He stopped hemodialysis after four weeks and was discharged stable after seven weeks, with persistent anemia and leg weakness but a return to baseline levels in terms of thrombocytopenia, leukocytosis, bilirubinemia, and renal function.

IMPACT/DISCUSSION: Leptospirosis is a globally significant zoonotic disease primarily found in the tropics. Most cases are mild, featuring symptoms such as fever, and myalgia. Severe cases are rare, accounting for only 1% of cases. We are presented with an exceedingly rare case of Weil's syndrome, a specific form of severe Leptospirosis. This condition is characterized by jaundice, acute renal failure, and hemolysis, with a mortality rate close to 50%. Leptospira can endure humid environments, increasing exposure risks during water activities and potential outbreaks. Emergence of antibodies after two weeks signifies the immune phase, accompanied by the bacterial migration from the blood to organs, resulting in direct cellular damage. The space of Disse can be invaded, leading to bilirubinemia, while liver transaminases remain relatively unaffected. Patients experience deteriorating clinical condition during this phase despite antibiotics. This case also describes a leukemoid reaction coinciding with shock and a peak in bilirubin, a phenomenon previously reported in only two human pediatric cases

CONCLUSION: In a patient presenting with bilateral leg pain, thrombocytopenia, bilirubinemia, and acute renal failure, it is prudent to consider Leptospirosis in the differentials. Given its broad spectrum of hosts, a Leptospirosis outbreak can occur in virtually any location.

FULL HOUSE: AN UNUSUAL CASE OF AN AKI, LUPUS PODOCYTOPATHY, AND CLASS II LUPUS NEPHRITIS

Margaret M. Kimzey, Kevin Bodker, Pranav Shah, Pamela Pride. Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4064991)

CASE: A 26-year-old male without significant past medical history presented with complaints of decreased urine output and generalized weakness. He reported a 4-week history of sore throat, general malaise and intermittent fevers. Physical exam was pertinent for an erythematous nodular rash limited to his chest. Patient did not have lower extremity edema. Laboratories were remarkable for serum creatinine 3.6mg/dL, BUN 86 mg/dL, albumin 2.4 g/dL, erythrocyte sedimentary rate 86 mm/hr, serum C3 46.7 mg/dL, and serum C4 17.2 mg/dL. Basic serum electrolytes were within normal limits. Further evaluation revealed proteinuria with 4.3 g/g on spot urine protein and creatinine. Serologies revealed positive serum anti-nuclear, anti-smith, and anti-smooth muscle antibodies. Renal function worsened over the following days ultimately requiring dialysis due to refractory hyperkalemia and developing concern uremic encephalopathy. Intravenous methylprednisolone 1 g was initiated due to concern for rapidly progressive glomerulonephritis (GN). Renal biopsy showed evidence of acute interstitial nephritis (AIN). AIN was considered mild and focal and concerned remained for additional pathologic etiologies. Immunofluorescence (IF) revealed a “full house” pattern consistent with LN. Final report on light microscopy and IF showed Lupus Nephritis class II. Electron microscopy revealed podocyte effacement consistent with lupus podocytopathy. Skin biopsy of chest lesions showed a “full house” pattern with patchy granular immunoprotein deposition. He was continued on steroid therapy and hydroxychloroquine. On discharge the patient had full renal recovery, only requiring two sessions of hemodialysis.

IMPACT/DISCUSSION: Acute kidney injury (AKI) and nephrotic range proteinuria are unexpected and uncommon findings in patients with class II lupus nephritis. These are more common manifestations in patients with class IV or V glomerulonephritis. Class II Lupus is generally treated supportively with improvement over time. Nephrotic range proteinuria can be explained by Lupus podocytopathy (LP); however, the AKI and need for dialysis are also uncommon in LP. Additionally, steroids are treatment of choice in LP, with significant improvement seen in proteinuria. AIN can be seen in SLE with type III hypersensitivity; however, the mild and focal findings rarely cause acute renal failure. Additional tissue may have shed light on alternative renal manifestations (acute tubular necrosis or glomerulosclerosis), but given the significant improvement with steroids, a repeat biopsy was not pursued.

CONCLUSION: This case illustrates multiple confounding factors and manifestations of Lupus. LN class II is generally supported conservatively; whereas LP has favorable outcomes with initiation of systemic steroids. AIN may also be seen as a hypersensitivity reaction in SLE and commonly improves with treatment or removal of the underlying cause.

FUROSEMIDE-TRIGGERED LEUKOCYTOCLASTIC VASCULITIS: UNVEILING A RARE CAUSE OF VASCULOPATHY

Gaurav Luthria¹; Yichen Zhang³; Jay Chan²; Samantha Wang³. ¹Stanford University School of Medicine, Stanford, CA; ²Santa Clara Valley Medical Center, San Jose, CA; ³Medicine, Stanford University, Stanford, CA. (Control ID #4060865)

CASE: A 67-year-old male with type 2 diabetes, hypertension, chronic kidney disease, and diastolic heart failure presented with a progressive nontender, non-pruritic purpuric rash on his extremities for 3 weeks. His medications included atorvastatin, irbesartan, furosemide, and insulin. He denied history of purpuric rashes. His vital signs were stable. He had 2+ bilateral lower extremity pitting edema, and palpable, non-blanching, purpuric lesions on his upper and lower extremities and abdomen. Laboratory results were notable for increased serum creatinine (2.9 mg/dL, baseline 1.9 mg/dL), ESR (51 mm/hr), and CRP (10.9 mg/dL). His urine analysis showed 2+ blood, 2+ protein, and 6-10 RBCs. A broad serologic workup was pursued due to concern for systemic vasculitis with renal involvement.

Serum markers for connective tissue diseases (rheumatoid factor, anti-Ro/La, ANA, and C3/C4 levels), infectious etiologies (anti-streptolysin, anti-DNase B, hepatitis B/C, HIV), cryoglobulinemic (serum cryoproteins) and ANCA (ANCA, PR3, MPO) associated vasculitides were unremarkable. Electromyography showed no signs of vasculitis-associated neuropathy. A punch biopsy revealed perivascular inflammation with neutrophils, lymphocytes, and fibrinoid necrosis in several vessels without significant IgA deposition, consistent with the diagnosis of leukocytoclastic vasculitis (LCV). His acute kidney injury improved with IV hydration alone. Upon further discussion, he shared that furosemide was a new medication that had replaced his previous torsemide. After discontinuing furosemide, there was a regression in the number and confluence of purpuric lesions over a 3-day hospital stay.

IMPACT/DISCUSSION: Cutaneous adverse reactions to furosemide such as bullous pemphigoid, lichenoid eruption, and Sweet syndrome are rare, occurring in less than 5% of treated individuals. We report an uncommon case of furosemide-induced LCV, a small-vessel vasculitis typically presenting with palpable purpura due to immune complex deposition and neutrophil-mediated damage to dermal vessels. LCV is commonly idiopathic but can be secondary to infectious, neoplastic, and autoimmune factors, or drug reactions. While the mechanism for furosemide-induced LCV is unclear, it is likely associated with a type 3 hypersensitivity reaction. Typically, discontinuation of the causative medication leads to symptom resolution, though more severe cases may require adjunctive steroid therapy. This case underscores the importance of considering medication related causes of LCV, including furosemide as a reversible trigger given its frequent prescription. The resolution of rash post-furosemide discontinuation without steroids highlights the drug's contributory role in the pathogenesis of LCV.

CONCLUSION: The association between furosemide and the development of LCV emphasizes the importance of eliciting a thorough medication history to identify potential triggers for vasculitis, especially when symptom onset coincides with medication changes.

GAIT IMBALANCE AS AN UNEXPECTED INITIAL PRESENTATION OF HODGKIN’S LYMPHOMA

Emmanuel Aguilar-Posada, Sarah Hsu. Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4064611)

CASE: Hodgkin’s Lymphoma is a malignancy classically characterized by B-symptoms; however rarely, it can initially present with neurologic symptoms, making diagnosis challenging. A 45-year-old male with a history of traumatic brain injury with residual mild cognitive deficits presented to the emergency department (ED) for two weeks of gait unsteadiness. He had a non-focal neurologic exam and a normal CT head and was sent home. Over the next few weeks, he presented to the ED multiple times, with progressively worse symptoms and development of mild dysarthria and word-finding difficulty. Neurologic evaluation during these visits revealed the same slightly wide-based, cautious gait, but given repeated normal lab work-up, and normal MRI brain, he was discharged with outpatient follow up. Two months after symptom onset, he was admitted to the hospital for night sweats for three days. His exam showed a 40lb weight loss in 2 months, inattention, paucity of speech, mild dysarthria, mild bilateral coordination issues, and markedly unsteady gait. Workup included a lumbar puncture with unremarkable CSF studies and a CT abdomen/pelvis showing multiple enlarged para-aortic and pelvic lymph nodes. These lymph nodes were initially thought to be incidental and unrelated to his neurological symptoms. Instead, despite having a minimal alcohol use history, he was thought to have an atypical presentation of Wernicke’s encephalopathy and was started on IV thiamine. The diagnosis of Whipple’s disease was entertained, but upper endoscopy was normal. Ultimately, a biopsy of an enlarged pelvic lymph node was performed. Pathology stained positive for Reed-Sternberg cells, revealing a diagnosis of Hodgkin’s Lymphoma. In the setting of this diagnosis, his presentation was attributed to paraneoplastic cerebellar degeneration. He was treated with chemotherapy with prompt improvement and eventual resolution of his neurologic symptoms. A paraneoplastic CSF panel was deferred due to the high cost of this test that would not change management given his symptomatic improvement.

IMPACT/DISCUSSION: This case illustrates the potential for paraneoplastic neurologic dysfunction as an initial presentation of Hodgkin’s Lymphoma. This presentation of Hodgkin’s is rare and can confound diagnostic evaluation if an underlying primary neurologic etiology is anchored upon. Although the presence of retroperitoneal lymphadenopathy was thought to be a red herring, it was important to pursue a lymph node biopsy to achieve the final diagnosis.

CONCLUSION: Keep paraneoplastic neurologic dysfunction on the differential for encephalopathy with neurologic abnormalities. This atypical presentation of malignancy demonstrates the importance of humility in the face of diagnostic uncertainty.

GASTRIC DIFFUSE LARGE B CELL LYMPHOMA PRESENTING WITH MASSIVE GASTROINTESTINAL BLEEDING

Connor Murakami¹; Kuo-Chiang Lian^2,1. ¹Medicine, University of Hawai'i System, Honolulu, HI; ²Hospitalist Program, The Queen's Health Systems, Honolulu, HI. (Control ID #4060703)

CASE: A 68-year-old male on rivaroxaban for atrial fibrillation and a history of pulmonary embolism presented to the Emergency Department with acute hematemesis reported as more than a cup of blood. Over the preceding months, he experienced nausea and poor appetite associated with greater than 100-pound weight loss. Additionally, he reported progressive fatigue and weakness, with intermittent syncopal episodes.

Physical examination was notable for mild tenderness in the RUQ and epigastric regions, with no other significant findings. Initial labs revealed profound anemia with hemoglobin of 8.8 g/dL following resuscitation. CT imaging of his abdomen and pelvis showed diffuse gastric wall thickening with multiple prominent perigastric lymph nodes, which were concerning for malignancy with nodal metastases.

He underwent an upper endoscopy, which revealed a large ulcerated mass in the gastric body and a fungating mass in the duodenum. Pathology results from endoscopic biopsy returned positive for diffuse large B-cell lymphoma (DLBCL), MYC negative. Staging evaluation with PET/CT imaging showed hypermetabolic gastric wall and gastroduodenal junction thickening with left paraaortic and perigastric lymph node involvement (Stage IIE, IPI 1).

The patient’s rivaroxaban was held from admission and he was treated with PPI infusion. Following initial stabilization, he remained stable from a bleeding standpoint. Medical Oncology was consulted and the patient was initiated on R-CHOP systemic chemotherapy, which he tolerated well. The patient was discharged with follow-up plans made for his next cycle of chemotherapy.

IMPACT/DISCUSSION: Among causes of upper GI bleeds, malignancies make up just 1%. Lymphomas are a rare type of neoplasm within this category and can present in extranodal sites, most commonly in the GI system. Primary gastric lymphomas (PGL) are a class of extranodal lymphomas that develop in the GI system, with the most common subtype being DLBCL. DLBCL and other PGL can present with nonspecific symptoms, such as abdominal pain, hematemesis or melena, anorexia, and anemia. B symptoms are also known to occur but are rare. The gold standard for initial diagnosis of DLBCL is EGD with biopsy since the gross appearance of the lesions of PGL and other gastric carcinomas are often indistinguishable. Regardless of stage, DLBCL is treated with systemic R-CHOP chemotherapy.

DLBCL is an aggressive neoplasm and can be fatal within a year if left untreated. This case demonstrates the importance of timely and accurate diagnosis for a patient with hematemesis and non-specific GI symptoms. With appropriate treatment, approximately two-thirds of patients with DLBCL can achieve complete remission.

CONCLUSION: Diagnosing primary gastric DLBCL can be difficult due to its presentation with non-specific GI symptoms.

Initial management of DLBCL consists of diagnostic staging and prompt initiation of systemic therapy.

GENERALIZED PRURITIS LEADING TO AN ULTRA RARE FIND

Sarah Grant¹; Drama M. Cumbie². ¹Internal Medicine Residency Program, East Alabama Medical Center, Opelika, AL; ²Edward Via College of Osteopathic Medicine, Auburn, AL. (Control ID #4064862)

CASE: A 32-year-old female with type 2 diabetes presented to the emergency department with one week of abdominal distension, intermittent abdominal pain, and lower extremity edema and roughly one year of generalized pruritus. She also had an unintended 4kg weight loss over the last 9 months. Initial CT abdomen and pelvis showed extensive lesions in the liver, lung bases, along with ascites and omental caking with multiple prominent retroperitoneal mesenteric lymph nodes. CT chest noted too numerous to count noncalcified, bilateral pulmonary nodules without effusion and MRI brain was negative for metastasis. Her liver biopsy was positive for epithelioid hemangioendothelioma confirmed using immunohistochemistry. During her outpatient hematology appointment, it was discussed that due to the rare number of cases of metastasis additional tissue sampling will take place of different sites to ensure two separate processes are not occurring simultaneously. In a clinic follow-up with her general practitioner the patient had significant abdominal ascites that required a therapeutic paracentesis and commencement of spironolactone and furosemide. The patient is also awaiting follow-up with Emory’s hematology and oncology department.

IMPACT/DISCUSSION: Epithelioid hemangioendothelioma is an ultra-rare vascular sarcoma with a prevalence of less than 1/1,000,000 with a slight female predominance. It is attributed to a translocation error of WWTR1-CAMTA1 fusion 90% or YAP1-TFE3 fusion 10% of the time. Data regarding progrognosis is limited and patients with serosal involvement are noted to have a 1-11 month life expectancy. The only negative biochemical marker for prognosis is anemia. Metastasis is seen in roughly half of the cases affecting mainly the lungs, liver, and bones. Diagnosis relies on tissue biopsy to identify and immunohistochemistry to distinguish from epithelioid angiosarcoma.

Treatment is recommended to take place in a sarcoma specialty center and typically revolves around surgical resection and/or radiation, when possible, regardless if the lesions are in the lungs, liver, or bones. Liver transplant is also an option for patients with unresectable liver lesions without extrahepatic involvement. Investigative systemic treatments including mTOR inhibitors are currently being researched along with Trametinib, a MEK signaling pathway inhibitor, for patients with metastasis.

The EHE foundation is a useful resource for patients and clinicians about the diagnosis and to identify available clinical trials, treatment centers, and a patient registry.

CONCLUSION: Epithelioid hemangioendothelioma is ultra-rare sarcoma and relies on biopsy and immunohistochemistry to diagnose.

Systemic treatment options are still under investigation. Currently, treatment relies predominantly on surgical resection or radiation when appropriate.

GIANT CELL MYOCARDITIS: FULMINANT MYOCARDITIS REQUIRING HEART TRANSPLANTATION IN A PATIENT WITH DRESS SYNDROME

Dana R. Arenz¹; Eric W. Rudofker²; Christine Sailer³. ¹Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²Cardiology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ³Advanced Heart Failure and Transplant Cardiology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4057945)

CASE: A 24-year-old woman with bipolar disorder presented with diffuse maculopapular rash, cervical lymphadenopathy, transaminitis, and eosinophilia 6 weeks after starting lamotrigine. Drug reaction with eosinophilia and systemic symptoms (DRESS) was suspected. She recieved IV cyclosporine and discharged on a prolonged prednisone course. Six weeks later, she presented with chest pain and elevated cardiac troponin (peak hs-troponin 9549 ng/L). The following tests were obtained: echocardiogram with left ventricular ejection fraction (LVEF) of 45% and normal right ventricular (RV) function, coronary angiography without coronary pathology, right heart catheterization (RHC) with elevated left ventricular (LV) end-diastolic pressures and normal cardiac output, and cardiac MRI with patchy mid-myocardial late gadolinium enhancement of septum and lateral LV. Prednisone was increased to 60mg daily for suspected eosinophilic myocarditis (EM). She returned 9 days later with abdominal pain and nausea. ECG showed junctional tachycardia and ST elevations in V1 and aVR. TTE showed stable LVEF, but new RV dilation with reduced systolic function and septal flattening. Hs-troponin was 109ng/L and and lactate 3.4mmol/L. RHC revealed cardiogenic shock with severe RV dysfunction (RA 18, PAP 22/16/28, PCWP 13, cardiac output/index of 2.4/1.2). She received 1g methylprednisolone IV daily, however she developed recurrent ventricular tachycardia and progressive cardiogenic shock despite escalating inotropes and antiarrhythmic medications. On hospital day 3 she was emergently cannulated for VA-ECMO and on hospital day 5 she underwent orthotopic heart transplant (OHT). Explanted heart pathology showed T cell and giant cell infiltrates without eosinophils, consistent with giant cell myocarditis (GCM). The postsurgical course was uncomplicated, and she discharged on hospital day 19.

IMPACT/DISCUSSION: DRESS syndrome is a drug rash associated with eosinophilia and systemic symptoms that typically occurs 2-6 weeks after starting an offending medication; lamotrigine in our case. EM is a rare and highly fatal sequelae of DRESS syndrome, occurring anytime from rash onset to months after symptom resolution. GCM is not a known sequelae of DRESS syndrome. GCM typically affects healthy, young individuals, though autoimmune disorders have been reported in 20% of cases. Initial presentation varies, but often includes heart failure, ventricular arrhythmias, AV block, and is rapidly fatal. With combination immunosuppression, median survival from symptom onset to death or transplant has improved from 3 months to almost a year. Although recurrence of GCM in transplanted hearts has been reported, overall post-transplant survival is similar to other etiologies.

CONCLUSION: Rapidly progressive heart failure unresponsive to therapy, with or without ventricular arrhythmias or heart block, warrants consideration of GCM. Prompt recognition and high-dose immunosuppression is critical for treatment, with OHT necessary in severe cases.

GI DISTRESS MASKING A GRAVE ILLNESS

Joanna Kilbane Myers, Sarah B. Merriam. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4063214)

CASE: A 52-year-old woman with no past medical history presents with a 3-week history of relapsing and remitting symptoms of nausea, epigastric pain, emesis, diarrhea and generalized weakness. Associated symptoms include dyspnea on exertion and poor oral intake with resultant weight loss. She denies chest pain, palpitations, vision changes, focal weakness, headache or prior cardiac history. Presenting vitals were as follows: afebrile, HR 135, BP 152/77, RR 18, SpO2 99% on RA. Initial evaluation was remarkable for an EKG with sinus tachycardia, WBC 5.5, Hgb 11.3, Cr 0.4, hs-trop 3 and d-dimer 0.61. CTA revealed no PE. Subsequent focused physical exam revealed a thyroid bruit and a TSH <0.01. The patient was admitted and ultimately diagnosed with Graves’ disease with a positive TSI thyroid stimulating immunoglobulin, free T4 6.37, and free T3 >20. She was prescribed propranolol and methimazole with subsequent clinical improvement.

IMPACT/DISCUSSION: A high degree of clinical suspicion is critical with new hyperthyroidism because many patients may present with nonspecific cardiac and gastrointestinal signs and symptoms. Classic presenting symptoms of thyrotoxicosis include palpitations, anxiety, asthenia, heat intolerance, tremors and weight loss. Cardiac or pulmonary manifestations of tachycardia, atrial fibrillation, edema, and dyspnea are more common in older patients. When thyrotoxicosis is diagnosed, it is also important to rapidly assess for the presence of, and initiate treatment for, thyroid storm which carries a 10-30% mortality rate.

The Burch-Wartofsky Point Scale (BWPS) is a succinct tool for the general internist to utilize when determining the severity of disease and need for hospitalization. The BWPS considers temperature, central nervous system effects, gastrointestinal-hepatic dysfunction, cardiovascular dysfunction, heart failure and precipitant history to determine the likelihood of current or impending thyroid storm. This patient’s BWPS score was 30, which suggests impending thyroid storm and warrants inpatient admission. If her TSI Ab had been negative, a RAIU scan would have been the next step in diagnosis of her new hyperthyroidism. Importantly, because she received iodinated contrast during CTA performed in the ED, a 4-8 week washout period would have been required before a formal diagnosis could be made.

CONCLUSION: Thyrotoxicosis, especially in the early stages, often presents with nonspecific signs and symptoms and requires a high index of suspicion. When diagnosed, the BWPS should be used to determine if a patient meets criteria for inpatient admission for thyrotoxicosis. Whenever possible, defer iodinated contrast in patients with suspected hyperthyroidism until basic thyroid testing is complete, given that iodinated contrast will preclude a timely RAIU scan.

GI TRACT LYMPHOMA MIMICKING BENIGN CONDITIONS

Nina Brahmbhatt¹; Grant A. Zydeck²; Momin Samad³; Dana Kabbani⁴. ¹Student, Wayne State University School of Medicine, Detroit, MI; ²School of Medicine, Wayne State University, Detroit, MI; ³Internal Medicine, Henry Ford Health System, Detroit, MI; ⁴Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4061304)

CASE: A 69-year-old male presented to the emergency department with sore throat, odynophagia associated with poor oral intake and unintentional weight loss of 30 pounds over the last year. Patient reports difficulty in following up with PCP, and often utilizes urban Emergency Department (ED) for care. Patient was treated with 4 courses of antibiotics including azithromycin, augmentin, clindamycin over 6 weeks for presumed respiratory infection, but found no relief from these regiments. Further workup was performed via ultrasound, CT imaging, and flexible laryngoscopy with findings revealing soft tissue thickening of the oropharynx, ulceration of base of tongue with right sided tonsillar mass highly suspicious for malignant neoplastic process. Oropharyngeal mass had rapidly progressed within 11 days, and prominent lymph nodes were also seen in level 1 and 2 bilaterally. Patient reported severe abdominal pain and melanotic stool, and CT imaging revealed free intraperitoneal air without a clear source. A diagnostic laparoscopy demonstrated a small bowel perforation of the ileum with multiple serosal masses s/p resection of 60cm small bowl with primary anastomosis and placement of GJ tube to address malnutrition and feeding needs.

Biopsy of oropharyngeal and small bowel masses preliminary revealed high-grade aggressive mature T-cell lymphoma with a nuclear proliferative rate of 80%.

Patient’s initial EPOCH chemotherapy was delayed due to acute hypoxia respiratory failure likely due to the oropharyngeal mass causing airway obstruction and aspiration. Patient was intubated and given high flow nasal cannula therapy. Patient started on EPOCH chemotherapy and palliative care for pain management for Stage IV T-cell lymphoma.

IMPACT/DISCUSSION: The patient’s initial diagnostic differential included epiglottitis, tonsillitis, streptococcal pharyngitis however malabsorption, poor oral intake, and unintentional significant weight loss should increase clinical suspicion for Gastrointestinal tract lymphoma. This is particularly important in cases with prolonged non-responsiveness to standard treatments such as antibiotics. The GI tract, including oropharynx, is the most common site of extranodal non-Hodgkin lymphoma, accounting for 20-40% of all extranodal lymphomas. More specifically, about 10-25% of all lymphomas of the intestines are of T-cell origin. Other significant malignancies that can cause symptoms of malabsorption and weight loss include adenocarcinoma of the small intestine, colon, or pancreas or metastasis of other cancers to the GI tract. In this case T cell lymphoma presented insidiously, masquerading as benign conditions, but other malignancies would present more obviously. Identifying these red flags early on remains pivotal in swiftly diagnosing and managing malignancies, ensuring improved patient outcomes.

CONCLUSION: Recognition of malabsorption and weight loss symptoms as easily identifiable risk factors for malignancies can lead to crucial diagnosis and early treatment.

GLUCOSE GAMBIT: NIVOLUMAB’S CHECKMATE MOVE FROM IMMUNITY TO INSULIN

Inemesit Akpan¹; Olawole Akinboboye¹; Sammudeen Ibrahim²; Sheri P. Walls¹; Christopher March¹. ¹Internal medicine, Piedmont Athens Regional Internal Medicine Residency Program, Athens, GA; ²Internal Medicine, Piedmont Athens Regional Internal Medicine Residency Program, Athens, GA. (Control ID #4064093)

CASE: A 77-year-old male with a history of high-grade papillary urothelial cancer stage 3A (T4AN1) status post bladder resection on nivolumab for 2 months and chronic kidney disease stage 4 was transferred from his oncologist’s office with nausea, non-bilious vomiting, abdominal pain, and weakness for 3 days which was associated with dry mouth, excessive thirst, and increased urinary output. He denied any known history of diabetes mellitus. Vitals were unremarkable. Exams were unremarkable and revealed a well-functioning urostomy draining clear yellow urine. Labs showed a plasma glucose of 729 mg/dl, bicarbonate 20 mmol/L, anion gap of 9, beta-hydroxybutyrate of 0.76, hemoglobin A1c of 7%, and a low C-peptide level of 0.56 ng/ml. He was then managed for new-onset diabetes mellitus with intravenous fluid and insulin. He improved clinically, received diabetes education, and was discharged home with insulin.

IMPACT/DISCUSSION: Nivolumab is an immune checkpoint inhibitor (ICI) that selectively blocks programmed cell death-1 (PD-1) to induce anti-tumor responses. Nivolumab serves as an important therapeutic agent in various malignancies. However, its use is associated with immune-related adverse events characterized by a dysregulated immune response against multiple organ systems including the gastrointestinal and endocrine systems. One such event is immune-mediated diabetes mellitus (IMDM) resulting from the destruction of pancreatic beta cells by autoreactive T cells.

Although diabetes mellitus secondary to nivolumab use only occurs in <1% of patients, it can present with fulminant type 1 diabetes mellitus or even diabetes ketoacidosis. Only about half of the patients with nivolumab-induced diabetes mellitus have been found to have islet autoantibodies suggesting nivolumab likely induces rapidly progressively type 1 DM through another mechanism independent of the presence of islet cell-related autoantibodies.

Unlike other autoimmune complications of ICI where steroids can be used, high-dose steroids are usually avoided in IMDM since they can exacerbate hyperglycemia. Hence, the mainstay of treatment includes discontinuing nivolumab and insulin replacement in the setting of acutely depleted beta cells.

In our patient scenario, nivolumab was discontinued and he was treated with insulin since the pathophysiology is in keeping with insulin deficiency from pancreatic beta cell destruction with subsequent resolution of his clinical symptoms. He was discharged on insulin to follow up with oncology who recommended discontinuation of nivolumab with plans for tumor surveillance given the patient’s comorbidities precluded alternative therapies.

CONCLUSION: As the use of immune checkpoint inhibitors increases, it is important for clinicians to closely monitor for the development of rare adverse effects such as IMDM. This will enable prompt management to avoid progression to more severe complications like diabetes ketoacidosis.

GROWING DESPITE ANTIBIOTICS-- WHEN IS WARMTH, ERYTHEMA, AND TENDERNESS NOT INFECTIOUS?

Swetha Vontela, Casey N. McQuade. Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #4064814)

CASE: A 38-year-old healthy female presented to the emergency department with 2 days of fevers and facial swelling. She initially developed mild left facial edema and pain 2 days ago associated with fevers up to 103°F at home. She then developed a progressive painful erythematous rash on her left face as well as worsening facial swelling of left cheek, eye and ear. Her rash was present on left cheek and neck and was notably warm and tender without fluctuance. CT maxillofacial and neck showed left parotiditis with associated skin edema. With IV Unasyn, the patient’s facial pain and swelling significantly improved by hospital day 2. However, the rash continued to extend down her neck onto the anterior chest and significant tenderness to light touch. Despite the addition of vancomycin, the rash extended further and significant pain persisted (see Figure 1). Labs demonstrated a normal white cell count and an elevated erythrocyte sedimentation rate of 42 mm/hr. Repeat CT neck and chest was unrevealing. Dermatology was consulted and punch biopsy was obtained. Pathology demonstrated perivascular and interstitial dermatitis with eosinophils, consistent with eosinophilic cellulitis. With initiation of prednisone 60 mg daily, there was significant decrease in pain and erythema within 24 hours. She was discharged on a 20-day prednisone taper.

IMPACT/DISCUSSION: The internist frequently encounters confluent erythematous rashes and the differential for etiologies is highly varied, including bacterial cellulitis, tinea corporis, erythema migrans, hypersensitivity reactions to insect bites, drug eruptions, and contact dermatitis. Eosinophilic cellulitis (EC) ought to be included on this differential despite its rarity given it is requirement for skin biopsy for diagnosis. EC classically resembles infectious cellulitis but without response to antimicrobial treatment. Its pathogenesis is unclear and appears to be an inflammatory eosinophilic reaction to variety of triggers with constellation of nonspecific clinical findings. Known triggers include infections, insect bites, vaccines, medications, and malignancy (particularly chronic lymphocytic leukemia). There is no consensus regarding optimal management due to a paucity of reported cases—typically topical corticosteroids are the first-line therapy unless there are systemic effects, in which case oral corticosteroids are used.

CONCLUSION: Eosinophilic cellulitis is a dermal inflammatory reaction that typically presents as an erythematous plaque-like rash. It should be included on the differential when an erythematous rash does not respond to antibiotics, as it typically requires steroids for treatment. It requires dermatologic consultation and skin biopsy for definitive diagnosis.

GUILLAIN-BARRé SYNDROME IN A CROHN'S DISEASE PATIENT TREATED WITH TUMOR NECROSIS FACTOR INHIBITORS

Wei Tang²; Vihanga Perera¹; Pritika Sharma²; Arushika Yedla²; Terry Park³. ¹Medicine, Westchester Medical Center Health Network, Valhalla, NY; ²Medicine, Westchester Medical Center, Valhalla, NY; ³Neurology, Westchester Medical Center, Valhalla, NY. (Control ID #4061782)

CASE: A 66-year-old female with a history of Crohn's disease (CD) and Stage IV chronic kidney disease presented with a 2-day history of acute-onset numbness and tingling of bilateral hands and feet.

The patient has a long-standing history of CD and underwent a right hemicolectomy with end ileostomy at the age of 13. She had a CD flare 5 months ago manifested as interstitial lung disease and diversion colitis, for which she was treated with high-dose steroids followed by infliximab as a steroid-sparing agent; she completed 5 mg/kg doses at Week 0, 2 and 6, and remained on every-8-week dosing with most recent one completed 5 weeks before admission.

Physical examination showed significant symmetrical muscle weakness, with muscle strength 3/5 on proximal upper extremities (UEs), 4/5 distal UEs, 2/5 proximal lower extremities (LEs), and 4/5 distal LEs; areflexia was also noticed in bilateral LEs. Cranial nerve functions were intact.

Routine laboratory tests documented a normal white cell count, baseline elevated creatinine, and mild inflammation with a CRP (2.80 mg/dL). Testing for thyroid function, vitamin B₁₂, vitamin B₁, folate, creatinine kinase (CK), syphilis, HIV and tuberculosis all returned as normal.

Guillain-Barré Syndrome (GBS) was highly suspected, electromyography (EMG) was obtained and demonstrated acute sensorimotor axonal neuropathy evidenced by the absence of left median, ulnar, sural and peroneal sensory potentials as well as low amplitude and borderline velocities of left ulnar, peroneal and tibial motor potentials with decreased recruitment.

GBS was diagnosed based on history, examination, and characteristic EMG findings. Further tests for antibodies against ganglioside (GM1), myelin-associated glycoprotein (MAG), and sulfatide were all negative. Patient was treated with intravenous immunoglobulin (IVIG) for 5 days; she had significant neurologic improvement and was discharged with follow-up for further discussion on antitumor necrosis factor (anti-TNF) therapy cessation.

IMPACT/DISCUSSION: We describe a rare case of GBS associated with Infliximab in a patient with severe CD. Evidence to date suggests an association between the use of anti-TNF therapy and the development of GBS. As such, GBS should be considered in any patient who develops sensory changes, motor weakness, areflexia, and ataxia in the setting of anti-TNF therapy. Patients should cease anti-TNF therapy and be referred promptly to a neurologist. Diagnosis of GBS is based on clinical history and physical examination and is supported by ancillary tests including EMG.

CONCLUSION: - GBS has been described in association with anti-TNF therapies including infliximab, especially for inflammatory bowel disease.

- Clinical suspicion for GBS needs to be particularly high in patients with sensory changes, motor weakness, areflexia or ataxia in the setting of anti-TNF therapy.

- Prompt referral to a neurologist, initiation of IVIG, and cessation of anti-TNF therapy will help prevent debilitating neurological deficits.

HEAR IT ECHOING: A CASE OF ASEPTIC MENINGITIS & PANCYTOPENIA

Raihan El-Naas. internal medicine, Weill Cornell Medicine, New York, NY. (Control ID #4023751)

CASE: 38yo woman w/ PCOS p/w fever for 1 day. She began having fevers, chills, myalgias as well as intermittent bitemporal headaches associated w/ lightheadedness & blurry vision for about a day. She denied rhinorrhea, sore throat, CP, SOB, N/V, abd pain, dysuria, vaginal discharge/pruritis, diarrhea or rashes. Denied sick contacts. Endorsed recently travelling to France & London 2 wks prior to presentation where she went to the beach & went hiking w/ her husband & 2 young children. Temp 38.3 HR 130 BP 85/55. On exam, she appeared comfortable. Had some neck stiffness and notable R conjunctival hemorrhage. BP improved to 118/78 after receiving 4L of IVF. Initial labs notable for a leukocytosis of 11.4 & stable Hgb at 13.3 & plts at 219. Infectious workup including CXR, urine/blood cultures, basic viral panel, & parasite testing were all neg. She then developed an oral apthous ulcer, diffuse hives, & a maculopapular rash on her face, chest, abdomen, arms & legs. Lab trend was notable for profound neutropenia (ANC 880) & thrombocytopenia (plts 33). A few days later, her daughter was febrile, had a vesicular rash, & was diagnosed w/ “Hand, foot, & mouth disease”. Pt then reports that she went to a water park w/ her daughter a few days prior to her symptoms. Given this history, full Enterovirus Ab testing was sent. Coxsackie was neg & Echovirus type 9 Ab came back positive w/ titers >1:640.

IMPACT/DISCUSSION: The acuity of the febrile illness & recent travel hx pointed towards a likely viral infection. However, the respiratory viral panel as well as EBV, CMV & HIV were neg. The presence of significant hypotension requiring IVF resuscitation raised suspicion for a possible bacterial infection but a comprehensive infectious work up including Ucx, Bcx, & CXR were neg. Given the recent travel & hiking hx, tick-borne illnesses were considered on the differential despite the initial absence of a rash or classic lab abnormalities (anemia, thrombocytopenia, eosinophilia, transaminitis) but parasite testing (including parasite smear, Lyme Ab, Erlichia, Anaplasma, & RCSF) was neg. It was only after asking about sick contacts AGAIN that the diagnosis was reached! Inquiring about sick contacts & travel hx is paramount! Multiple inquiries may be required as family members may become ill later during the patient’s course. Another key learning point is thinking broadly of a differential diagnosis. Enteroviruses such as Coxsackie & Echovirus can cause summer outbreaks in adults through direct contact & should be considered as potential etiologies when working up an acute febrile illness. Specifically, this viral genus can cause fever, urticaria-like eruptions, aseptic meningitis, & acute hemorrhagic conjunctivitis all of which were present in our patient. Moreover, these viruses can cause acute bone marrow suppression & result in an immune-mediated pancytopenia.

CONCLUSION: Key takeaway is recognizing the significance of inquiring about travel hx & sick contacts as well as the 2 learning objectives below!

HEART ATTACK WITH NO PLAQUES? CONSIDER MINOCA AND MRI (CARDIAC)

Shawn Mahmood¹; Mary C. Wirtz²; Thomas Mason⁴; Akash Goyal³. ¹Internal Medicine, Western University of Health Sciences, Pomona, CA; ²Internal Medicine, The Ohio State University, Columbus, OH; ³Cardiology, The Ohio State University, Columbus, OH; ⁴Internal Medicine / Pediatrics, The Ohio State University, Columbus, OH. (Control ID #4064503)

CASE: 58-year-old male with a history of morbid obesity, hypertension, hypertriglyceridemia, Type 2 Diabetes (A1c 8.1%), obstructive sleep apnea on CPAP, gout, and hypothyroidism taking Allopurinol, Levothyroxine, Nifedipine, Metoprolol, Dapagaflozin, Insulin, Ethyl Eicosapenaenoic Acid and Fenofibrate who presented with a ventricular fibrillation arrest. EKG showed an ST elevation in the inferior leads with troponin elevation. Surprisingly, emergent left heart catheterization demonstrated no obstructive disease. CT Angiography of the coronaries revealed no focal significant stenosis. Transthoracic echocardiogram showed ejection fraction of 50-55% and grade 1 diastolic dysfunction. Cardiac MRI showed a low normal biventricular function with a late gadolinium enhancement demonstrating transmural (75+%) basal-mid inferior lateral infarct scar with a small area of associated microvascular obstruction. The cardiac MRI suggested MINCOA caused by either transient non-obstructive eccentric plaque thrombosis, coronary erosion, or a microvascular obstruction. Less likely coronary vasopasm as previously on calcium channel blocker. He was discharged home on dual anti-platelet therapy, high intensity statin, beta blocker, sodium-glucose transport protein 2 inhibitor, angiotensin-converting enzyme inhibitor after an AICD was placed.

IMPACT/DISCUSSION: MINCOA is considered in a patient that meets certain criteria. Universal acute MI criteria, infarct-related epicardial stenosis <50% during angiography, absence of overt alternative systemic causes and absence of obvious non-ischemic causes of myocardial injury. There are no current standardized approaches to MINCOA. Contrary to historical thoughts, a recent systemic review demonstrated that MINCOA carries a significant disease burden a year after diagnosis. So, determining the underlying mechanism may improve long-term disease burden. MINCOA should be thought of as a working diagnosis with either atherosclerotic or non-atherosclerotic causes. Non-Atherosclerotic causes include systemic supply-demand mismatch including sepsis and anemia, spontaneous coronary artery dissection (SCAD), Coronary microvascular dysfunction, coronary vasospasm, Coronary artery embolism, myocarditis, Takotsubo and other cardiomyopathies. Clinicians should consider the non-invasive diagnostic Cardiac MRI with gadolinium contrast as this will help determine type of myocardial injury. The treatment plan and work-up could change depending on the cause. By better understanding the utility of cardiac MRI in the diagnostic approach of MINOCA may help clinicians reduce disease burden in the long-term. However, further studies would need to be done.

CONCLUSION: MINCOA, MI non-obstructive coronary artery, is a heterogenous working diagnosis that should prompt further diagnostic evaluation of the underlying etiology with cardiac MRI with gadolinium contrast. Treatment of the underlying cause can lead to more guideline based therapeutic strategies which may improve long-term outcomes.

HEARTBOUND HAVOC: NAVIGATING THE INTRICACIES OF HEPATOCELLULAR CARCINOMA WITH INTRACARDIAC TUMOR THROMBUS

Caroline Ross. Internal Medicine, Boston Medical Center, Boston, MA. (Control ID #4059389)

CASE: 68 year old Cape Verdean male with a history of recurrent atypical meningioma (WHO grade II) s/p resection and radiation in 2019 and repeat irradiation in 2022, hepatic adenoma, and atrial fibrillation presented to the ED with left lower extremity paresthesia and abdominal pain. He underwent a CT abdomen/pelvis which showed a 6.9 cm heterogeneous mass centered within the segment II/III representing neoplasm with extension into the IVC, right atrium, and right ventricle, resulting in a 5.8 cm tumor thrombus within the right heart. He underwent a liver biopsy that demonstrated well differentiated hepatocellular carcinoma.

His course was complicated by multiple runs of stable SVT and NSVT, presumed secondary to the intracardiac tumor thrombus. He was evaluated by cardiology and was initiated on metoprolol with suppression of ectopy. He was evaluated by cardiothoracic surgery for consideration of surgical management of his tumor thrombus. However, he was deemed not to be a surgical candidate given extent of the tumor thrombus. He was discharged from the hospital and subsequently initiated on durvalumab for treatment of HCC.

IMPACT/DISCUSSION: Hepatocellular carcinoma is one of the leading cause of cancer death worldwide and is often diagnosed in late stages due to minimal symptoms in early disease and lack of regular surveillance in high risk patients. Intra-hepatic vascular invasion is common, however tumor thrombus of the IVC, RA, and RV are rare and portend a poor prognosis with a median survival on the order of months. Complications of intracardiac tumor thrombi include complete occlusion of the IVC and hepatic vein leading to Budd-Chiari and associated complications, pulmonary embolism, and rarely arrhythmias. There is no consensus on treatment of intracardiac tumor thrombus in HCC. Surgery has been shown to modestly improve survival, but can have high morbidity and may not be feasible at all depending on size and location of tumor thrombus. Other treatment options include radiation, TACE, chemotherapy, and immunotherapy.

Our patient had multiple runs of SVT and NSVT that were ultimately controlled with beta blockade. As he did not have complete obstruction of the IVC, he had no signs of Budd Chiari. A CTPA performed showed multiple small pulmonary nodules concerning for metastases, but no pulmonary tumor emboli. He remains at high risk of sudden cardiac death from arrhythmias, pulmonary embolus, and complete right sided obstruction.

CONCLUSION: - Physicians should recognize that IVC and intracardiac tumor thrombi are rare, but serious complications of hepatocellular carcinomas.

- The complications of IVC and intracardiac tumor thrombi include Budd-Chiari and IVC syndrome, pulmonary embolism, and arrhythmias.

- Treatment of intracardiac tumor thrombi can include surgery, TACE, radiation, chemotherapy, and immunotherapy, but overall there is no consensus on treatment of intracardiac tumor thrombus.

HEART FAILURE CIRRHOSIS AND NEPHROSIS OH MY A STORY OF FLUID OVERLOAD

Ellen Murchie¹; Geeda Maddaleni². ¹Internal Medicine Residency Program, University of Massachusetts System, Boston, MA; ²Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4061029)

CASE: A 40-year-old male with a past medical history of opioid use disorder with IV drug use, infective endocarditis, and untreated Hepatitis B and C presented with one week of bilateral lower extremity and abdominal swelling and dyspnea. Exam revealed pitting edema to his hips, ascites, and pulmonary edema. Labs were notable for hypoalbuminemia and elevated BNP. An echocardiogram showed an ejection fraction of 46%, and an abdominal ultrasound revealed cirrhosis morphology. A paracentesis yielded ascitic fluid with undetectable albumin, making a serum ascites albumin gradient (SAAG) incalculable. Further testing revealed 2+ protein on urinalysis and urine protein/creatinine ratio of 18,667. Nephrology was consulted for potential nephrotic syndrome. The patient was started on a 25% albumin infusion, which slowly improved his response to diuresis. A renal biopsy demonstrated amyloid deposition. Serologic workup and cardiac nuclear testing ruled out AL amyloidosis and transthyretin amyloid cardiomyopathy, respectively; however, further amyloid protein characterization could not be performed due to inadequate sampling. Given this limitation, a presumptive diagnosis of AA amyloidosis in the setting of untreated HBV/HCV was made. The patient was discharged on diuretics, losartan and methadone for his opioid use disorder and follow-up for treatment of HBV/ HCV.

IMPACT/DISCUSSION: This patient presented with significant anasarca in the setting of newly diagnosed heart failure and cirrhosis. Amyloidosis was a confounding factor not appreciated initially. Without kidney dysfunction on presentation, a renal cause of hypoalbuminemia was not considered, especially given that both heart failure and cirrhosis can cause hypoalbuminemia. An indeterminate SAAG and prior urinalysis with proteinuria prompted further workup and ultimately a diagnosis of AA amyloidosis. Despite nephrotic syndrome’s decreased prevalence, internists should consider it as a cause of edema in patients with chronic infections, such as hepatitis and endocarditis. The significance of AA amyloidosis in the setting of untreated HBV/HCV is that the disease can progress to affect other organs, including the heart and liver. Additionally, this patient had several social factors affecting his care, including opioid use disorder and being uninsured. A diagnosis of amyloidosis requires follow-up to ensure response to treatment and management of symptoms, which is difficult without insurance to help cover costs. Also, the risk of continued IV drug use can lead to re-infection with hepatitis once treated, causing further amyloid deposition.

CONCLUSION: Nephrotic syndrome should be considered as a cause of edema in patients with untreated Hepatitis B and C.

Social determinants of health need to be addressed to help mitigate the effects on patient outcomes.

HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS PRESENTING WITH CHOLESTATIC PATTERN OF LIVER INJURY SECONDARY TO UNKNOWN HODGKIN LYMPHOMA

Hammad Sheikh¹; Patrick Tobin-Schnittger²; Ahmed Shaikh². ¹Internal Medicine, Mount Sinai Health System, New York, NY; ²Pulmonary Critical Care, Mount Sinai Health System, New York, NY. (Control ID #4064361)

CASE: Hemophagocytic Lymphohistiocytosis (HLH) is a rare systemic hyperinflammatory disease that can result from a wide array of conditions. The secondary form of HLH is observed in adults with infections, malignancies, and acquired immunodeficiencies. In fact, HLH has been found in approximately 1% of patients diagnosed with a hematological malignancy, of which Lymphoma is the most common.

An 82-year-old man presented with unintentional weight loss of over 20lbs and generalized weakness for over 2 weeks. On admission he was found to have anemia, conjugated hyperbilirubinemia, and elevated alkaline phosphatase. Initial vitals were remarkable for a fever (38.8 °C). Physical exam revealed a cachectic man with otherwise benign findings. Computed tomography showed right axillary and mediastinal adenopathy and a nodular contour of the liver. MRI demonstrated lymph nodes concerning for lymphoma. Unfortunately, biopsy showed absence of classic Reed-Sternberg cells, non-diagnostic for Hodgkin Lymphoma. On day 20 of hospitalization, patient became febrile (39.4°C) and encephalopathic; started on broad spectrum antibiotics and transferred to the ICU. Urine cultures grew Candida tropicalis and EBV PCR positive. He continued to have high-grade fevers >39°C and developed severely elevated inflammatory markers including ferritin 18,602 ng/mL, triglyceride >200 mg/dL, total bilirubin >12 mg/dL, CD25 level 140,912/μL, anemia, thrombocytopenia, and leukopenia. Given our concern for HLH (H-Score 196 (80-88% probability of HLH) treatment with high dose steroids and etoposide was initiated. Later, his bone marrow biopsy confirmed HLH and Hodgkin lymphoma. As the patient’s clinical course worsened, he was considered a poor candidate for cancer-directed therapy and succumbed to multi-organ failure.

IMPACT/DISCUSSION: HLH is a rare, but potentially fatal disease with a challenging diagnosis given the non-specific symptoms and findings. The initial clinical suspicion regarding our patient was hepatocellular disease, given the worsening cholestatic liver injury pattern. After an unremarkable lymph node biopsy, the primary diagnosis was delayed until a bone marrow biopsy confirmed both HLH and Hodgkin Lymphoma. It is imperative for clinicians to recognize the variable presentation because even with treatment, patients can rapidly deteriorate. Our patient had an unknown underlying malignancy with a cholestatic injury profile, which hindered recognition of secondary HLH.

CONCLUSION: Diagnosis rests on the HLH-2004 trial findings, requiring five of the eight criteria. HLH remains difficult to diagnosis and manage given the variable clinical presentations, creating a challenge for clinicians, and leading to a delay of treatment. A literature review of multiple HLH cases showed fever, hepatomegaly, and cytopenia were the most common presentations associated with Lymphoma. Regardless of other findings like cholestatic biliary pattern or inconclusive biopsy, HLH needs to be excluded.

HEPARINIZE OR NOT: A MANAGEMENT DILEMMA

Muhammad A. Munir¹; Sonia Mukhtar²; Kristin A. Swedish³. ¹Internal Medicine, Montefiore Health System, Bronx, NY; ²Internal Medicine, Lahore Medical and Dental College, Lahore, Punjab, Pakistan; ³Medicine, Division of General Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4064902)

CASE: A 96-year-old woman presented after a witnessed fall. Physical exam was significant for altered mentation with intact cranial nerve exam. Labs were significant for troponemia and COVID positive. MRI revealed acute infarct in the left precentral gyrus and left lateral postcentral gyrus. EKG was remarkable for evolving anterolateral T-wave changes. As the primary team caring for her, we debated whether or not she should be given heparin for the developing NSTEMI.

IMPACT/DISCUSSION: COVID-19 induces a hypercoagulable state, increasing the risk of thrombotic events. Heparin may play a role in mitigating this risk, but the potential for hemorrhagic conversion must be weighed carefully. The type and severity of the stroke influence the decision. The development of NSTEMI raises concerns about coronary artery thrombosis. Balancing the need for anticoagulation in the setting of acute stroke with the risk of exacerbating myocardial infarction requires a nuanced approach.

The decision to start anticoagulation in this scenario was particularly tricky as patient had anterolateral T-wave changes and up-trending troponin. Scoring systems such as HEART, TIMI RISk index and NIHSS can be helpful to assess the urgency of starting heparin but we determined that risk of hemorrhagic conversion was too great for our patient. Per recent data, in such scenarios it is paramount to have significant EKG changes with reciprocal rise in troponin to actually diagnose it as acute coronary syndrome, ruling out cardiac changes due to stroke burden. Moreover, as COVID-19 itself could be a risk factor for thrombotic stroke, it is important to know the stroke distribution prior to initiating therapy. Unless the stroke involves a large territory (large vessel), conservative single-agent antiplatelet therapy is recommended with close cardiac monitoring. Initial cardiac enzymes and EKG could be secondary to demand ischemia and cerebral waves.

CONCLUSION: The decision to heparinize or not in a patient with COVID-19, acute stroke, and NSTEMI necessitates a thorough understanding of the complex interplay between thrombotic and hemorrhagic risks. Tailoring treatment strategies to individual patient profiles is paramount, with a careful assessment of the potential benefits and drawbacks of heparin administration.

HEPATIC AND BRAIN ABSCESSES OF UNKNOWN ORIGIN

Charles Lamberton, Spencer Bonnerup, Colin Martyn. Southwest Internal Medicine Residency, Indiana University School of Medicine, Indianapolis, IN. (Control ID #4058175)

CASE: We present a case of a 63-year-old woman with hypertension and depression who was hospitalized following two weeks of chills and generalized abdominal pain. Initial workup showed white blood cell count elevation to 18 k/cumm (3.2-11.0 k/cumm) and CT of the abdomen showed a 7.6 x 6 cm septated cystic lesion with several smaller surrounding abscesses in the left lobe of the liver. Empiric antibiotic therapy was initiated with vancomycin and meropenem, followed by CT-guided percutaneous drain insertion into the largest intrahepatic abscess. However, the patient required revision of drain placement due to progressive abdominal distension and leukocytosis to greater than 33 k/cumm. Subsequently, the patient became encephalopathic and a CT of the head was obtained after the patient sustained a mechanical fall which demonstrated a loss of a grey-white matter differentiation in the right frontoparietal region. Follow up MRI of the brain with contrast revealed two abscesses along the right parietal vertex measuring 14 x 9 and 8 x 11 mm. Lumbar puncture did not identify a bacterial or viral source of infection, however, admission blood cultures grew Peptoniphilus asaccharolyticus. The patient completed a five-week course of meropenem per the recommendations of Infectious Diseases and was discharged on day 14 of admission with follow-up surveillance imaging.

IMPACT/DISCUSSION: Hepatic and brain abscesses are associated with high mortality. Hematogenous dissemination of bacteria is responsible for approximately a third of cases of brain abscess and immunosuppression is a key predisposing factor. In this case, the patient did not have a history of malignancy or transplantation, and HIV testing during admission was negative. Underlying cardiac diseases such as endocarditis or congenital anomalies are common in hematogenous spread. Transesophageal echocardiogram did not show infective endocarditis and the patient had no congenital disease. Contiguous brain abscesses, which account for approximately half of all cases of brain abscesses, occur when pathogens spread directly to the brain. In our patient, thorough physical examination did not demonstrate head and neck infection. Additionally, P. asaccharolyticus is an uncommon pathogen in cases of brain abscess. Hepatic abscess is also a rare condition and can be attributed to parasitic, fungal, or bacterial pathogens. In Western countries, approximately 80% of hepatic abscesses are bacterial and most frequently associated with hepatobiliary disease, spread contiguously in inflammatory processes, or superimposed infections on biliary cysts or tumors. Interestingly, none of these processes were discovered in this patient.

CONCLUSION: This case demonstrates a unique combination of hepatic and brain abscesses without obvious risk factors for either. It remains unclear what underlying factors contributed to the development of these abscesses, but fortunately, the patient responded well to antibiotics alone and did not require surgical intervention.

HEPATITIS A-INDUCED ACUTE LIVER INJURY AND BILATERAL PLEURAL EFFUSIONS IN A 28-YEAR-OLD FEMALE

Michael Dybala¹; Elena Pezzino¹; Josh Levitsky². ¹Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4060707)

CASE: A 28 year old female presented with dysuria, back pain, epigastric pain, and shortness of breath for one week. She traveled to Mexico 1 month prior. She reported no personal or family history of liver, GI, or autoimmune disease. She had not been vaccinated for prevention of hepatitis A or B. She endorsed minimal alcohol consumption and no tobacco or illicit drug use.

Vitals on admission were normal. Her physical exam was significant for diminished breath sounds at the bilateral lung bases and a distended and mildly tender abdomen. On laboratory evaluation, Hgb, WBC, and platelet counts were normal. AST 8317, AST > 5000, ALP 122. Total (direct) bilirubin 3.8 (2.7). INR 2.5. HAV IgM positive. HBV, HCV, HEV markers were negative.

An expedited liver transplant evaluation was initiated for acute liver injury. On hospital day 4, she had sinus tachycardia to a rate of 160. A CTA of the chest revealed moderate right and small left pleural effusions and ascites. Ascitic fluid from a paracentesis was consistent with portal hypertension from liver disease (SAAG >1.1, total protein 2.0) with an ANC of 2, and pleural fluid from a right thoracentesis indicated a transudative effusion. Her tachycardia and markers of liver injury improved with symptomatic management. Liver transplant was deferred given rapid recovery.

The patient has not had imaging since hospitalization. Clinically, her abdominal distension and dyspnea resolved at one month post-discharge as had her elevated INR. Her weight decreased to 75 kg from 85 kg during her admission. Markers of liver injury normalized by 3 months post-discharge.

IMPACT/DISCUSSION: Hepatitis A virus (HAV) is an uncommon cause of acute liver injury in the US, and extrahepatic complications of HAV are even rarer. Only approximately 20 cases of pleural effusion following acute HAV infection have been documented, mostly in the pediatric population. Possible mechanisms for pathogenesis include viral invasion of the pleural space causing immune complex deposition and inflammation, ascitic fluid translocation via diaphragmatic defects, and low plasma oncotic pressure with portal hypertension or compression of hepatic sinusoids. Evaluating for pleural effusion by ultrasound or radiography in patients with acute HAV may be useful in patients with abnormal vitals, including hypoxemia or tachycardia. Thoracentesis may be of utility to rule out other causes of pleural effusion, such as superinfection or malignancy, and may be therapeutic in cases of hypoxemia. Pleural effusion should be recognized as a rare extrahepatic complication of acute HAV infection in adults.

CONCLUSION: Pleural effusion is a rare complication of acute HAV infection in adults that generally resolves following recovery from infection

Thoracentesis may not be necessary to to treat pleural effusion related to acute HAV

HEREDITARY ANGIOEDEMA (HAE)- UNRAVELING THE MYSTERY BEHIND 26 YEARS OF ABDOMINAL AGONY

TEJA SREE VALLAPU REDDY, Anunaya Aashish, Aitazaz shah, Anthony J. Neira Lazaro, Asma Ahmed, Kamran Chaudhry, Mandvi Pandey, Miriam Sanchez Luna. INTERNAL MEDICINE, Texas Health Resources, Arlington, TX. (Control ID #4025467)

CASE: A 36-year-old woman presented to the hospital for severe abdominal pain. Since she was 10, she had similar episodes of abdominal cramping pain associated with diarrhea and vomiting. Denies common triggering and relieving factors, fever, jaundice, melena, hematochezia, urinary changes, rashes, correlation with menstrual cycles, sick contacts, or recent travel. In 26 years, she has had over 50 admissions to multiple community and tertiary hospitals, where she underwent multiple imaging studies, diagnostic colonoscopies, EGDs, push enteroscopy, paracentesis, and invasive procedures such as empiric cholecystectomy, appendectomy, and total abdominal hysterectomy with bilateral salpingo-oophorectomy. The pathological findings were benign. The only pertinent positive findings were abdominal CTs with ileocolitis, mesenteric edema, and ascites, of varying intensity. IBS and food allergies were considered, and the patient followed strict diets without any improvement. Due to no definitive diagnosis with previous workup, a broad differential was considered during this admission including celiac disease, acute intermittent porphyria, food allergy, IgA deficiency, and hyperthyroidism. Tissue transglutaminase antibody, gliadin antibody, ANCAs, porphyrinogens, porphyrins, IgA levels, celiac panel, infectious work up, thyroid profile, and food allergens test were all negative. The recurrent bowel edema with negative endoscopic biopsies also prompted a workup for HAE. The levels of C1 esterase inhibitor and complement-4 levels came back low, with normal C1q level. The patient was diagnosed with C1-INH HAE and referred to an Allergy-Immunology specialist.

IMPACT/DISCUSSION: Hereditary Angioedema is a rare disease caused by a dysfunctional mutated C1 esterase inhibitor, resulting in recurrent attacks of severe swelling, most commonly in the face, hands, feet, intestinal tract, and airways. The diagnosis may get delayed when the presentation is localized to intestinal mucosa. Limited awareness of HAE as a differential for abdominal pain can exacerbate the delay for a correct diagnosis, as seen in this case. Once diagnosed, HAE can be treated with on-demand self-administered C1 esterase inhibitor injections or prophylactic therapy. The 26-year delay in her diagnosis, with several unnecessary empiric invasive treatments, reveals the lack of awareness about HAE and its different presentations. Our goal is to increase awareness to facilitate prompt diagnosis and treatment.

CONCLUSION: Recognizing that abdominal pain alone may indicate HAE is crucial, even in the absence of typical cutaneous and respiratory symptoms. This awareness saves significant costs on extensive tests, avoids unnecessary invasive procedures and ensures a prompt improvement in their quality of life with appropriate treatment.

HERPES PNEUMONIA: A NOT-SO-SIMPLEX DIAGNOSIS

Nicholas Rigler, Katherine R. White, Christine Tsai. Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4064849)

CASE: A 71-year-old male with a history of renal transplant (on mycophenolate, tacrolimus, and prednisone) and CML (on nilotinib) presented in November with 3 days of progressive dyspnea.

On arrival, his oxygen saturation was 89% on room air. Other vitals were normal. Exam was notable for tachypnea, crackles over the right posterior lung fields, and anterior cervical lymphadenopathy. He had a leukocytosis of 25 K/uL. CXR showed subtle right mid-lung opacification.

He was initially treated for community-acquired pneumonia with ceftriaxone and azithromycin; however, he became progressively hypoxic despite 48 hours of treatment. Sputum culture and nasopharyngeal pathogen panel were negative. Antibiotics were broadened to cover methicillin-resistant staphylococcus aureus and pseudomonas. Chest CT without contrast revealed diffuse, bilateral ground-glass opacities. Empiric treatment for Pneumocystis jirovecii pneumonia was initiated, without improvement. Ultimately, bronchoalveolar lavage washings detected Human Herpes Simplex Virus-1 (HSV-1) DNA by RT-PCR. Cytology showed abundant hemosiderin-laden macrophages suggestive of alveolar hemorrhage. He started IV acyclovir and subsequently experienced rapid clinical improvement, highly suggestive of HSV-1 pneumonia.

IMPACT/DISCUSSION: HSV-1 is a double-stranded DNA virus that infects a host’s neural ganglion cells. While it is a common cause of gingivostomatitis and pharyngitis, lower respiratory involvement leading to clinically significant pneumonia is rare. Historically, it has been a difficult diagnosis to make with clarity; even the most astute diagnosticians struggle. This is largely attributed to difficulty distinguishing HSV-1 carrier state from true disease. In our patient’s case, only a positive HSV-1 DNA by RT-PCR in combination with rapid improvement with acyclovir and predisposing conditions allowed us to make this diagnosis with confidence. This is especially true as cytology failed to show intranuclear inclusions classically associated with HSV-1 infection.

Interestingly, cytology did show an abundance of hemosiderin-laden macrophages. This raises suspicion for coexisting alveolar hemorrhage, in addition to HSV-1 pneumonia, with the patient’s nilotinib therapy a potential inciting culprit. We hypothesize that nilotinib therapy may have altered our patient’s pulmonary endothelial integrity, causing a previously non-invasive HSV-1 carrier state to progress to pathologic invasion of lung tissue. Tyrosine kinase inhibitors like nilotinib have been linked to increased endothelial apoptosis and impaired vascular permeability.

CONCLUSION: ● HSV-1 pneumonia is a difficult diagnosis to make; there are no well-established clinical criteria. Multiple clinical clues (i.e. presence of risk factors, response to antivirals) must be combined with objective data to distinguish a carrier state from true disease.

● Pneumonitis is a rare yet well-described complication of tyrosine kinase inhibitor therapy and can predispose to more severe lung disease.

HIDDEN AGONY: SEVERE PAIN WITH A DECEPTIVE BLANK CANVAS - A RARE CASE OF POSTTRAUMATIC PYOMYOSITIS.

Zein Barakat, Sami Ghozayel, Lamia Khan. Internal medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4060341)

CASE: A 28-year-old female with history of congestive heart failure secondary to postpartum cardiomyopathy, major depressive disorder, obesity, and methamphetamine abuse presents with severe right thigh pain, following a fall a week earlier. Her vitals were stable and afebrile. On physical exam, there was tenderness along the medial aspect of the right thigh extending to the knee, but no erythema, swelling, or restricted range of motion. A CT scan without contrast revealed significant skin thickening, subcutaneous and interstitial soft tissue edema in the medial right thigh. The patient was started on vancomycin and piperacillin-tazobactam for cellulitis. Notably, urine toxicology was positive for methamphetamines. On the subsequent day, the patient became altered and combative. On exam, there was evidence of edema and erythema along the medial, posterior thigh. Her kidney function was deteriorating; thus, vancomycin was replaced with daptomycin. On the third day, there was notable edema and erythema in the right knee. There was no evidence of bacteremia, based on blood cultures and the patient remained afebrile. Upon improvement of the renal function, an MRI was ordered which revealed a large multiloculated fluid collection in the posterior compartment extending from the right hip to the knee. There were signs of mild myositis, along with a small effusion in the right knee joint. Orthopedic evaluation prompted a surgical irrigation and debridement. The abscess measured 8cm wide by 18cm long, emphasizing the extent of the hidden pathology. Results revealed positive Methicillin Resistant Staph Aureus (MRSA), and negative fungal, anaerobic, AFB cultures. Post-operatively, patients' pain improved and she was discharged on doxycycline for three weeks and encouraged to follow up with surgery outpatient.

IMPACT/DISCUSSION: The patient's journey began with a fall, leading to significant underlying muscle fiber injury and the subsequent symptoms. Despite an initially benign clinical trajectory, her condition rapidly deteriorated, culminating in profound pain and functional impairment. Alongside the pain, her altered mental status and combative behavior introduced a confounding element to the diagnostic process. While substance abuse with aberrant pain seeking behavior was initially considered, a complete evaluation led to its exclusion. Daily physical examinations offer crucial insights for understanding and unraveling complex diagnoses. This case underscores the significance of employing a holistic osteopathic approach and emphasizes the need for a broad differential diagnosis, particularly in patients with intricate medical histories.

CONCLUSION: Traumatic pyomyositis is an uncommon and clinically significant manifestation of deep-seated soft tissue infections. Although less common than superficial skin and soft tissue infections, its occurrence can lead to severe morbidity and occasionally mortality if not promptly diagnosed and appropriately managed.

HIDDEN IN PLAIN SIGHT: LETHAL CONSEQUENCE OF A COMMON MEDICATION

Wagma Nizami, Sujan Badal. Internal Medicine, Washington State University, Pullman, WA. (Control ID #4052854)

CASE: A 34-year-old female with history of Sjogren’s syndrome, OSA, and non-specified mood disorder presented with 4 days of fever, headache, and emesis. She had travelled to Hawaii 2-weeks prior to admission and recently (~10 days) started taking 25mg of twice daily lamotrigine for her mood disorder. She was up to date on her immunizations and did not have history of substance use or known allergies.

On admission she was febrile (104°F) and tachycardic. Exam revealed photophobia without nuchal rigidity, neurological deficit, organomegaly, rash or heart murmur. Initial labs were unremarkable. CT-head was negative, while her CSF demonstrated elevated WBC (113/mm³) with negative bacterial cultures. Empiric treatment for aseptic meningitis was initiated.

On hospital day 3, she developed new morbilliform rash involving chest and back, extensive bilateral cervical/axillary lymphadenopathy, and respiratory distress. Labs revealed creatinine 2.71mg/dL, Hgb 9.5g/dL, plt 62k U/L, AST 260U/L, ALT 106U/L, INR 1.5, PT 17.9s, LDH 4500U/L, ferritin 8250ng/mL, CPK 249U/L, ESR 18mm/hr, CRP 171mg/L, fibrinogen 67mg/dL. She was intubated and moved to the ICU. IV solumedrol was added. Extensive infectious and rheumatologic evaluations were negative. She did not tolerate a bone marrow biopsy due to acute decompensation. Her condition deteriorated and on day-7 she was started on etoposide, dexamethasone, intrathecal methotrexate for suspected hemophagocytic lymphohistiocytosis (HLH).

Despite treatment she developed multi-organ failure and passed away on day-11. Autopsy revealed bone marrow with hypocellular marrow space with hemophagocytosis. Previous elevated serum CXCL9 (>1mil, ref <647pg/ml) was also noted. A post-autopsy diagnosis of HLH was confirmed.

IMPACT/DISCUSSION: HLH is a severe inflammatory condition of immune dysregulation, which in adults is often incited by an infection, malignancy, or rheumatological disease. It is a challenging diagnosis requiring high index of suspicion. Diagnosis is based on strict criteria: Molecular diagnosis or fulfilling 5/9 - fever; splenomegaly; >2 cytopenia; high triglyceride/low fibrinogen; ferritin ≥500 ng/mL; low or absent NK cell; hemophagocytosis; elevated CD25; elevated CXCL9. In our case the patient ultimately met 6/9 criteria.

In rare cases lamotrigine has been associated with HLH, although the exact mechanism is unknown. Limited case reports suggest typical onset of HLH following lamotrigine initiation of 15 days at 25–250mg daily dose. In our case, the patient became severely symptomatic at day-13. Lamotrigine was stopped on day-3 of hospitalization. Despite starting treatment per known guideline (HLH-94 protocol: 8-week regimen above) the patient passed away from multi-system failure.

CONCLUSION: Lamotrigine-associated HLH is a rare but lethal condition that requires early recognition and therapeutic intervention. This case underscores the importance of vigilantly investigating common as well as rare causes of HLH to mitigate its devastating consequences.

HIDDEN IN PLAIN SIGHT - A DELAYED DIAGNOSIS OF WERNICKE'S ENCEPHALOPATHY PROLONGED BY REFEEDING SYNDROME

Sally Namboodiri^1,2. ¹Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, OH; ²Case Western Reserve University School of Medicine, Cleveland, OH. (Control ID #4014407)

CASE: A 62 year old male with alcohol use disorder (AUD) was admitted with a 40 pound weight loss, memory issues, and weakness for 2 months. On exam, he displayed poor strength and balance. CT scans of head, chest, abdomen and pelvis were normal. On hospital day 4, he fell out of bed. CT head showed no acute change. Two days later, he could not follow commands and was diagnosed with delirium. An infectious work up and MRI of the brain were negative. On day 14, a neurologic exam revealed bilateral horizontal nystagmus and cerebellar ataxia. He was started on IV Thiamine for 8 days followed by oral thiamine for presumed Wernicke's encephalopathy (WE). A neurology consult concurred with the diagnosis. He developed hypokalemia on days 18-25 that persisted despite oral supplementation; in hindsight, he was felt to have refeeding syndrome (RFS). For the next 3 weeks, he exhibited hallucinations, jerking movements of extremities, and insomnia. Electroencephalogram was negative for seizures. Although his acute neurologic symptoms resolved by hospital day 43, his physical debility persisted despite therapy. He was placed in a long term care facility.

IMPACT/DISCUSSION: WE is a life-threatening disorder that is often undiagnosed per autopsy studies due to low recognition. The classic triad of ataxia, encephalopathy and ophthalmic abnormalities is present in less than 20% of patients. Early treatment with IV thiamine can restore neurologic function and prevent permanent damage, such as Korsakoff's dementia. On admission, our patient had two Caine criteria that suggested WE diagnosis (i.e. dietary deficiency and memory impairment), with other possible Caine criteria as well (i.e. oculomotor disorder and cerebellar dysfunction). However, the diagnosis was initially unrecognized and may have been suspected if a neurologic exam had been performed earlier in the hospital course. Per National Institute for Health Care guidelines, our patient's chronic malnutrition and AUD also put him at risk for RFS, which can present as hypokalemia, hypophosphatemia, or hypomagnesemia. Refeeding stimulated insulin secretion, intracellular potassium shifts, and further thiamine depletion, thus prolonging his WE symptoms. To prevent RFS, his refeeding should have been started slowly, after repletion of thiamine, with IV instead of oral potassium supplementation. The delay in WE diagnosis and unrecognized risk for RFS led to our patient's prolonged hospital stay and permanent physical disability.

CONCLUSION: WE is underrecognized due to lack of emphasis on thiamine deficiency as a cause of delirium in clinical guidelines.

WE should be considered and IV thiamine promptly initiated for patients who have two of more of the following Caine criteria: dietary deficiency, memory impairment, ocular disorders or cerebellar dysfunction.

Patients with WE are at high risk for refeeding syndrome, a complication that can prolong WE; slow refeeding with IV electrolyte supplementation should be implemented after thiamine repletion.

HIGH MORTALITY NECESSITATES EARLY IDENTIFICATION: A CASE OF CLOZAPINE-INDUCED MYOCARDITIS

Leia Wedlund¹; Peggy B. Leung²; Helene Strauss². ¹Internal Medicine, Weill Cornell Medicine, New York, NY; ²Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY. (Control ID #4061310)

CASE: C.H. is a 20 year-old female with no PMH, found wandering barefoot on private property in response to command hallucinations. She was admitted to the inpatient psychiatry unit for psychosis.

While admitted, hallucinations persisted despite maximum-dose risperidone. Clozapine was started, and on day 12 of clozapine uptitration she became tachycardic and febrile, with 2/10 chest pain.

Exam: T 38 C. BP stable. HR 100-130. No abnormal heart/lung sounds or edema.

Diagnostics:

- EKG: sinus, HR 107

- HS-troponin: 146 ng/L (ULN: 40)

- CRP: 2.1 mg/dL (ULN 0.9)

- WBC 6/L (normal differential)

- Transthoracic echo: diffuse hypokinesis, left ventricular ejection fraction: 45%

- Cardiac MR: myocardial edema and inflammation consistent with acute myocarditis

Clozapine was discontinued; no steroids or new medications were given. Within two days, troponin peaked at 2883 ng/L and chest pain resolved. Five days after clozapine discontinuation, repeat echo showed improved ejection fraction (53%).

IMPACT/DISCUSSION: Clozapine-induced myocarditis is a life-threatening complication that occurs in approximately 3% of patients with 10-30% mortality. In contrast, clozapine-related agranulocytosis affects 0.4% of patients with 12% mortality.

Myocarditis typically arises in the first month of therapy, though some cases occur years later. Initial symptoms may be non-specific (fever, tachycardia), but signs of heart failure develop if untreated. CRP is often the first laboratory marker to rise.

Advanced age and rapid uptitration are the primary risk factors, but cases can be unpredictable. Of note, the titration schedule used in this case (increments of 12-25 mg daily) was slower than the standard clozapine titration regimen used in many institutions.

Though not seen in this patient, two-thirds of clozapine-induced myocarditis patients have hypereosininophilia, suggesting underlying IgE-hypersensitivity reaction. Given this proposed mechanism, pathophysiology and case reports support the use of steroids in patients with evidence of cardiogenic shock. Care is otherwise supportive only (as in this case), and discontinuation of clozapine is critical. With early medication discontinuation, over 90% of patients show improvement or full recovery of cardiac function within 5 days. Rechallenging with clozapine is not recommended.

CONCLUSION: 1. Clozapine-induced myocarditis typically arises in the first month of treatment with fever or tachycardia followed by heart failure.

2. Rapid dose escalation and advanced age increase the risk of this complication.

3. Early and permanent discontinuation of clozapine is the cornerstone of treatment. Steroid therapy may be indicated for patients in cardiogenic shock.

4. Most patients recover normal cardiac function with timely diagnosis and supportive measures.

HOCUS POCUS: A SPOOKY PRESENTATION OF PE

Shannon Y. Su¹; Megan C. LaRocca¹; Daniel Adamkiewicz¹; Jason P. Williams^1,2. ¹School of Medicine, Emory University School of Medicine, Atlanta, GA; ²Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, GA. (Control ID #4052355)

CASE: A 51-year-old female with a history of obesity, Ehlers-Danlos syndrome and PTSD presented with 1 week of exertional dyspnea. At baseline, she ambulates independently and completes all instrumental activities of daily living. One week prior to admission, she had begun using her albuterol inhaler approximately 6 times a day with mild improvement. Five days prior, EMS provided a nebulized bronchodilator therapy that improved her symptoms and delayed her admission. Three days prior, she endorsed persistent mid-sternal chest tightness without radiation.

Admission vitals were notable only for mild tachypnea. Labs were significant for an elevated troponin I at 0.04 and BNP at 556. She had mild, reproducible, sternal tenderness and appeared euvolemic. Her chest Xray was negative for cardiopulmonary disease. 1 dose of IV Lasix 40 mg resolved her shortness of breath.

She was admitted to the floor for further evaluation. Bedside ultrasound by the primary team showed moderate right heart dilation, septal flattening, and an estimated right ventricle systolic pressure (RVSP) of 45-50 mmHg. D-dimer and CTA were then ordered and revealed significant elevation (4665) and extensive bilateral pulmonary emboli (PE) involving all lobes and nearly all segments; many, if not most, emboli were occlusive. A right perihilar ground glass opacity was suggestive of a potential developing infarct. A formal echocardiogram confirmed moderate-severe RV dysfunction. She underwent catheter directed TPA (20mg infused over 20 hours), and repeat echocardiogram two days later documented resolution of RV dysfunction.

IMPACT/DISCUSSION: Diagnostic uncertainty remains when screening for PE using clinical decision tools. Some literature shows a high Wells score to only be approximately 40% sensitive for the diagnosis of PE. Other tools, such as the PERC criteria may be more sensitive (98%) but are lacking in specificity (7%) and could lead to over-imaging. Point-of-care multiorgan ultrasonography is shown to be 90% sensitive for PE, performing comparably to CTPA (83% sensitive), and VQ scan (85% sensitive). Bedside cardiac ultrasound was shown to be 30% sensitive but over 90% specific for PE. Point-of-care ultrasound aids in augmenting providers’ diagnostic ability in atypical presentations of PE. The patient on presentation did not have symptoms typically associated with PE, given a Well’s score of 0 and only one positive PERC criteria. However, ultrasound results expedited the diagnosis and treatment of submassive PE.

CONCLUSION: Clinical diagnosis of pulmonary embolism continues to pose a significant challenge, particularly when patients have atypical or nonspecific symptoms. Point-of-care multiorgan ultrasound is a safe, sensitive, and cost-effective way to improve diagnostic certainty in ambiguous situations.

HODGKIN LYMPHOMA PRESENTING AS RECURRENT EBV-ASSOCIATED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

Hannah Jarvis¹; Albert Jang¹; Larisa Schwartzman²; Timothy O'Brien²; Abhishek Thakur². ¹Internal Medicine, University Hospitals, Cleveland, OH; ²Louis Stokes Cleveland VA Medical Center, Cleveland, OH. (Control ID #4064929)

CASE: A 75-year-old man presented with fatigue, chills, night sweats, and nocturnal fevers for the past three nights. He had a remote history of HL treated more than 20 years ago, EBV+ lymphoproliferative disorder (LD) on lymph node biopsy diagnosed 3 years ago, and EBV-induced HLH diagnosed 10 months ago when he presented with B-symptoms, hepatosplenomegaly, pancytopenia, ferritin > 20,000 ng/mL, elevated serum IL-2 receptor, and EBV DNA PCR of 25,000 IU/mL. Both prior EBV-associated events were successfully treated with short courses of steroids and rituximab. On exam, he had no rash and no palpable hepatosplenomegaly or lymphadenopathy. His vitals were notable for daily nocturnal fevers, the highest at 102.5 F, which coincided with his symptoms. Labs revealed Hgb of 12.1 g/dL, WBC of 3.1 K/μL, and platelets of 83 K/μL; all later declined during admission. He had elevated ferritin of 721 ng/mL, which rose to 2215 ng/mL in a matter of days. EBV DNA PCR was 6510 IU/mL. CT noncontrast of chest, abdomen, and pelvis were unremarkable along with remaining labs including coagulation profile and blood cultures. Due to concern for early HLH relapse, he underwent another bone marrow biopsy and was started on steroid with rituximab with rapid improvement of pancytopenia, elevated serum ferritin, and B-symptoms. Marrow biopsy revealed classic HL with Reed-Sternberg cells that stained positive for CD15 and PAX-5 and negative for CD20 and CD30. PET/CT revealed splenic and axial bony lesions suspicious for metastatic disease.

IMPACT/DISCUSSION: This case highlights the intertwinement of EBV infection with several hematologic diseases. A point of interest is the evolving bone marrow and lymph node biopsy findings over several years which eventually culminated in a diagnosis of HL. We cannot rule out the possibility that this patient had indolent HL for years that influenced his development of EBV-associated LD and HLH, and that his treatment for these two entities kept his HL at bay. His prior presentations of EBV+ lymphoproliferative disorder and EBV+ HLH were treated with rituximab resulting in excellent clinical response. Rituximab targets CD20 of B-lymphocytes and is often used in treatment regimens for lymphomas, including HL. We suspect his polyclonal host-immune B-cell response was tamped down by rituximab, causing a partial though temporary clinical response.

CONCLUSION: EBV infection is commonly implicated in lymphoproliferative disorders, HLH, and lymphomas. Bone marrow biopsy is a useful tool for diagnosing these conditions, though is not a perfect test and should be utilized alongside other clinical information including peripheral blood studies and imaging. This case highlights that symptoms identical to a prior presentation can be misleading and that full diagnostic workup is essential for accurate diagnosis.

HOLE-Y MOLEY: A DELAYED PRESENTATION OF CONGENITAL HEART DISEASE

Kriya Patel, Staci Blackburn, Kristin M. Collier. Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #4063985)

CASE: 68 yo female with hypothyroidism, GERD, and anxiety presented with progressive hypoxia on exertion. She had undergone a left TKA one week earlier, but hypoxia at home prompted ED evaluation, which revealed a left leg DVT. CT-PE at the time did not show a PE. She was started on Eliquis and discharged on 2L O2. Records from the outside hospital are limited but patient reported she had a negative stress test and CT Chest so she was referred to our academic hospital system two months later. She presented for PFTs which were normal, but she required 15L during a hall walk test and was sent to the ED. No murmurs or clubbing appreciated on physical exam. CTPE was repeated but negative for PE. HRCT showed mild ILD. EKG was unremarkable. She was admitted for further workup. An ECHO with bubble study showed a right to left shunt and cardiac MRI showed a sinus venosus atrial septal defect with partial anomalous pulmonary venous return from the right superior pulmonary vein into the SVC. She underwent cardiac catherization which revealed two right upper pulmonary veins draining to the posterior caudal aspect of SVC and bi-atrial drainage of the SVC across the sinus venosus defect. She underwent transcatheter closure of her ASD with a stent implantation. She has been hemodynamically stable on room air since.

IMPACT/DISCUSSION: Upon presentation the differential was broad and included ILD, sarcoidosis, bronchiolitis and pulmonary HTN along with valvular abnormality. Due to her advanced age and lack of previous symptoms we did not initially consider a congenial cardiac abnormality. In addition, only 4-11% of ASD cases are caused by sinus venosus ASD. While there was never a confirmed post-operative PE we suspect that an unidentified PE led to her clinical decompensation. She denied any symptoms prior to age 68. She did not have a history of prior pregnancies, which in theory could precipitate symptoms at an earlier age due to physiologic changes associated with pregnancy. Ultimately, cardiac MRI was the most helpful modality to determine the cause of her hypoxia. Prior studies demonstrated the clinical utility of cMRI especially for diagnosing sinus venosus ASD. Literature established possible interventions included transcatheter closure vs cardiac surgery. Based on patient anatomy and preference the ASD was repaired with transcatheter stent closure. Studies have shown transcatheter closure is associated with lower complications and mean hospital stay. Her procedure was uneventful, she was saturating in the mid 90s on room air immediately post-op, and was discharged home the following day. Follow up months later confirmed patient still doing well without a home oxygen requirement.

CONCLUSION: Patients with sinus venosus defects can live asymptomatically into adulthood and this should be a consideration for otherwise unexplained hypoxia

Cardiac MRI is a helpful modality in visualizing ASD defects

Transcatheter closure of septal defect can be as effective as cardiac surgery patch closure.

HOW LONG IS TOO LONG? A CASE OF DELAYED PRESENTATION OF PRIMARY ADRENAL INSUFFICIENCY

Evan Gross, Zach Rubnitz, Meenu Singh. Internal medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4061184)

CASE: A 75-year-old with PMH of multiple myeloma s/p chemotherapy, auto-HSCT, and CAR-T, now with complete response, and recent diagnosis of SCC of the right temple s/p Mohs surgery and adjuvant radiation to the temple six weeks prior, was admitted with hypotension, fatigue, diarrhea, and vomiting lasting for 3 weeks. On presentation BP was 83/51 and did not improve with 3L of crystalloid. Exam was most notable for normal mentation and a nontoxic appearance. Initial labs demonstrated a sodium of 135, potassium of 4.6, creatinine of 2.5 increased from a baseline of 1.6, blood sugar of 92, and a normal CBC. Lactic acid was 0.7. A respiratory viral panel tested positive for the common coronavirus and rhinovirus+enterovirus.

The patient was transferred to the MICU due to persistent hypotension. On hospital day one he was started on a D10 drip for hypoglycemia to <60. A morning cortisol on hospital day two returned low at 4.4 (normal 6.0-18). ACTH stimulation test demonstrated a low peak cortisol of 6.9. ACTH was elevated at 373.

A CT did not demonstrate any new mass or infiltrative process of the adrenal glands. TB, HIV, fungal markers, and 21-hydroxylase antibody were negative. His pituitary axis was found to be intact with normal IGF-1, testosterone, TSH, and free thyroxine, and elevated FSH and LH. Renin was mildly elevated at 4.3 (normal 1-4). He had taken dexamethasone as part of combination chemotherapy 1.5 years prior, but he had no other exogenous steroid use.

The patient was started on physiologic hydrocortisone, as well as fludrocortisone 0.05mg daily. On this dose hypoglycemia resolved but hypotension persisted, so he was treated with stress dose hydrocortisone, following which his BP improved. Hydrocortisone was able to be tapered prior to discharge home.

IMPACT/DISCUSSION: This case exhibits a patient with new primary adrenal insufficiency (AI), noted by a low cortisol in the morning and on ACTH stimulation, and with an elevated ACTH. The presentation was characteristic of AI with BPs that did not respond to multiple liters of crystalloid, persistent hypoglycemia, fevers, vomiting, anorexia, and fatigue. His workup for infectious, autoimmune, and infiltrative causes of AI was broadly negative. While he did have steroid exposure, it was initially disregarded given it had been over a year prior to his presentation. Review of the literature shows that exogenous steroid suppression can persist for greater than a year, and recovery is often unpredictable. This patient likely demonstrated subclinical suppression following completion of his multiple myeloma therapy, which was unveiled by his concurrent coronavirus/enterovirus infection.

CONCLUSION: AI should be considered in patients with refractory hypotension, especially in the setting of hypoglycemia or other electrolyte derangements.

AI from exogenous steroids can persist for greater than a year following discontinuation of steroids.

HOW LONG WILL I NEED PREDNISONE? NAVIGATING THE COMPLEXITIES OF VEXAS SYNDROME

Amany Elshaer, Eiad Habib, chelsea marshall, Sujata Singh. Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ. (Control ID #4062229)

CASE: A 69-year-old man arrived at our hospital, complaining of fever and vomiting. Over the past year, he had experienced a variety of symptoms, including myopathy, severe weakness, fevers, night sweats, weight loss, painful skin lesions, abscesses, bilateral deep vein thromboses, and respiratory issues. The patient's symptoms improved with high doses of steroids (prednisone >20 mg/day) but recurred when the dosage was reduced below 20 mg. Due to his ongoing symptoms, the patient decided to present to our ED. Upon arrival, he was febrile to 38.2° C and his oxygen saturation was 88%. On physical examination, we observed multiple raised nodules on his bilateral upper and lower extremities. Labs revealed a hemoglobin level of 9.4 with an MCV of 101.7, leukocytosis, and elevated CRP and ESR. A chest CT scan revealed increased peripheral ground-glass opacities throughout the lungs with more nodular changes in the bilateral lower lobes. A bronchoalveolar lavage was done, which showed hemosiderin-laden macrophages but no signs of infection. Considering the patient's symptoms, elevated inflammatory markers, and macrocytic anemia, we suspected VEXAS syndrome. To confirm the diagnosis, the patient underwent a bone marrow biopsy, which revealed a hypercellular marrow (90%) with granulocytic expansion, megaloblastoid maturation, and prominent vacuolization of myeloid and erythroid precursors, consistent with VEXAS syndrome. Additionally, UBA1 somatic mutation testing was positive; thus, confirming the diagnosis. The patient continued to receive high doses of prednisone with remarkable improvement of his symptoms, and discussions about the possibility of undergoing allogeneic stem cell transplantation were initiated.

IMPACT/DISCUSSION: VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a disorder found in patients with adult-onset inflammatory syndrome. It has somatic mutations in the UBA1 gene, leading to reduced ubiquitylation activity causing hyperinflammation. It was first described in 2020, and many healthcare providers may not be familiar with this diagnosis. Severity of the disease may vary widely among patients, ranging from mild manifestations to life-threatening complications. Some of the key symptoms associated include recurrent fevers, painful skin lesions, abscesses, deep vein thrombosis, respitatory symptoms, and cytopenias. Our case demonstrates the impact of a delay in diagnosis, as our patient endured a year of persistent and bothersome symptoms prior to obtaining the correct diagnosis.

CONCLUSION: Patients with VEXAS syndrome may exhibit symptoms of relapsing polychondritis, macrocytic anemia, and progressive cytopenia among other autoinflammatory symptoms. Patients typically respond to high-dose glucocorticoids. Given its recent discovery, there are currently no established guidelines for optimal management. Further research is needed to determine alternative treatment modalities, including the possibility of allogeneic stem cell transplant.

HOW MUCH IS TOO MUCH: A CASE OF HYPERPERFUSION SYNDROME WITH CONCOMITANT STROKE AFTER AN ELECTIVE CEA

Stewart R. Malave¹; Nojan Valadi¹; Nathan Douthit². ¹Internal Medicine, East Alabama Medical Center, Opelika, AL; ²Internal Medicine Residency, East Alabama Medical Center, Opelika, AL. (Control ID #4044983)

CASE: A 76-year-old M with PMHx of HTN, HLD, hypothyroidism, and CAD was admitted for elective right carotid artery surgery via TCAR and stenting. For 6 months, the patient complained of weakness, orthostatic hypotension, and vertigo. A CTA of the head and neck showed an 80% stenosis of the proximal right ICA caused by noncalcified plaque, as well as up to 80% stenosis of the intracranial left vertebral artery proximal to the formation of the basilar segment. The patient decided to proceed with an elective CEA. 5 hrs post-surgery, the patient developed dysarthria, left facial droop, left homonymous hemianopsia, left tongue deviation, and left arm weakness. Vitals showed labile BP between 106/47 and 160/69 with HR between 50-60s, requiring pressor support. The patient was treated with dual antiplatelets, statin therapy, and permissive hypertension. An echocardiogram and CT of the brain showed no acute findings. An MRI of the brain showed extensive right frontal, parietal, temporal and insular cortex DWI signal hyperintensity. An EEG demonstrated decreased right hemispheric amplitudes. Despite suspicion for cerebral hyperperfusion syndrome (CHS), permissive hypertension was allowed. Seizures were treated with antiepileptics. The patient started improving clinically with follow-up MRI showing resolution of imaging. Given the patient's seizure activity, improving MRI, and cortical ribbon changes, CHS was confirmed. The patient had multiple complications during his hospitalization, including sepsis, and ultimately died.

IMPACT/DISCUSSION: CHS is a complication of cerebral reperfusion, with the most common clinical presentation being a headache, and facial pain. Less common and more severe symptoms include focal neurological deficits, seizures, and LOC. Radiologic studies usually show patchy or diffuse white matter edema on the posterior parieto-occipital lobe, focal infarction, and petechial hemorrhage. However, negative radiological findings cannot exclude CHS. Transcranial color duplex, cerebral perfusion imaging, and new MRI techniques, such as arterial spin labeling and quantitative MRI, can help make the diagnosis. BP control is critical in patients at high risk of CHS, with studies suggesting an ideal BP less than 120/80 mmHg. In our patient, it was challenging to maintain a strict SBP after the incidence of CHS because the patient presented with a concomitant stroke on imaging. Despite allowing permissive hypertension, our patient maintained a SBP control between 130-160 and improved neurologically despite hospital complications.

CONCLUSION: CHS is an uncommon sequela of carotid endarterectomy (CEA) occurring because of an impairment of cerebral autoregulation in response to a sudden increase in blood flow. This case emphasizes the possibility of reperfusion brain injury with concomitant stroke findings following CEA and the importance of establishing BP targets before, during, and after a revascularization procedure, with labetalol as the proposed ideal antihypertensive.

HYPERAMMONEMIA IN THE SETTING OF CAPECITABINE AND AN UNDIAGNOSED ORNITHINE TRANSCARBAMYLASE DEFICIENCY

Robert S. Giglio¹; Brandon Kiser²; Hannah Florian²; Tony Dang². ¹Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; ²Internal Medicine, Atrium Health, Charlotte, NC. (Control ID #4057041)

CASE: A 69-year-old man with metastatic colon cancer on capecitabine (Xeloda), presented to our hospital with a sixth episode of hyperammonemia-induced delirium within 4 months of capecitabine initiation. An extensive workup was conducted for this patient to rule out common causes of hyperammonemia. Plasma amino acids were obtained, and urine orotic acid level was sent out for workup of a urea cycle disorder. Lab results indicated that our patient had an underlying Ornithine Transcarbamylase deficiency. A message was sent to his oncologist about the discovery, and he is due to follow up soon to discuss chemotherapeutic medication adjustment. He was discharged back to his skilled nursing facility at his mental baseline.

IMPACT/DISCUSSION: Our patient’s recurrent episodes of hyperammonemia were likely due to chemotherapy treatment with capecitabine in the setting of an underlying urea cycle disorder, ornithine transcarbamylase (OTC) deficiency. Capecitabine is a widely used drug for cancer treatment, and is a derivative of 5-Fluorouracil (5-FU). A known complication of 5-FU is hyperammonemia leading to complications such as encephalopathy. Based on literature review, there are only two case reports of hyperammonemia related to capecitabine. One of those documented occurrences happened in the setting of a urea cycle disorder and the other did not perform further investigation. Our research suggests that capecitabine is less likely to induce hyperammonemia than 5-FU because thymidine phosphorylase, the enzyme that hydrolyzes 5’-DFUR to the active form of 5-fluorouracil (5-FU) in capecitabine metabolism, is more highly expressed in tumor cells. Therefore, capecitabine induces a lower ammonia burden such that in otherwise healthy individuals, there exists a lower risk of hyperammonemia. However, In the setting of urea cycle disorders, even the lower elevation in ammonia becomes systemically impactful burden. With a urea cycle disorder, the body has limited capability to process the increased ammonia induced by capecitabine. Urea cycle disorders therefore magnify a typically asymptomatic side effect of capecitabine leading to significant complications.

CONCLUSION: We present a case of a patient with multiple hospital admissions for hyperammonemia induced encephalopathy while prescribed capecitabine in the setting of a urea cycle disorder. Capecitabine is usually well tolerated in the average patient population and does not have a large base of evidence suggesting that it causes hyperammonemia in the general population. We hope that documenting this patient’s case of capecitabine induced hyperammonemia in the setting of a urea cycle disorder will help providers better understand the risk, albeit low, of hyperammonemia in the setting of capecitabine. Specifically, the risk in patients with underlying metabolic derangements that cause impairments in processing ammonia such as gene mutations or liver dysfunction which are relatively common in the general population.

HYPEREOSINOPHILIC SYNDROME: THE NEW GREAT MASQUERADER

Vijay S. Duggirala^3,1; Evelyn Goodyear². ¹Division of Hospital Medicine, The Ohio State Wexner Medical Center, Columbus, OH; ²The Ohio State University College of Medicine, Columbus, OH; ³Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4064310)

CASE: An 18-year-old female with no medical history was evaluated at an outside hospital for erythematous rash on her forearms, abdominal pain, chest pain, and leukocytosis. Chest Computed Tomography revealed hilar adenopathy. Transthoracic echocardiography showed RA and RV dilation with low EF. She was then transferred to our institution.

Repeat history obtained when she arrived at our institution noted urticaria and bronchitis in the past month, recent diagnosis of incidental leukocytosis and outpatient evaluation for lymphoma with pending lymph node biopsy. Family history disclosed paternal asthma. Physical exam demonstrated tachycardia, lower extremity edema and decreased breath sounds.

Lab evaluation yielded WBC count of 26,000 with 42% eosinophils, troponin of 11.26 (Reference < 0.11 ng/mL) and BNP of 146. EKG showed T wave inversions diffusely. Cardiac MRI showed RV dilation with EF < 20%. Bone marrow biopsy showed >40% eosinophils with no abnormal blasts. Right heart catheterization yielded no shunt or pulmonary hypertension. Infectious workup was negative. Lymph node biopsy was reactive with no malignancy. Concerned for hypereosinophilic syndrome with systemic involvement high dose steroids were initiated with significant decline in eosinophil count. Hospital course was complicated by dyspnea, cough, and abdominal pain which all resolved with initiation of steroids. She was discharged home with prednisone, hydroxyurea, and outpatient hematology follow-up.

IMPACT/DISCUSSION: Hypereosinophilia (HE), defined as counts ≥1,500,000 is exceptionally rare. Various causes, including allergies, infections, cancers, genetics, and immune issues, lead to diverse symptoms impacting different organs. Diagnosis relies on a comprehensive assessment involving medical history, physical examination, and blood tests. Initial tests cover blood counts, chemistries, immunoglobulin levels, B12, tryptase, lymphocyte assessment, and helminth testing if relevant.

Hypereosinophilic syndrome (HES) refers to hypereosinophilia & end-organ dysfunction. HES is subdivided into 6 subtypes: Myeloid HE/HES, Lymphocytic variant HE/HES, Overlap HES, Associated HE/HES (e.g., helminth infection or neoplasm), Familial HE/HES & Idiopathic HE/HES

Corticosteroids are the primary treatment for HES, but newer targeted therapies are increasingly replacing traditional immunosuppressive agents.

CONCLUSION: Hypereosinophilic syndrome is defined as hypereosinophilia & end-organ dysfunction. HES is group of rare disorders with a multitude of clinical manifestations. A focused clinical evaluation to identify end-organ manifestations & the clinical subtype of HES is imperative for both therapeutic and prognostic reasons. Early recognition is imperative, thus, HES should be in clinicians’ differential if confronted with hypereosinophilia.

HYPEREOSINOPHILIC SYNDROME AS A RARE CAUSE OF PERICARDIAL EFFUSION

Tanjeev Ahmad¹; Kevin Tea¹; William A. Bath¹; Kanika Gupta²; Jeffrey G. Wiese³. ¹Internal Medicine, Tulane Medical Center, New Orleans, LA; ²Internal Medicine, Tulane University, New Orleans, LA; ³Internal Medicine, Tulane University, New Orleans, LA. (Control ID #4064064)

CASE: A 42-year-old female Ethiopian immigrant with a history of asthma and atopic dermatitis presented with worsening dyspnea on exertion and bilateral lower extremity edema over one month. She arrived afebrile with normal hemodynamic status. Physical examination revealed jugular venous distension, hepatojugular reflux, and bilateral 2+ lower extremity edema to thighs. Electrocardiogram displayed normal sinus rhythm. Chest x-ray showed interstitial edema and a CT angiogram chest revealed a moderate pericardial effusion. Transthoracic echocardiogram (TTE) confirmed moderate pericardial effusion with normal ejection fraction. Pericardiocentesis removed 210ml of serosanguinous fluid with a drain left in place. Periprocedural right heart catheterization was remarkable for mild decrease in right atrial and right ventricular filling pressures after pericardiocentesis. The pericardial fluid cell count was remarkable for 3000 white blood cells (WBC) with 78% eosinophils. The patient’s peripheral blood count was also remarkable for absolute eosinophils elevated to 1550/mm³, normal WBC count. Fluid culture yielded no growth. Fluid analysis was notable for normal cytology and normal flow in situ hybridization (FISH). Fluid adenosine deaminase and sputum AFB were negative, as were Strongyloides, echinococcus, aspergillus, Histoplasma, Ascaris, and Toxocara antigens. ANA was positive, however ENA panel and ANCA were unremarkable. The patient’s pericardial drain was removed after decreased output with repeat TTE demonstrating resolution of the pericardial effusion. Total IgE was elevated to 155 and she was diagnosed with idiopathic hypereosinophilic syndrome (HES). She was discharged on colchicine, ibuprofen, and low-dose prednisone with immunology follow-up.

IMPACT/DISCUSSION: The differential diagnosis of pericardial effusion is broad, encompassing infectious, autoimmune, traumatic, cardiac, iatrogenic, and idiopathic etiologies. We present a rare case of pericardial effusion secondary to idiopathic HES. HES is first evident when peripheral eosinophils and total IgE are elevated. Pericardiocentesis allows for detection of eosinophils in the pericardial effusion and further fluid analysis. FISH is required to exclude genetic mutations particularly PDGFRA, commonly mutated in cardiac HES. Cytology is required to exclude malignancy-associated HES. ANA, ANCA, and ENA panel may be required to rule out vasculitis and autoimmune etiologies. Despite careful evaluation, most HES is idiopathic and patients will require therapy guided by immunology consultation. This case is important for expanding the differential diagnosis of pericardial effusion given the scarcity of documented reports of HES-induced pericardial effusion.

CONCLUSION: Diagnosis of pericardial effusion may require pericardial fluid analysis to determine the underlying etiology. In the rare event of HES-induced pericardial effusion, further workup may determine the underlying etiology of the HES to guide subsequent treatment.

HYPERKALEMIA IN CHRONIC LYMPHOCYTIC LEUKEMIA - TO TREAT OR NOT TO TREAT?

Jorge L. Rodriguez Vazquez¹; Meron Tesfaye²; Megan Mai²; Pranav Ganta⁴; Barath Rangaswamy³; Priya Velumani¹. ¹Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²School of Medicine, Texas Tech University Health Sciences Center School of Medicine Odessa, Odessa, TX; ³internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ⁴Harvard College, Cambridge, MA. (Control ID #4065087)

CASE: A 66-year-old female patient with history of chronic lymphocytic leukemia (CLL) presented to ER following elevated potassium levels noted during a routine follow-up. She was recently started acalabrutinib chemotherapy. After two days of chemotherapy, potassium levels spiked to 6.2 mmol/L, warranting an urgent evaluation for potential tumor lysis syndrome. In the ER, she was hemodynamically stable, initial labs showed white blood cells (WBCs) of 338 thousand/mm³, K 6.2 mmol/L renal function and other electrolytes like phosphorus, calcium, magnesium, bicarbonate, and uric acid were unremarkable. Her lactate dehydrogenase was normal. EKG revealed normal sinus rhythm without any T-wave changes. Patient was treated with hyperkalemia protocol with Calcium gluconate IV, D50, insulin and sodium zirconium cyclosilicate. K decreased to 5.4 mmol/L; Patient was then admitted to internal medicine wards. Subsequent readings revealed a concerning ascent to 6.9 mmol/L, leading to further interventions such as IV bumetanide, scheduled oral sodium zirconium cyclosilicate which then corrected the level to 3.6 mmol/L. Nonetheless, a persistent fluctuation was observed, with a rebound to 5.6 mmol/L, the same interventions were repeated, with potassium levels decreasing to 3.0 at one point. Though patient was asymptomatic, she had a frustrating five days of hospital stay with multiple blood draws and medication administrations on daily basis. She was discharged home with normalized potassium of 4.8meq/L for outpatient follow up.

IMPACT/DISCUSSION: Cases of pseudohyperkalemia associated with thrombocytosis and leukocytosis have been well reported in the literature. Pseudohyperkalemia is an increase in potassium associated with Leukocytosis in patients with CLL due to increased cell fragility and lysis during the centrifugation process. In our patient, causes of true hyperkalemia such as acute renal failure, tumor lysis syndrome, and acidosis were ruled out based on the normal labs, however pseudohyperkalemia was not considered. Differentiating true hyperkalemia from pseudohyperkalemia is important to prevent inappropriate treatment leading to potentially dangerous hypokalemia. If pseudohyperkalemia is suspected, ABG potassium can be used to confirm the suspicion as the ABG analyzer does not require centrifugation. Alternatively, blood sample can be drawn in a non-heparinized tube, allowing it to clot, thus stabilizing the leukemic cells with fibrin. Smudge cells on peripheral smears can also provide evidence for fragility of leukemic cells in CLL.

CONCLUSION: This case highlights the importance of understanding the mechanism of pseudohyperkalemia in CLL. Awareness of pseudohyperkalemia and methods to differentiate it from true hyperkalemia helps high value care avoiding potentiallydetrimental treatment strategies.

HYPERTENSIVE SHOCK?: A CONTRADICTORY CASE OF HYPERTENSIVE CARDIOGENIC SHOCK IN A PATIENT WITH HEART BLOCK

Rebecca A. Scharf¹; Lillian C. Flashner¹; Nir Ayalon². ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Boston Medical Center, Boston, MA. (Control ID #4061201)

CASE: An 85-year-old female with a history of T2DM and HTN presented with shortness of breath, chest pain, and dizziness. Vital signs were notable for BP 225/95, HR 30s, and SpO2 85% on room air. Exam was notable for altered mental status, bibasilar crackles, and lower extremity pitting edema. Chest x-ray showed bibasilar opacities and bilateral pleural effusions. ECG showed 3:1 Mobitz II heart block, a right bundle branch block, and a left anterior fascicular block. Labs were notable for lactate 2.5, high-sensitivity troponin 40, BNP 524 (prior <10), Cr 1.28 (baseline 0.8), and HCO3 14. Due to bradycardia, patient was given 2mg atropine without improvement. Transcutaneous pacing was trialed, but unsuccessful given inability to capture. She was briefly placed on dopamine, but this worsened her hypertension, requiring initiation of a nitroglycerin drip and admission to the cardiac care unit. Given persistent bradycardia, she was started on an isoproterenol drip with minimal improvement. Repeat labs showed HCO3 12 and lactate uptrending to 5.6. She also developed anuria unresponsive to diuretics.

Despite ongoing hypertension, there was concern for a normotensive cardiogenic shock (CS) given the significant bradycardia leading to decreased tissue perfusion and lactic acidosis. Temporary pacing wire was placed with significant improvement in her subjective symptoms. The patient ultimately underwent dual-chamber left bundle area PPM with resolution of the lactic acidosis and normalization of her renal function.

IMPACT/DISCUSSION: This case illustrates that patients with normal blood pressure may still have CS. In general, CS is accompanied by a >30mm drop from baseline blood pressure; however, there can be a significant compensatory vasoconstriction leading to hypertension. A small percentage of cardiogenic shock is associated with normal SBPs (~5%). In this case, low cardiac output was driven primarily by bradycardia, leading to anuria and volume overload. She failed to respond to initial attempts to increase heart rate or diurese, and ultimately required temporary wire placement. Early recognition of her shock state was crucial to initiate invasive therapy.

Normotensive CS may be evaluated with both noninvasive and invasive testing. Evidence of end-organ damage such as uptrending cardiac biomarkers, anuria, lactic acidosis, and cool/mottled skin are highly suggestive of CS. ECG, chest x-ray, and TTE should be obtained. Invasive testing such as left and right heart catheterization may confirm the diagnosis and allow for therapeutic intervention. Treatment is aimed at improving cardiac index, which may be achieved by invasive methods including transvenous pacing, coronary revascularization, or mechanical support.

CONCLUSION: - Normotensive CS is a rare but morbid condition that requires early recognition for appropriate treatment.

- In CS, SVR may increase significantly, leading to reflex hypertension.

I'VE GOT A WARM FUZZY FEELING INSIDE: A CASE OF FUNGAL PERICARDITIS

Hannah Mixer-Kephart²; Sara A. Armstrong¹; Ruth A. Bishop¹; Pranav Shah¹. ¹Internal Medicine, Medical University of South Carolina, Charleston, SC; ²Medical University of South Carolina, Charleston, SC. (Control ID #4064708)

CASE: A 66-year-old man with a past medical history of sarcoidosis, heart failure with preserved ejection fraction, obstructive sleep apnea, type 2 diabetes, atrial fibrillation/flutter and previously treated bronchopulmonary aspergillosis presented to the emergency room with worsening shortness of breath requiring an increase in his home oxygen requirement from 2 to 5 liters. He denied any fevers, chills, or chest pain. On arrival, he was afebrile, blood pressure 93/71 mmHg, heart rate 133 beats/minute, respiratory rate 22 breaths/minute, and SpO2 97% on 4L nasal cannula. Initial labs were remarkable for leukocyte count of 8300 cells/μL, pCO2 of 114 mmHg, NT-pro-brain natriuretic peptide of 398 pg/mL, and high sensitivity troponin of 21.5 pg/mL. Electrocardiogram showed sinus tachycardia. Chest x-ray illustrated cardiomegaly and pulmonary parenchymal opacities with bilateral pleural effusions. An echocardiogram showed an ejection fraction of 49% with a large circumferential pericardial effusion without tamponade physiology. Subsequent pericardiocentesis removed 700 mL of serosanguinous fluid. Unfortunately, his pericardial effusion promptly returned, resulting in tamponade physiology. He underwent a pericardial window with placement of two drains. His course was complicated by acute on chronic hypercapnic hypoxic respiratory failure requiring intubation and vasopressors for multifactorial shock. Several days into his course, his pericardial fluid cultures were positive for Aspergillus flavus. Additional infectious and rheumatologic work-up was unremarkable. Voriconazole was initiated which resulted in improvement in his symptoms and subsequent discharge home.

IMPACT/DISCUSSION: Aspergillus pericarditis is an incredibly rare infection that has a predilection for immunocompromised individuals. Risk factors for fungal infections include immunosuppression, neutropenia, total parenteral nutrition, and autoimmune disorders. Aspergillus fumigatus is the most frequently isolated, but cases due to aspergillus flavus and niger have also been reported. Concurrent pulmonary aspergillosis is more common with myocardial involvement, often diagnosed from pericardial tissue or fluid culture. Management of aspergillus pericarditis involves swift initiation of voriconazole which achieves adequate levels within pericardial fluid but often requires pericardial drainage or pericardiectomy for source control and prevention of fluid re-accumulation. Unfortunately, aspergillus pericarditis has a high mortality rate even with aggressive treatment.

CONCLUSION: This case illustrates a rare cause of pericarditis in an immunosuppressed patient, complicated by recurrent pericardial effusion and tamponade physiology. Diagnosis was made from a pericardial fluid culture, and prompt treatment with voriconazole led to a favorable outcome thus far.

I CAN'T HEAR YOU; SNHL AS AN EXTRAPULMONARY MANIFESTATION OF COVID-19

Malu Abbott Castillo¹; Karla De Jesus Nunez¹; Kristin A. Swedish². ¹Internal Medicine, Montefiore Medical Center, New York, NY; ²Medicine, Division of General Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4063743)

CASE: A 39-year-old man with no past medical history presented with malaise and sudden onset bilateral hearing loss for three days. Review of systems was positive for 40-pound weight loss and chronic dry cough. On exam, he had normal appearing tympanic membranes and decreased hearing. Initial chest x-ray revealed interstitial and patchy opacities present at the right upper lobe and left midlung. Laboratory findings were remarkable for normocytic normochromic anemia, hyponatremia, transaminitis, and positive SARS-COVID-19. Initial microbiology-related studies were negative for infection. Brain MRI revealed no acute intracranial pathology. Audiogram reported bilateral mild to moderate sensorineural hearing loss. The patient was treated with Nirmatrelvir - Ritonavir and prednisone. ENT evaluation attributed his hearing loss to COVID-19 infection. Treatment with steroids were continued, and hearing function was recovered.

IMPACT/DISCUSSION: SNHL is defined as the loss of at least 30 decibels in three connected frequencies within 72 hours without an identified cause. This symptom is more newly recognized as an extrapulmonary manifestation associated with COVID-19, with an incidence rate of 0.2 - 7.6%. In recent years an increase in SNHL has been noted, making this unusual presentation a topic of interest with cases reporting it as the initial or sometimes the only symptom of COVID-19 infection.

The pathophysiology of COVID19 related SNHL is thought to involve one of three different mechanisms or the combination of them: (1) direct invasion of the cochlear nerve by the virus resulting in neuritis, (2) direct inflammation of the cochlea, and/or (3) immune related antigen cross reactivity involving viral antigens in the inner ear. Testing the genuine existence of hearing loss is one of the first steps in diagnosing SNHL, with studies including: otoacoustic emissions, turning forks tests, auditory brainstem response, suppression head impulse, and pure tone audiometry, the standard gold method.

As in the standard treatment for SNHL, corticosteroids are the first line of treatment for COVID-19 induced SNHL, as they target and suppress cytokine release (IL-6). No differences in outcomes have been found in using different forms of corticosteroids (oral, intravenous, or intratympanic). On the other hand, little literature can be found on the use antiretrovirals as a treatment option for SNHL but one thing to keep in mind is their potential to cause ototoxic side effects, more commonly seen with the use of Remdesevir, Favipiravir and Lopinavir.

CONCLUSION: SNHL, the loss of at least 30 decibels in three connected frequencies within 72 hours without an identified cause, is newly recognized as an extrapulmonary symptom of COVID-19. Diagnostic gold standard is pure tone audiometry. Corticosteroids are the first-line of treatment, more susccesful than antivirals for treating COVID-induced SNHL. By presenting this case we aim to raise awareness of an uncommon presentation of a common disease.

I CANNET BELIEVE IT’S NOT PNEUMONIA!: AN ENDOCRINOLOGICALLY SILENT PRESENTATION OF PULMONARY CARCINOID

Priyanka Solanki, Audrey Lim. Department of Medicine, UPMC, Pittsburgh, PA. (Control ID #4064834)

CASE: A 27-year-old woman with exercise-induced asthma presented with intermittent fevers, shortness of breath, and non-productive cough. Symptoms began one week earlier during a cruise to the Carribean. She was prescribed cefuroxime and steroids for suspected bronchitis. Given ongoing symptoms, she presented to the ED where she was found to have the following vitals: T 37.2C, HR 118, BP 138/98, RR 24, SpO2 96% on room air. Labs were notable for mild leukocytosis and elevated inflammatory markers. Chest XR showed ovoid retrocardiac left lower lobe (LLL) consolidation concerning for pneumonia. A subsequent CTA chest demonstrated LLL 7.8 x 6.8 cm heterogenous mass with necrosis. She was admitted for treatment of presumed bacterial pneumonia and started on vancomycin, ceftriaxone, and azithromycin. A broad infectious workup, including tests for Strep, Covid, Monospot, HIV, and Legionella, were negative. Bronchoscopy with biopsy revealed a hypervascular tumor consistent with pulmonary carcinoid. One month later, the patient successfully underwent definitive management with a left pneumonectomy.

IMPACT/DISCUSSION: The combination of fever, dyspnea, and cough is a common illness script for bacterial pneumonia. These clinical reasoning tools organize and summarize clinical details to formulate diagnoses. However this patient’s lack of symptomatic improvement, despite appropriate antimicrobial therapy, resulted in the re-evaluation of our diagnosis. The limitations of illness scripts are exacerbated within atypical presentations, like for this young and healthy patient with minimal risk factors for a bacterial infection. Despite a broad and negative infectious workup, this conventional diagnostic reasoning approach resulted in premature closure of a diagnosis.

Gathering and evaluating old and new data helps reduce diagnostic uncertainty. Her initial clinical picture was obscured by the lack of typical endocrinological signs common within carcinoid tumors, such as chest pain, diarrhea, wheezing, and facial flushing; further evaluation with bronchoscopy to evaluate the patient’s ongoing symptoms led to her final diagnosis of pulmonary carcinoid. This case highlights a not uncommon presentation of pulmonary neuroendocrine tumor.

CONCLUSION: > A valuable diagnostic reasoning tool that summarizes symptoms is an illness script. Yet, these scripts can overgeneralize symptoms and result in a premature closure bias. The foundation of clinical reasoning lies within continuous reassessment of clinical data to maintain a broad differential diagnosis.

> Pulmonary neuroendocrine tumors are exceptionally rare, representing <1% of pulmonary malignancies. Many patients do not exhibit typical carcinoid-like symptoms. Tumors can be endocrinologically silent, leading to presentations of post obstructive pneumonias.

IDENTIFICATION AND MANAGEMENT OF SEVERE SUBCUTANEOUS EMPHYSEMA

Christiana Choi, Teena Thomas. Internal Medicine, Mount Sinai West Medical Center, New York, NY. (Control ID #4064820)

CASE: A 68 year old male with a recent history of pneumonia presented with shortness of breath. Chest x-ray (CXR) revealed complete opacification of the right hemithorax with left tracheal deviation. CT scan showed large right pleural effusion, right lung collapse, and mediastinal shift. He subsequently underwent thoracoscopy and pleural biopsy; an intrapleural catheter was placed to remove 4.8L fluid. Afterwards, patient became hypoxic to 84% - repeat CXR showed infiltrates in the right lung and subcutaneous emphysema of right chest wall. Patient was then admitted for respiratory stabilization while on BiPAP.

The next day, patient developed acute facial swelling with voice changes after eating. With concern for anaphylaxis, a macintosh blade was used to assess airway, which revealed no mucosal swelling. Oxygen saturation remained above 95% but physical exam revealed palpable crepitus throughout the chest, bilateral upper extremities, neck, and face. CXR confirmed extensive subcutaneous emphysema. With concern for possible respiratory compromise, chest tube was placed on suction and bilateral infraclavicular incisions were made. He improved soon after intervention and pleural biopsy later resulted with concerns for malignancy.

IMPACT/DISCUSSION: Subcutaneous emphysema is the entrapment of air within the subcutaneous layer. Common etiologies include thoracic/sinus injuries, rupture of pulmonary blebs, esophageal/tracheal damage, and barotrauma. It presents with soft tissue swelling and crepitus on palpation. As the swelling worsens, vocal cord compression and compartment syndrome can also occur.

Mild-moderate presentations of subcutaneous emphysema are often self-limited; air is gradually reabsorbed over time, sometimes facilitated by supplemental oxygen. Severe presentations may require decompression in the form of subcutaneous incisions ("blowhole incision"). However, complete resolution can only be achieved with adequate source control. In our patient who developed acute swelling of the face with voice changes, it was appropriate to favor procedural therapy.

With rapidly progressing subcutaneous emphysema, it can often mimic anaphylaxis. It was especially concerning in our patient who developed the swelling acutely after eating. An important way to distinguish is via physical exam and close monitoring of vital signs. In anaphylaxis, multi-system involvement is often noted, including the skin (urticaria), respiratory (laryngeal edema, worsening hypoxia), cardiovascular (hypotension, tachycardia), and gastrointestinal (vomiting, diarrhea).

CONCLUSION: Subcutaneous emphysema can occur with injuries to the respiratory tract or thoracic cavity. Mild to moderate presentation can often be treated conservatively while severe presentations may require more invasive intervention with blowhole incisions. As subcutaneous emphysema progresses, it can mimic severe allergic reactions such as anaphylaxis. Thorough physical exam and history can narrow the differential and prevent delay in treatment.

IDIOPATHIC HYPEREOSINOPHILIC SYNDROME: A RARE CASE OF CYSTIC LUNG DISEASE

Trisha Agarwal¹; Fernando Holguin². ¹Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4053106)

CASE: A 37-year old male presented to Severe Asthma Clinic in the Mountain West for progressively worsening dyspnea, right-sided chest soreness and productive cough. His history is significant for child onset asthma without requiring albuterol, never smoker, and an incidental finding of cystic changes in his right lower lobe 1 year ago. He was admitted nine months ago for dyspnea with new air-fluid levels within his previous cystic lesions and a new airspace consolidation in his right lower lobe. A large right-sided pleural effusion was noted with 66% eosinophils and no signs of infection along with a bronchoalveolar lavage with 71% eosinophils. Workup at the time also revealed an elevated serum IgE (282 IU/mL) and peripheral blood eosinophils (1.1 10*9/L). After chest tube drainage and discharge, further workup included a negative bone marrow biopsy and FISH eosinophilia panel (including FIP1L1-PDGFRA), negative parasitic workup, and normal pulmonary function tests. Six months later, he presented to our clinic with worsening dyspnea and enlarging cystic lesions. He was started on mepolizumab (Anti IL-5 mAb) with improving symptoms, decreasing size of his right lower lobe cystic lesions, and reduction of eosinophil count.

IMPACT/DISCUSSION: Our differential for our patient’s cystic lung disease with marked eosinophilia was significant for allergic bronchopulmonary aspergillosis (ABPA), eosinophilic pneumonia, and hypereosinophilic syndrome (HES). He did not have a history of poorly controlled asthma or cystic fibrosis that would suggest ABPA. In addition, pulmonary function testing was normal and lack of leukocytosis made eosinophilic pneumonia less likely. HES has been defined as (1) AEC ≥ 1500/μL and clinical manifestations attributable to eosinophilia or tissue with blood eosinophilia and (2) an exclusion of secondary causes, for which our patient met criteria. Of the 6 clinical variants of HES (myeloproliferative, lymphocytic, overlap, associated, familial, and idiopathic), our patient's condition aligned most closely with the diagnosis of idiopathic hypereosinophilic syndrome (I-HES), a diagnosis of exclusion. I-HES is suggested to be responsible for over 40% of HES. Pulmonary involvement in HES is common but is mostly seen as infiltration of the lung with subsequent fibrosis, heart failure, or pulmonary emboli and less commonly as pleural effusion. Our patient’s pleural effusion with cystic lesions has rarely been reported.

CONCLUSION: This case reinforces the vital role interdisciplinary collaboration for advanced diagnostic testing plays in identifying patients with HES. As the data on the increasing incidence and burden of HES remains limited, it is important to continue this interdisciplinary approach to help improve the identification and reporting of I-HES.

IDIOPATHIC HYPEREOSINOPHILIC SYNDROME: NAVIGATING DIAGNOSTIC CHALLENGES AND SUCCESSFUL MANAGEMENT

Diana I. Zamora¹; Chelsea Azevedo²; John Mailolo³. ¹Internal Medicine, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, AZ; ²Internal Medicine, Creighton University School of Medicine, Omaha, NE; ³Medicine, Creighton University School of Medicine Phoenix Health Sciences Campus, Phoenix, AZ. (Control ID #4064955)

CASE: 33-year-old Indian gentleman with no significant past medical history who initially presented with fevers, myalgias, and cough. In the outpatient setting, he had been treated for an upper respiratory infection with amoxicillin. He had persistent symptoms and presented to his primary care physician where laboratory workup revealed elevated liver enzymes and leukocytosis with eosinophilic predominance (45%). He continued to experience worsening cough, fevers, weight loss, and abdominal pain and presented to the hospital. Imaging studies revealed diffuse bronchial wall thickening, common hepatic and bile duct wall enhancement, edematous gallbladder wall thickening, and lymphadenopathy of pericardial, porta hepatitis, gastrohepatic, and retroperitoneal nodes. He underwent bronchoscopy with endobronchial biopsy and EBUS directed TBNA of lymph nodes; BAL revealed eosinophilia. He decompensated on the floor and required intubation for acute hypoxic respiratory failure and new imaging revealed bilateral lung consolidations and new irregular enhancement of the myocardium. Further laboratory workup revealed eosinophilia ranging from 14,230 to 19,910, elevated total IgG of 3,0040 with specific elevation in IgG4 (108). Serum protein electrophoresis showed polyclonal hypogammaglobinemia. Bone marrow biopsy revealed hypercellular marrow with tri-lineage hematopoiesis and increased eosinophils (24%). Negative immunohistochemistry ruled out myeloid and T-cell abnormalities. Secondary causes of hypereosinophilia were ruled out including parasitic infection, significant rheumatologic conditions, and proliferative and malignant hematologic conditions. After this extensive workup, the patient was diagnosed with idiopathic hypereosinophilic syndrome and was started on imatinib and methylprednisolone resulting in improvement in his eosinophilia. He remained stable for many years, with a goal eosinophil count less than 1.5x10^9/L

IMPACT/DISCUSSION: Clinical Impact: This case highlights the diagnostic intricacies of idiopathic HES, showcasing its potential for multi-organ involvement and underscoring the need for a systematic evaluation.

Teaching Points: Emphasizes the importance of considering HES in patients with unexplained eosinophilia and diverse organ involvement. Discusses the role of imaging, bronchoscopy, and comprehensive laboratory studies in diagnosis.

Clinical Practice Change: Illustrates the successful use of imatinib and methylprednisolone in managing HES, contributing to evolving treatment strategies.

Literature Contribution: Adds to the literature by presenting a comprehensive case of idiopathic HES with detailed diagnostic and management insights.

CONCLUSION: Idiopathic HES demands a high index of suspicion and a thorough diagnostic workup. Timely initiation of imatinib and methylprednisolone can result in sustained improvement. Comprehensive evaluation, including imaging and bronchoscopy, is crucial for accurate diagnosis.

IMMUNE CHECKPOINT INHIBITOR INDUCED AUTOIMMUNE TOXICITY: A COMPREHENSIVE HOSPITALIZATION REVIEW

Nikita R. Chintapally, Farah Bani Hani, Gaby Weissman. Internal Medicine, MedStar Washington Hospital Center, Washington, DC. (Control ID #4043010)

CASE: Our patient is a 66-year-old male with metastatic renal cell carcinoma presenting with fatigue, myalgias, and flu-like symptoms shortly after receiving one cycle of Pembrolizumab. Examination revealed generalized muscle weakness and tenderness. Labs were remarkable for elevated CK and troponin. He was initially managed with intravenous hydration and steroids, but his course was complicated by development of complete heart block requiring transvenous pacing. Despite high suspicion for ICI related myocarditis, diagnostic imaging with cardiac MRI and endomyocardial biopsy were precluded by the imminent pacing requirements. His clinical picture failed to improve, with emergence of bulbar symptoms despite high-dose corticosteroids and mycophenolate mofetil. Eventually, he developed hypercapnic respiratory failure due to myasthenic crisis confirmed with positive anti acetyl-choline receptor antibodies, anti-titin antibodies, and an elevated striated muscle IgG titer. A course of IVIG yielded minimal improvement and the patient was ultimately intubated given worsening negative inspiratory force readings. Given the severity of the patient's illness pyridostigmine was started and the immunosuppressive regimen was escalated with the addition of abatacept. He was unsuccessfully weaned off mechanical ventilation, ultimately requiring a tracheostomy and PEG tube. Abatacept and mycophenolate mofetil were discontinued after 30 days. He was discharged after a 43-day hospitalization with a permanent pacemaker and was continued on pyridostigmine.

IMPACT/DISCUSSION: The primary objective of this case is to highlight rare immune related adverse events secondary to ICI and report the barriers to successful diagnosis and treatment. The introduction of immune checkpoint inhibitors (ICI) posed an undeniable advancement in cancer immunotherapy. However, the complexity of accompanying side effects, albeit rare, are serious and lead to significant morbidity and mortality, making it challenging to follow the progression and allow for a complete side effect profile to be documented in the literature.

ICI induced myocarditis, myositis, and myasthenic crisis, also known as the overlap syndrome, is rare but carries high mortality. The non-specific nature of the immune response and multiorgan involvement, makes the diagnosis complex and is the reason its true incidence is unknown. The severity of events, as seen in our case, precludes definitive testing in some patients. Treatment of such events remains reliant on observational studies despite a rise in utilization of ICI.

CONCLUSION: Immunosuppression remains a mainstay in treatment but currently no guidelines exist, further studies are required to compare various agents, in their efficacy and safety, as well as establishing treatment guidelines, especially in steroid refractory cases.

IMMUNOGLOBULIN G: THE GREAT IMITATOR OF SYSTEMIC LUPUS ERYTHEMATOSUS

Corinne Zalomek¹; Tarek Ayoub¹; Kathleen Jenkins^1,2; Jeffrey G. Wiese¹. ¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4033723)

CASE: A 39-year-old female with a history of Grave’s Disease complained of body aches and proximal joint pain for two months. She endorsed swollen, tender lymph nodes, fatigue, and red rash on bilateral upper extremities.

She was afebrile, hypertensive to 168/101 mmHg, heart rate of 90 bpm, and oxygen saturation of 99% on room air. Proximal, metacarpophalangeal, and wrist joints were tender bilaterally. Discolored, erythematous patches were seen along bilateral upper extremities and scalp.

Laboratory findings were notable for an anti-nuclear antibody titer of 1:640, anti-dsDNA 1:160, anti-Sgoren’s-syndrome-related antigen A autoantibodies >8, and anti-histone of 7.8. HIV and H. pylori screenings were negative, Epstein-Barr virus PCR was positive. She was treated supportively and significantly improved.

IMPACT/DISCUSSION: SLE is a multiorgan autoimmune disease characterized by high levels of IgG antibodies against nuclear antigens. ANA self-antigens are made against cellular nuclear material due to a combination of genetic and environmental factors. This stimulates further production of IgG that then attack different tissues in the body through antigenic mimicry. Thus, initially perceived self-antigen dictates which tissues will be attacked, and the presenting symptoms of the disease.

Processes that inappropriately hyperproduce IgG are capable of triggering molecular mimicry, causing symptoms of SLE. Five notable processes hyperproduce IgG: autoimmune diseases, adenocarcinoma, B-cell lymphoma, medications/immunizations, and chronic infections.

Viral infections that mimic SLE such as Parvovirus B19, Hepatitis B and C, and HIV, often have positive ANAs, but no lupus autoantibodies on serology. The lupus-like syndromes triggered by these processes are often transient and self-limited. Chronic infections that directly affect B-lymphocytes like H. pylori, EBV, and HIV may cause lupus-like syndromes. EBV IgG antibodies from infection correlate positively with lupus antibody EBNA-1, and lupus autoantigens, Sm-B, Sm-D, and Ro. In patients with previous EBV infection and a genetic predisposition to lupus, cross-reactivity will occur between the EBNA-1 antibodies and the dsDNA antigen, increasing the risk of developing clinical symptoms of SLE. Mimicry with EBV epitopes allows loss of tolerance to self-antigens, which then target additional self-epitopes, leading to pathogenic responses and clinical SLE.

CONCLUSION: In patients with symptoms concerning for SLE, it is essential to rule out other disease processes with hyperproduction of IgG. The five immunologic-inducing processes to consider are primary autoimmune lupus, adenocarcinoma, B-cell lymphoma, chronic infections affecting B-lymphocytes, and medications/immunizations.

INFECTION OF UNKNOWN ORIGIN LEADS TO STAPHYLOCOCCUS AUREUS-RELATED TRICUSPID VALVE ENDOCARDITIS AND STROKE

Robert S. Pinches^1,2; Igor Dombrovsky²; Juan Polanco²; Maria Mahfouz²; Sarah L. Adams²; John W. Pakan^1,2; Michael Rehr². ¹Philadelphia College of Osteopathic Medicine, Philadelphia, PA; ²Internal Medicine, Pennsylvania Hospital, Philadelphia, PA. (Control ID #4062056)

CASE: The 19-year-old male patient was admitted to the hospital with complaints of hyperventilation and somnolence. His recent past medical history included poorly controlled type 1 diabetes mellitus (DM1) complicated by recent hospitalizations for DKA. He was ill-appearing but hemodynamically stable. He complained of nausea, vomiting, and knee pain. He denied chest pain, fevers, recent sick contacts, and intravenous drug use.

Upon admission for DKA treatment, the patient was in respiratory distress with rhonchi on exam. Chest x-ray disclosed signs of pneumonia. Laboratory workup disclosed blood and respiratory cultures positive for Staphylococcus aureus. Broad-spectrum antibiotics were initiated. The next day, the patient rapidly declined and was maintained with pressors and ventilation. Point of care ultrasound revealed a 1.2x0.9cm vegetation on the tricuspid valve later confirmed with TTE. After improving with treatment, he showed a right-sided facial droop and change in mental status. Subsequent imaging showed multiple infarcts in the brain and previously unidentified patent foramen ovale (PFO) assumed to be the source of the stroke through paradoxical septic emboli.

IMPACT/DISCUSSION: Right-sided endocarditis, often linked to risk factors like intravenous drug use, generally occurs in middle aged to older patients(1). Our 19-year-old patient, without typical risk factors, developed life-threatening tricuspid endocarditis from an unknown source of infection. Recent evidence suggested a higher incidence of vegetations in diabetic patients, leading to increased risks of heart failure, embolic events, and mortality (2). The rarity of this case continued with the diagnosis of a stroke from a paradoxical embolism due to PFO. Tricuspid valve endocarditis accounts for 5-10% of infective endocarditis and while PFO’s can be found in almost 30% of the population, cases of septic paradoxical embolism are extremely rare (3). In this case, our approach included TTE with serial blood cultures that were essential to diagnosis. Additional TEE with bubble study confirmed our suspicions and should be considered in similar cases.

Sources:

1. Nandakumar, R., & Raju, G. (1997). Isolated tricuspid valve endocarditis in nonaddicted patients: a diagnostic challenge. The American journal of the medical sciences, 314(3), 207-212.

2. Benvenga, R. M. et al. (2019). Infective endocarditis and diabetes mellitus: Results from a single-center study from 1994 to 2017. PLoS One, 14(11), e0223710.

3. Nii, T., Yoshikawa, et al. (2014). Septic pulmonary and systemic embolism in tricuspid endocarditis. BMJ case reports, 2014, bcr2014206569.

CONCLUSION: 1. In bacteremic patients with comorbidities such as DM1, valvular vegetations should be considered

2. Risk for stroke should be considered in patients recently diagnosed with right sided endocarditis as previously undiagnosed PFO can predispose to embolic events.

INITIAL PRESENTATION OF PALPABLE PURPURA AND A NEW DIAGNOSIS OF IGA VASCULITIS AND IGA NEPHROPATHY

Beza Tayachew^1,2; David Gamble^1,2; Michelle Knees³. ¹Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²University of Colorado Internal Medicine Residency Program, Aurora, CO; ³Department of Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #4062481)

CASE: A 29-year-old female with minimal past medical history presented to the emergency room with a 10-day history of purpuric rash and recent upper respiratory infection (URI) three weeks prior to the onset of the rash. The rash started on bilateral anterior thighs and progressed to bilateral legs, arms, and abdomen. Other ROS were negative. On admission, she was afebrile and hemodynamically stable. Exam was relevant for diffuse, non-blanching, palpable purpuric macules and papules on the abdomen and bilateral upper and lower extremities. Notable work up included a normal renal function but sub-nephrotic range proteinuria, glucosuria, and hematuria with a normal renal ultrasound. She also had elevated inflammatory markers (ESR 126 and CRP 137) and an elevated immunoglobulin A (IgA) of 655. She had normal complement levels and otherwise negative serologies for autoimmune and infectious diseases. A skin biopsy showed leukocytoclastic vasculitis with scattered eosinophils and direct immunofluorescence (DIF) showed IgA with 2+ grains in focal superficial vessels, consistent with IgA vasculitis (IgAV). Renal biopsy showed mesangial IgA nephropathy (IgAN) with deposition of IgA and C3, no crescents, and minimal interstitial fibrosis.

IMPACT/DISCUSSION: This patient initially presented with palpable purpura after a recent URI and was found to have renal dysfunction; a diagnosis of IgAV was made based on a DIF stain of skin biopsy and IgAN was confirmed with a renal biopsy. Most patients with IgAN present with hematuria and mild proteinuria and it is usually accompanied by recent URI. Further, IgAV has kidney findings that are identical to that in IgAN, as observed in this patient. Renal involvement in IgAV typically occurs within one month after the onset of symptoms of IgAV. Hematuria, nephrotic range proteinuria, and elevated serum creatinine are associated with progressive renal disease. In contrast, this patient did not develop severe renal dysfunction with stable creatinine and sub-nephrotic range proteinuria.

CONCLUSION: In patients with IgAV without kidney involvement at initial presentation, treatment with glucocorticoids is not recommended to prevent the development of IgAV nephritis. Adults with proteinuria over half a gram per day are treated with an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), and in adults with proteinuria of over one gram per day or a sustained increase in creatinine, a kidney biopsy is performed to guide aggressive therapy. For adults with more severe renal involvement and evidence of crescentic glomerulonephritis on biopsy, immunosuppressive therapy with glucocorticoids is recommended in addition to treatment with ACEi/ARB. If there are active crescents on biopsy, treatment with cyclophosphamide, mycophenolate mofetil, or rituximab, in addition to six-month of glucocorticoids, is recommended. Given the absence of crescents, inpatient immunosuppressive therapy was not initiated.

INTERNAL JUGULAR VENOUS THROMBOSIS DUE TO ANGULATED NECK COMPRESSION

Stephen J. Susman, Eden B. Taddese, Lauren D. Spaeth, Jay Anderson. Internal Medicine, Riverside Methodist Hospital, Columbus, OH. (Control ID #4063616)

CASE: A 29-year-old female on oral medroxyprogesterone presented with progressive left sided neck swelling over 2 days. She had no history of ovarian-stimulating drugs, active cancers, neck procedures, trauma, central venous catheters, or thrombotic events. She endorsed extended periods of angulated neck positioning while sleeping for the last 2 months. She denied upper respiratory symptoms, dysphagia, fever, headache, or other neurologic symptoms. Examination revealed left neck swelling with tenderness to palpation and cervical adenopathy. Body mass index of 44. Her vital signs were normal. Labs revealed unmarkable white blood cells, platelets, and INR. D-dimer and fibrinogen testing were elevated at 0.98 ug/mL FEU and 520 mg/dL respectively. Urine pregnancy testing was negative. Computed tomography with contrast of the neck showed a 19 mm occlusion of the left internal jugular vein not extending into the cerebral sinuses. Otolaryngology and peripheral vascular specialists were consulted, cultures obtained, and the patient was given unfractionated heparin, cefepime, and metronidazole. Given the patient’s stability and negative blood cultures, antibiotics were discontinued. The patient was discharged on apixaban and given education about not compressing her neck. Follow-up CTA showed improvement of her internal jugular vein thrombosis to 7 mm. At her 3-month follow-up, apixaban was discontinued as the patient had full resolution of her symptoms.

IMPACT/DISCUSSION: Internal jugular vein thrombosis (IJVT) is a rare cause of neck pain and swelling in adults, often accompanied by erythema, palpable cord, fever, or signs of intracranial hypertension. We present a case of IJVT secondary to chronic neck compression. The most common causes are central venous catheterization, malignancy, infection, trauma, surgery, intravenous drug use, and ovarian hyperstimulation syndrome. The etiology involves Virchow’s Triad of endothelial damage, blood stasis, and a hypercoagulable state. In our patient, the cause was likely chronic compression due to a pillow, causing venous stasis and endothelial injury. This cause is not well documented, though positional IJVT was noted by Weber et al. It is unclear if her oral medroxyprogesterone played a role in this pathology, as this has not been shown to increase risk for thromboembolic events. Diagnosis is primarily made with doppler ultrasound, though CT or MR venography are valuable for identifying cerebral venous sinus thrombosis. Treatment recommendations for IJVT do not differ from the treatment for lower extremity deep vein thrombosis, with direct oral anticoagulation for 3-12 months.

CONCLUSION: Internal jugular vein thrombosis is a rare cause of neck pain and swelling, caused by derangements of Virchow’s Triad. A thorough history is required to identify unusual causes like external compression.

INTERNUCLEAR OPHTHALMOPLEGIA (INO) IS A DISTINCT EYE GAZE DISORDER, MOST ASSOCIATED WITH MULTIPLE SCLEROSIS (MS) OR STROKE, STEMMING FROM A LESION IN THE MEDIAL LONGITUDINAL FASCICULUS (MLF). LYME DISEASE PRESENTING AS INO IS AN UNUSUAL CORRELATION. FEW INSTANCES OF LYME-ASSOCIATED INO HAVE BEEN DOCUMENTED, AND HEREIN, WE PRESENT A CASE OF ACUTE BILATERAL INO LINKED TO NEUROLOGIC LYME DISEASE, WHICH SAW SIGNIFICANT IMPROVEMENT POST-CEFTRIAXONE TREATMENT.

Gabriel A. Ramos¹; Prodip Paul³; Julio A. Ramos²; Mishouri Paul¹. ¹Medicine, University of Virginia, Charlottesville, VA; ²Ramos Rheumatology, Avoca, PA; ³Medicine, Geisinger Medical Center, Danville, PA. (Control ID #4035921)

CASE: An 81-year-old female with a past medical history of hypertension, hyperlipidemia, and gastroesophageal reflux disease had been experiencing double vision, ataxia, and dizziness for over 20 months. These symptoms emerged abruptly. Initial evaluations by a neurologist and an ophthalmologist, including a magnetic resonance imaging brain scan and video oculography (VOG), did not offer conclusive findings. However, a physical examination revealed bilateral INO. A subsequent Lyme Disease western blot test returned positive. Given the lack of alternative explanations for her neurological symptoms, a tentative Lyme disease diagnosis was proposed, prompting the commencement of oral doxycycline treatment. However, due to a negligible improvement in her symptoms, the therapy was switched to intravenous ceftriaxone at 2gm daily. Two weeks after this transition, the patient began displaying gradual neurological betterment. Having completed a month of treatment with ceftriaxone, her condition steadily ameliorated. A three-month post-treatment check-up recorded almost total alleviation of diplopia and ataxia, with no observable INO clinically.

IMPACT/DISCUSSION: Lyme Disease, caused by the spirochete Borrelia burgdorferi, is a tick-borne illness with the potential to impact the heart, skin, joints, and central nervous system. Its broad symptom spectrum often complicates timely diagnosis. Although INO is predominantly linked to Multiple Sclerosis and stroke, it is also a seldom-seen manifestation of neurologic Lyme disease. In this context, an inconclusive MRI, positive Lyme serology, and the patient's responsiveness to ceftriaxone bolster the Lyme disease diagnosis; still, an isolated INO presentation remains a rarity.

CONCLUSION: While INO frequently presents in the context of MS and stroke, clinicians must recognize its potential, albeit rare, association with neurologic Lyme disease. This awareness ensures timely and appropriate therapeutic interventions.

INTRACELLULAR CUE – HGA CONTRIBUTING TO ACUTE GENERALIZED TONIC CLINIC SEIZURES

QI SHI²; Pragya Dhaubhadel¹; Roop S. Parlapalli²; Venu Gopal Kankani²; YueXiu Wu³. ¹Infectious Diseases, Geisinger Health, Danville, PA; ²Hospital Medicine, Geisinger Health, Danville, PA; ³Wright Center for Graduate Medical Education, Scranton, PA. (Control ID #4045136)

CASE: 52-year-old man from Northeast Pennsylvania was transferred to our hospital with acute hyponatremia. He had no past medical or surgical history, had history of tobacco and alcohol use, consumed six beers per day. He was confused with unsteady gait and fell at home with bruise on left scalp. On arrival vital signs: Blood pressure:180/110 mmHg, Heart rate:106/min, temp 100.7F, saturating 96% on RA. Pertinent labs: Sodium111mmol/L, potassium3.2mmol/L, Chlorine77mmol/L, white blood count 2.61K/uL, hemoglobin13.1 g/dL, Platelets 26 K/uL. Ethanol level was negative at our facility, was 14 mg/dl before transfer, high AST and ALT. CT at outside facility showed left parietal scalp contusion, no intracranial mass or bleed. He was treated with IV normal saline and CIWA protocol. 3 hours after admission, developed a fever of 102.6F and generalized tonic clonic seizures, requiring intubation and mechanical ventilation. Peripheral smear showed rare neutrophils with inclusions suggestive of either Ehrlichia or Anaplasmosis. DNA PCR was positive for Anaplasma Phagocytophilum. Neurology and Infectious Disease followed, started on doxycycline. He received hypertonic saline in intensive care unit as per Nephrology. Fevers resolved and blood counts improved to normal range, was discharged to alcohol rehab.

IMPACT/DISCUSSION: Our case illustrates the challenges in diagnosing life-threatening seizures, considering multiple potential causes: alcohol withdrawal, hyponatremia and infection. HGA, despite being a rare cause can lead to seizures, complicating the diagnostic process. The patient’s recent alcohol consumption and acute hyponatremia raised concerns of alcohol withdrawal. However, fevers are unusual with hyponatremia from alcohol intake causing seizures, and with positive evidence of anaplasmosis raised the suspicion of infectious etiology. HGA, transmitted by ticks, can present with neurologic complications like seizures, in patients with weak immune response like our patient with chronic alcohol use, sometimes overshadowed by more common causes. Timely identification of etiology allowed appropriate treatment, preventing potential complications. The involvement of consultants (Infectious disease, Hematology, Nephrology, Neurology and Critical care) highlights the necessity of interprofessional collaboration in managing such complex ensuring a comprehensive evaluation and treatment plan.

CONCLUSION: This case shows how life-threatening seizures due to HGA can masquerade common causes, necessitating a meticulous diagnostic approach. Interprofessional collaboration is crucial for timely decision-making in such cases, addressing all underlying factors, mitigating the risk of Sudden Unexpected Death in Epilepsy (SUDEP). Clinicians in tick-endemic regions should have high suspicion for tick-borne diseases in specific clinical presentations.

INTRAMURAL HEMATOMA PRESENTING AS PSEUDO-APPENDICITIS IN UNTREATED HEMOPHILIA A

Gloria Mensah¹; Sachi Singhal²; Siddharth Gupta³; Michael Bromberg². ¹School of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA; ²Hematology, Temple University Hospital, Philadelphia, PA; ³Internal Medicine, Baptist Memorial Hospital North Mississippi, Oxford, MS. (Control ID #4049740)

CASE: A 32-year-old man presents to the emergency department with four days of bright red bloody stools. He has a past medical history of hemophilia A and has been off factor replacement for 8 years. His last recorded Factor VIII level was 3% 16 months ago, and his hemoglobin was 14 g/dL four months ago. He denies a history of prior gastrointestinal (GI) bleed, alcohol and NSAID use. On arrival, his hemoglobin was 5.1 g/dL and he was admitted for GI bleed. He was treated with factor infusion and received 4 units of packed red blood cells, raising his hemoglobin to 7.3 g/dL. A prompt GI work-up showed an unremarkable colonoscopy and upper endoscopy. He also continued to endorse mild right lower quadrant abdominal pain without guarding or rigidity. In this setting of non-specific symptoms and unexplained blood loss anemia, a non-contrast CT of the abdomen/pelvis was ordered. This revealed complex inflammatory changes of the right lower quadrant suggesting appendicitis. However, he was strikingly asymptomatic otherwise, including a total absence of elevated white blood cell count, fever, nausea, vomiting or acute abdominal pain. A CT scan of the abdomen/pelvis with contrast was ordered to further evaluate findings and showed concern for peri-rectal abscess and findings similar to that of perforated contained appendicitis. Given the absence of signs and symptoms of an infectious or inflammatory etiology, his severe untreated hemophilia, the 8.9 g/dL drop in hemoglobin since his last labs, and his acute overt gastrointestinal bleeding on presentation – a diagnosis of pseudo-appendicitis was made. On discharge, the patient’s Factor VIII level was 80%, his hemoglobin was stable, and he appeared well.

IMPACT/DISCUSSION: Intramural hematoma of the gastrointestinal (GI) tract is a rare, potentially life-threatening clinical manifestation of untreated hemophilia A. It can present with signs of GI obstruction, including abdominal pain, nausea, vomiting and hematemesis. In patients with hemophilia (PWH), intramural hematoma at the juncture of small and large intestines may mimic appendicitis on imaging modalities. Between 1956 and 2022, there have been only 79 reported cases of intramural hematoma in PWH, with a mortality rate of 23.3% in children and 4.9% in adults.[1] . It is thought to be grossly underreported and underdiagnosed due to the lack of CT imaging till late 20^th century. Prompt conservative management with timely Factor VIII administration is crucial to optimizing patient outcomes.

[1] Teng WJ, Kung CH, Cheng MM, Tsai JR, Chang CY. Intramural Hematoma of Gastrointestinal Tract in People with Hemophilia A and B. J Clin Med. 2023 Apr 24;12(9):3093. doi: 10.3390/jcm12093093. PMID: 37176534; PMCID: PMC10179287.

CONCLUSION: It is imperative to investigate unexplained GI bleeding in untreated hemophilia A until diagnosis is established. prompt identification of intramural hematoma and Factor VIII supplementation is lifesaving and spares unnecessary antibiotic/surgical interventions.

INTRIGUING CASE OF HYDRALAZINE-INDUCED CYTOPENIA

Maria Khouri, Srividhya Lakshmanan. Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4063939)

CASE: 92-year-old female with medical history of lung adenocarcinoma in remission, interstitial lung disease (ILD), poorly controlled hypertension (HTN), & chronic kidney disease (stage 3a) presented to emergency department (ED) for shortness of breath. She was found to have acute bronchitis with ILD flare, & uncontrolled HTN. Patient treated with ceftriaxone inpatient and transitioned to cefpodoxime upon discharge for ten days. She was started on prednisone 50 mg daily with taper over next 2 weeks & Hydralazine 50 mg every 8 hours to control her HTN. Two weeks after discharge, her labs showed white blood cell count (WBC) of 10.4 x10⁹/L [absolute neutrophil count (ANC) of 9.0], Hemoglobin level of 12 g/dL, & platelet count of 131 x 10⁹/L. She stopped prednisone, as per tapering schedule.

Two weeks later, home visiting nurse noted that she was ill-looking, pale, and fatigued. Blood pressure was in low 80’s. Labs showed severe leukopenia (WBC of 1.3 x10⁹/L, with ANC of 0) and decrease of Hgb 9.8 g/dL. Her platelets increased to 196x10⁹/L. Patient was transported to the ED. At the ED, she was alert and oriented, afebrile, and not tachycardiac or tachypneic. Review of systems was negative except for fatigue. Patient was compliant with her medications and had not taken any new ones since her hospital discharge. Differential diagnosis for her neutropenia included infection, medication, autoimmune processes, nutritional deficiency, or hematological malignancy. Hydralazine-induced hematological toxicity was highly suspicious given her most recent initiation of the drug. Hydralazine was immediately discontinued. Extensive workup included: peripheral blood smear which revealed no blasts; next generation sequencing, peripheral blood flow cytometry; reticulocyte count, vitamin B12 & folate level. Patient undertook infection screening tests for human-immunodeficiency virus, Hepatitis B & C, tickborne panel, & respiratory viral panel including COVID; quantitative Epstein-barr virus & cytomegalovirus. Results were all normal. Antinuclear antibody & antineutrophil cytoplasmic antibodies were not detected. Patient was started on filgrastim with good response as neutropenia resolved after 3 days.

IMPACT/DISCUSSION: Hydralazine-induced cytopenia was highly suspicious as possible culprit considering the rapid drop over a span of weeks after its initiation. While it has been associated with anemia, hydralazine-related neutropenia is uncommon. This is a diagnosis of exclusion as other more serious causes of neutropenia, including malignancy, infection, autoimmune or nutritional deficiency, must be ruled out beforehand.

Hydralazine should be considered as offending agent when a patient presents with neutropenia. It is important to obtain a complete medical history from patients as this patient’s history was integral to understanding her lab findings.

CONCLUSION: Clinicians should analyze the hydralazine-induced adverse effects before initiating therapy and continue clinical vigilance while patients are on it.

IT'S IN THE DIET - A CASE OF HEMATOCHEZIA SECONDARY TO SCURVY IN A PATEINT WITH SCHIZOPHRENIA

Martin Emmanuel Garcia, Debbie Marie R. Fermin. Internal Medicine, Mount Sinai West Medical Center, New York, NY. (Control ID #4064728)

CASE: 57 year old female with history of schizophrenia presented to the hospital with two episodes of hematochezia. She described them as small amount of bright red blood in her stools. This was accompanied by progressive malaise and fatigue for several weeks. Her diet consisted mainly of bran and milk. Her only medication is Aripiprazole. She was tangential on interview and appeared unkempt, with multiple petechiae and ecchymoses present on the face, neck, and legs. Oral exam showed poor dentition and edematous and erythematous gums. Abdomen was soft, non-tender and non-distended. Rectal exam unremarkable for blood. Leg edema present. Labs showed microcytic anemia of 7.5 mg/dL with iron studies consistent with iron deficiency. Vitamin levels were significant for vitamin C <0.1 mg/dL, B1 and B12, methylmalonic acid, and copper were all normal. Subsequently, hemoglobin decreased to 6.8 mg/dL requiring transfusion with 1 pRBC. She was given IV pantoprazole and IV Vitamin C. She underwent endoscopy and colonoscopy with findings significant for erythematous mucosa in the stomach, a non-bleeding ulcer in the duodenum, and scattered mucosal lesions in the colon suggestive of scurvy. Gastric biospy showed gastritis. Medications on discharge were multivitamins, pantoprazole and iron. She followed up after 2 months with Gastroenterology, hemoglobin improved and stable at 12.7 mg/dL and had no recurrence of GI bleed.

IMPACT/DISCUSSION: Scurvy is an ancient disease that is still present today with a prevalence of 7.1% in the United States and can be more common in patients with psychiatric illness, including schizophrenia. (1) Patients with schizophrenia are at higher risk due to poor dietary habits, believed to stem from the dysregulation of the reward circuitry in the mesolimbic pathway and regions responsible for cognitive control. (3) Vitamin C is crucial in the synthesis of collagen as it activates hydrolases that stabilize the elements within the collagen triple-helix structure. Vitamin C deficiency can cause the small vessels in the skin and mucosa to become fragile, resulting in submucosal hemorrhage in the gastrointestinal tract presenting as either hematochezia or melena. (4) Clinical manifestations of scurvy include anemia, petechiae, gum disease, and poor wound healing. Advanced cases can manifest as widespread edema, hemolysis or acute bleeding. (5) This case highlights the importance of recognizing the signs and symptoms of severe scurvy and understanding the mechanism behind it as it can cause life-threatening bleeding. Management is replacement with oral or intravenous 1-2 g of Vitamin C for the first 3 days, followed by 500 mg for one week then 100 mg daily for 1-3 months. (5)

CONCLUSION: Neuropsychiatric patients are at higher risk for vitamin and nutritional deficiencies due to poor eating habits and would benefit from vitamin supplementation.

Scurvy can manifest as life-threatening gastrointestinal bleeding and therefore early recognition and prevention are important.

IT IS NOT STROKE, IT IS D-LACTIC ACIDOSIS

Amish M. Khan¹; Akul Yajnik¹; Nick Huang¹; Sarah Jones². ¹Medicine, University of Pittsburgh, Pittsburgh, PA; ²General Internal Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4064108)

CASE: Our patient is a 47-year-old male with a history of omphalocele and malrotation status-post Ladd procedure and partial small bowel resection complicated by Short Gut Syndrome. One month prior, he was treated for ischiorectal abscess with incision and drainage and 3-weeks of ertapenem.

The patient presented with 1 week of episodic ataxia, dysmetria, and dysarthria. He has chronic diarrhea with 2-3 watery, brown bowel movements daily. He reports no other focal neurological deficits, sensory deficits, acute changes in vision or hearing, fever or chills. He did not ingest ethylene glycol, ethanol, menthol, salicylates, or acetaminophen. On exam, vital signs were normal. Neurologic exam was notable for a wide-based gait with irregular steps and lateral veering, mild dysarthria and dysdiadochokinesia, and dysmetria.

Serologic workup showed an anion gap metabolic acidosis with a venous pH 7.28, bicarbonate of 15, anion gap of 17, L-lactate 0.9. Stroke imaging was unremarkable. D-lactate level was elevated at 2.06 mmol/L (normal <0.25).

The patient was treated with a 7-day course of metronidazole, low carbohydrate diet, and sodium bicarbonate with complete resolution of symptoms.

IMPACT/DISCUSSION: D-Lactic acidosis presents with episodic neurological symptoms, generally triggered by carbohydrate rich meals. Common neurological sequelae include altered mental status, dysarthria, and cerebellar ataxia.

D-lactate is the stereoisomer of L-lactate and is produced by colonic microbiota. The level of production of D-lactate is determined by two factors:

1. The composition of the gut microbiome. In Short Bowel Syndrome, there is an increased concentration of bacterial species that contain D-lactate dehydrogenase, promoting the production of D-lactate. Prolonged courses of antibiotics, such as the 3-week course of Ertapenem our patient received, may further precipitate shifts in the colonic microbiome.

2. The quantity of carbohydrate substrate delivered to the colon. In Short Bowel Syndrome, incomplete carbohydrate absorption in the proximal bowel leads to increased carbohydrate delivery to the colon.

The standard assay for lactate selectively measures the L-lactate stereoisomer, however, empiric treatment supports the diagnosis of D-lactic acidosis. Antimicrobials with poor oral bioavailability, such as metronidazole and vancomycin, assist to rebalance the colonic microbiome. Thiamine, a pyruvate dehydrogenase cofactor, may assist in shunting D-lactate towards the Kreb Cycle. Sodium bicarbonate inhibits growth of acidophiles, which synthesize additional D-lactate. Lastly, a low carbohydrate diet limits substrate delivery to the colon for conversion to D-lactate.

CONCLUSION: High-index of suspicion for the diagnosis of D-lactic acidosis is warranted in individuals with malabsorptive syndromes, especially after recent antibiotic exposure, who present with dysarthria and ataxia.

D-lactate testing may not be timely or available. Clinical response to empiric treatment supports the diagnosis.

JOINT PAIN? ALSO THINK ABOUT THE GUTS!

Divya Vundamati¹; David A. Feldstein²; Linda Baier²; Keshvi Chauhan³. ¹Internal Medicine, University of Wisconsin-Madison, Madison, WI; ²Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; ³Department of Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4063071)

CASE: A 40yo male with a history of ulcerative colitis presents to the ED five months post curative total colectomy and proctectomy with ileal pouch creation. He complains of three weeks of chills, night sweats, oral ulcers with two weeks of non-migratory arthralgias in bilateral knees, prominent morning stiffness, and abdominal pain with symptom onset post a tick bite. Although Lyme serologies were negative, he was empirically treated with a complete course of doxycycline. Exam was notable for bilateral wrist synovitis, tiny effusions of bilateral knees, significant erythema of bilateral ankle joints, and shallow ulcers on lips and sublingual mucosa. Labs indicated elevated ESR at 85 and leukocytosis with WBC 12.8. Additional tests assessed for other tick-borne illnesses. Rheumatoid factor was negative. Abdominal CT showed thickening of the ileal pouch suggestive of infectious or inflammatory proctitis. Further evaluation revealed an anal fissure and elevated fecal calprotectin. Differential diagnosis included infectious causes (tick borne illness, septic arthritis) versus inflammatory conditions (IBD, lupus, Bechet's). He underwent an ileal pouch endoscopy consistent with deep ulceration in the ileal pouch and neo-terminal ileum and possible rectal fistula. Infectious work up was negative and his constellation of symptoms was considered most consistent with enteropathic arthritis despite previous surgical intervention. Joint symptoms resolved after treatment with oral prednisone and azathioprine.

IMPACT/DISCUSSION: Enteropathic arthritis is a spondylarthritis associated with IBD, and joint involvement is the most common extraintestinal manifestation of IBD. Joint symptoms may predate onset of intestinal manifestations of IBD in about 20% of patients. Symptoms include axial, peripheral, or combined symptomatology which occur more commonly with Crohn’s disease rather than ulcerative colitis. Peripheral arthritis is the most common musculoskeletal manifestation and may follow an oligoarticular or polyarticular pattern. This case changed my approach in patients with spondylarthritis to obtain history including changes in bowel habits, appetite, weight loss, rectal bleeding, oral ulcerations, and perianal pain. Systemic glucocorticoids may be used for acute flares of peripheral joint and inflammatory bowel symptoms. To limit adverse effects, prescribe glucocorticoids at the lowest dose for the shortest time. This patient received 30 mg prednisone and noted improvement within a day. Azathioprine, while efficacious in patients with peripheral arthritis, is not effective to treat axial symptoms of spondylitis.

CONCLUSION: Enteropathic arthritis is the most common extraintestinal manifestation of IBD. Initial treatment for a flare is systemic glucocorticoids, but azathioprine is an effective steroid-sparing treatment in most cases.

KETAMINE IN THE TREATMENT OF STATUS ASTHMATICUS

mohammed Nor¹; John Fomeche²; Forugh Homayounrooz¹. ¹internal medicine, Stamford Hospital, Stamford, CT; ²medicine, Stamford Hospital, Stamford, CT. (Control ID #4064992)

CASE: A 64-year-old male with pulmonary embolism on rivaroxaban, obstructive sleep apnea and severe asthma with two prior intubations during prior admissions presented to the pulmonologist office for subacute asthma exacerbation. Despite being maintained on dupilumab, inhaled steroids, and long-acting bronchodilators, patient deteriorated, and was started on oral steroids and increased albuterol. Presented to pulmonologist's office with escalating symptoms, the patient received Tezepelumab as a trial medication but soon acutely deteriorated. He presented to emergency department (ED) given concern of status asthmaticus and possible superimposed anaphylaxis.

Vitals were BP 129/91 mmHg, pulse 124 bpm,RR 40, and oxygen saturation of 96% on room air. Patient was visibly tachypneic and diaphoretic, with increased use of accessory muscles, and auscultation revealed decreased breath sounds bilaterally, with no audible wheezing. Laboratory results showed a WBC of 13.5 x 10^9/L, ABG with pH 7.39, pCO2 35 mmHg, pO2 58 mmHg, and HCO3 21 mEq/L. Chest X-ray showed hyperinflated lungs, with no other acute abnormalities noted. Despite receiving multiple treatments, including dexamethasone, nebulized therapies, magnesium, and epinephrine, the patient remained in significant respiratory distress. Patient was admitted to ICU for status asthmaticus with concern for impending airway compromise. Given clinical deterioration, initiated ketamine infusion, patient was maintained at arate of 0.3 kg/mg/hr, accompanied by high-dose IV Solumedrol, inhaled corticosteroids, bronchodilators. After a 3-day treatment, his condition markedly improved, with successful de-escalation of the ketamine infusion and systemic IV steroids.

Notably, patient did not require intubation, a contrast to previous admission in which more aggressive measures.

IMPACT/DISCUSSION: Ketamine, a well-known N-methyl-D-aspartate receptor antagonist has emerged as a promising off-label adjunctive treatment for this condition in cases refractory to first-line therapies. It achieves bronchodilation by inhibiting smooth muscle contraction, reducing hyperreactivity, and suppressing inflammation. Its safety profile is largely favorable, though transient hypertension, tachycardia, and psychomimetic effects may occur. Practitioners must be vigilant in monitoring cardiovascular comorbidities and potential neuropsychiatric effects.

CONCLUSION: The initiation of ketamine infusion in this case was vital in achieving bronchodilation and averting respiratory failure, where conventional treatment proved ineffective. This patient's subsequent improvement in respiratory symptoms and vital sign stabilization is evidence of ketamine's therapeutic potential in managing refractory status asthmaticus. While this case lends support to the growing interest in ketamine as a treatment option, further studies and clinical trials are essential to fully assess its efficacy and safety and to identify potential target populations.

LARGE MYCOTIC ANEURYSM WITH RETROPERITONEAL HEMATOMA IN THE SETTING OF LISTERIA BACTEREMIA

Angelina Piryani³; Nikita Piryani¹; Mark Ehioghae¹; Abhijai Singh². ¹Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; ²Internal Medicine, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; ³Ross University School of Medicine, Miramar, FL. (Control ID #4064984)

CASE: A 74-year-old male with a past medical history significant for heart failure, coronary artery disease, peripheral artery disease, diabetes, chronic kidney disease, and pulmonary hypertension presented with fever, SOB, fluid overload, and fatigue. The patient was hypoxic, tachypneic, and febrile. Chest X-ray revealed cardiomegaly with mild pulmonary congestion and possible consolidation in the right midlung. With an admitting diagnosis of community-acquired pneumonia, the patient was started on empiric antibiotics.

On the third day, blood cultures confirmed the presence of Listeria monocytogenes. Given the patient's recurrent Listeriosis and adverse event to ceftriaxone, the patient was transitioned to linezolid. The patient’s platelet counts were closely monitored as he had a history of thrombocytopenia while on the medication.

While on treatment, the patient developed increasing dyspnea and chest pain. A repeat chest X-ray showed new right lung opacities. CT chest without contrast was obtained revealing a new short segment dissection versus an intramural hematoma. CT angiography was deferred secondary to an elevated creatinine. A penicillin challenge was recommended due to concern of endovascular infection, and it was well-tolerated. The patient was switched to IV ampicillin.

On the sixth day of admission, the patient reported new abdominal pain and CT without contrast revealed retroperitoneal hemorrhage and thickening around the abdominal aorta. Stat CT angiography was performed, confirming acute to subacute ulcers in the distal aortic arch and a 4.9 cm irregular ulcer in the suprarenal abdominal aorta. Due to the patient’s comorbidities, surgical intervention was not recommended, and medical management was started involving six weeks of IV ampicillin. Dialysis and antibiotic lines were placed, and the patient received follow-up care from nephrology and physical/occupational therapy. After discharge, the patient continued home health care and outpatient dialysis.

IMPACT/DISCUSSION: Of the 18 cases of infectious aortitis cited in literature, only 9 are reported as abdominal aortic aneurysms. This presentation of Listeriosis is an extremely rare finding. Vulnerable aortic walls due to arteriosclerosis increases the chances of developing a mycotic aneurysm. The bacteria can infiltrate the cardiovascular system including the vaso vasorum of the arterial walls, tunica intima, arteriosclerotic plaques, or thrombus material. The patient’s history of arterial disease placed him at high risk for developing a ruptured mycotic aneurysm.

CONCLUSION: Overall, this case highlights several key learning points. Firstly, awareness for recurrent Listeriosis needs to be increased amongst clinicians. Secondly, early workup for endovascular complications is paramount. Lastly, although worsening complications while on treatment is rare, heightened clinical suspicion for this uncommon presentation of retroperitoneal hemorrhage in the setting of contained abdominal aortic aneurysm is vital.

LATE-ONSET COMPLETE HEART BLOCK REQUIRING PERMANENT PACEMAKER IMPLANTATION AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT.

Prodip Paul¹; Syed Muhammad Hussain Zaidi²; Mishouri Paul¹; Keshav Bhandari¹; Koushik Paul³. ¹Medicine, Geisinger Community Medical Center, Scranton, PA; ²Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ³Geisinger Health, Danville, PA. (Control ID #4061333)

CASE: An 83-year-old female with a significant past medical history of COPD, ischemic stroke, aortic stenosis status post TAVR 5 months ago, hypertension, hyperlipidemia presented to the emergency room after a fall at home. Patient reported that she felt dizzy and fell, unsure about the loss of consciousness. She was evaluated by the Trauma Surgery team and cleared from a trauma standpoint. While in the bathroom in the ER, she felt dizzy and had another fall. On telemetry monitoring, she was noted to have a transient 3rd-degree AV block with no clear escape rhythm lasting for about 7 seconds. Her labs revealed hypokalemia 3.2 mmol/L and Mg of 1.2 mg/dL. Electrophysiologist was consulted, TSH and Lyme panel were pending, electrolytes were supplemented, and dopamine infusion was started. She had another episode of AV block, just a few minutes after initiating dopamine. The cath lab team was activated with the plan to take the patient in for an emergent transvenous pacemaker (TVP) placement. While that was being done, the patient went into AV block again, with an unresponsive episode and loss of pulse, code blue was called in and CPR was initiated for <1 minute with starting cutaneous pacing after which she regained pulses and consciousness. The patient then underwent emergent TVP placement. She underwent a permanent pacemaker placement and was discharged in stable condition on the fourth day of hospital admission.

IMPACT/DISCUSSION: One of the major complications with TAVR is the damage to the conduction system. Therefore, it's not surprising that AV block is recognized as a complication of TAVR and most high grade atrioventricular block(HAVB) occurs within 48 hours of the procedure. Few studies have focused specifically on late-onset HAVB. Pacemaker implantation usually occurs within 14 days post-TAVR and has been associated with an increased mortality. In our patient , other reversible causes of heart block including thyroid disease and Lyme disease were ruled out. It was determined to be a significant late complication of TAVR which is a rare occurrence. Studies have shown that patients who require post-TAVR PPM implantation may be at higher risk of short- and long-term morbidity and mortality. Our patient's symptoms improved significantly post pacemaker implantation. Late onset bradycardia causing heart block requiring permanent pacemaker is a rare complication which should be in differential for such patients presenting with late Post-TAVR heart block symptoms.

CONCLUSION: Post-TAVR atrioventricular block requiring PPM placement remains a common complication. Remote ambulatory cardiac monitoring, especially in the first 2 weeks after discharge, may be needed. Post-TAVR complications of heart block should be a differential in patients presenting months later with symptoms related to bradyarrhythmia.

LEADLESS PACEMAKER IMPLANTATION FOR ATRIOVENTRICULAR BLOCK DUE TO STREPTOCOCCUS GALLOLYTICUS ENDOCARDITIS COMPLICATED BY AORTIC ROOT ABSCESS

Matthew Sangoi^2,1; Andrew Murphy^2,1; Maxwell Ambrosino^3,1; Nasser Monzer^2,1; Balaram Krishna Hanumanthu^2,1; Jeffrey Luebbert^2,1. ¹Internal Medicine, Penn Medicine, Philadelphia, PA; ²Internal Medicine, Pennsylvania Hospital, Philadelphia, PA; ³Internal medicine, Pennsylvania Hospital, Philadelphia, PA. (Control ID #4064930)

CASE: We present a 78-year-old male with a bioprosthetic aortic valve, ischemic cardiomyopathy and atrial fibrillation who presented with altered mental status and syncope. He was admitted for septic shock due to Streptococcus Gallolyticus bacteremia. Initial electrocardiogram showed marked first-degree atrioventricular (AV) block and right bundle branch block. Transthoracic echocardiogram was unrevealing. While admitted, he progressed to Mobitz II second-degree AV block and had an episode of symptomatic high-grade AV block requiring temporary transvenous pacing. Follow up transesophageal echocardiogram revealed native mitral valve vegetations and an aortic root abscess. He was planned for long-term IV antibiotics due to high perioperative surgical risk. A leadless pacemaker was pursued given the risk of infection with transvenous pacing leads. Intracardiac echocardiography (ICE) revealed bioprosthetic aortic valve vegetations and redemonstrated a perivalvular aortic root abscess. The ICE catheter was used to guide pacemaker implantation along with fluoroscopy. He underwent an electrophysiological study at time of implantation, which demonstrated AV nodal delay and high risk of developing third-degree AV block. A St. Jude leadless pacemaker was implanted in the mid-right ventricular septum with appropriate sensing and thresholds. No complications and normal device function at 1-year follow up.

IMPACT/DISCUSSION: Atrioventricular (AV) block is a known complication of perivalvular aortic abscess in the setting of infective endocarditis. Management of this conduction deficit typically involves antibiotic therapy, surgical evaluation, and permanent transvenous pacing. Leadless pacemakers provide an alternative for transvenous systems in patients with prohibitive surgical risk who need permanent pacing with active infective endocarditis. We demonstrate successful ICE-guided leadless pacemaker implantation for AV block in a patient with native mitral valve and bioprosthetic aortic valve Streptococcus Gallolyticus endocarditis complicated by an aortic root abscess.

CONCLUSION: This case highlights the efficacy and safety of ICE-guided leadless pacemaker implantation in patients with infective endocarditis complicated by AV block who are not candidates for surgical source control.

LEFT ATRIAL MYXOMA PRESENTING AS TRANSIENT ISCHEMIC ATTACK

Mohammed Abdelsalam¹; Alex Collins³; Onyinye Ugoala³; Rajesh Nambiar²; Agustin Cabrera². ¹Internal medicine, Texas Tech University System, Lubbock, TX; ²Amarillo Heart Group, Amarillo, TX; ³Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX. (Control ID #4064821)

CASE: A 59-year-old female with a past medical history of hypertension and obesity presented to the ER with her family after she started feeling weakness in her right hand along with dysarthria as she was preparing dinner. Symptoms resolved shortly afterwards. She denied previous similar episodes, focal loss of sensation, blurry vision, diplopia, gait ataxia, chest pain, palpitation, and dyspnea. Vital signs were normal and physical exam was remarkable for mid-diastolic murmur. CT brain revealed mild chronic small vessel disease, a small old lacunar infarct in the right cerebellar hemisphere but no acute intracranial abnormality. CT angiogram did not show any significant vascular stenosis. MRI brain showed acute to subacute left cerebral infarcts suggesting an embolic source. Transesophageal echocardiogram exhibited large left atrial mass with prolapse across the mitral valve plane. Atrial mass resection with atrial appendage occlusion was done. Pathology of the tissue was consistent with atrial myxoma with associated chronic inflammation. Postoperatively she developed atrial fibrillation which improved with amiodarone and digoxin and she was discharged home after a week from admission.

IMPACT/DISCUSSION: Myxomas are the most common primary cardiac tumor. They usually occur between the 4^th and 6^th decade of life more in females than males. They consist of scattered cells within mucopolysaccharide stroma. More than 75% of myxomas are located in the left atrium at the mitral annulus or at the fossa ovalis border of the interatrial septum. 20% of myxomas arise in the right atrium. Myxomas are usually pedunculated and gelatinous with smooth, villous or friable surface. The diameter ranges from 1 to 15 cm. 35% of myxomas are villous or friable and are associated with embolic events. Smooth myxomas are usually large and associated more with cardiovascular symptoms. 67% of patients with myxoma show obstruction symptoms including dyspnea, orthopnea and pulmonary edema while 29% present with systemic embolization and 20% show neurological deficits as in this case. Systemic embolization occurs more in males. Constitutional symptoms including fever and weight loss are commonly seen. Echocardiography is the diagnostic modality of choice particularly transesophageal echo. Coronary angiogram can be done in patients undergoing surgical resection to assess the tumor’s blood supply. Prompt surgical excision is the treatment of choice due to the high risk of embolization and cardiovascular complications including sudden death. The result of surgical excision is excellent with mortality rate below 5%. Recurrence rate in sporadic myxomas is 1%-3%..

CONCLUSION: Myxomas are benign cardiac neoplasm that can present with neurological deficits including TIA as in this case. surgical resection is the main treatment with very good prognosis and very low operative mortality.

LEMIERRE IS HERE: AN UNUSUAL ABDOMINAL VARIANT OF LEMIERRE’S SYNDROME

Richard Lowell T. Barr, Benjamin Fuller, Milad Memari. Internal Medicine, University of Virginia, Charlottesville, VA. (Control ID #4061942)

CASE: A 30 year old previously healthy male presented with subacute (7-day) onset of fatigue, rigors, and night sweats with progressive development of cough, sore throat, nausea, vomiting, 20 lb unintentional weight loss, and right upper quadrant pain. He reported no significant past medical history and took no medications prior to presentation. He endorsed drinking 15 alcoholic beverages per week, had no high risk social behaviors, no travel history, no occupational exposures, and his only outdoor activity was golf. Vitals on admission were remarkable for fever, tachycardia, and tachypnea. The patient was mildly distressed, tachypneic, and actively rigoring during the initial exam, which was otherwise remarkable for bilateral diffuse rhonchi and a non-tender, mildly distended abdomen. The complete blood count was remarkable for mild thrombocytopenia and complete metabolic panel revealed a fluid-responsive acute kidney injury, unremarkable electrolytes, a total bilirubin of 1.5 mg/dL, and mild transaminitis. A computed tomography (CT) scan of the chest, abdomen, and pelvis were remarkable for multifocal pneumonia and multiple hepatic hypodensities, further characterized on abdominal ultrasound as hepatic abscesses. The patient was admitted and started on broad spectrum antibiotics. Two sets of blood cultures drawn on admission resulted growing Fusobacterium necrophorum, as did a culture obtained from IR-guided aspiration of one hepatic abscess. The patient clinically improved with ampicillin-sulbactam, but continued to fever, prompting repeat imaging on hospital day 9, which revealed a new right hepatic vein thrombosis. After starting therapeutic anticoagulation and broadening antibiotics to ceftriaxone and metronidazole, he defervesced. He was discharged on apixaban with a plan for 4 weeks of IV antibiotics. Of note, no clear source was found for infection, with unremarkable neck CT and normal upper and lower endoscopies, and was presumed secondary to pharyngitis, as evidenced by sore throat which began concurrently with other systemic symptoms.

IMPACT/DISCUSSION: Our case describing disseminated F. necrophorum infection associated with hepatic vein thrombophlebitis demonstrates an abdominal variant of Lemierre’s syndrome as a cause of severe sepsis in an otherwise healthy young adult. Although previously described in several case reports, these cases developed as a result of a clear preceding source of infection. Our patient, on the other hand, had no source identified on imaging or endoscopy. Our case adds to the literature by demonstrating a case of abdominal Lemierre’s syndrome without clear evidence of preceding infection and highlights the need to include F. necrophorum in the differential when approaching young patients with sepsis.

CONCLUSION: - Our case demonstrates an abdominal variant of Lemierre’s syndrome as the cause of sepsis in an otherwise young, healthy patient

- Our case highlights that Lemierre’s syndrome can occur without clear evidence of preceding infection.

LEPTOSPIROSIS IN THE MID-ATLANTIC UNITED STATES: A RARE CASE OF HYPERBILIRUBINEMIA, PULMONARY HEMORRHAGE, THROMBOCYTOPENIA, AND ACUTE RENAL FAILURE

Shelley Verma, Prakruti Pandya, Amna Shah, Aashi Parashar, Akash Parashar, Diana Pomakova. Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY. (Control ID #4042732)

CASE: A 30-year-old white male living in the Mid-Atlantic USA presented after 4 days of high-grade fever, generalized myalgia, jaundice, and hemoptysis. He denied chest pain, dyspnea, abdominal pain, or bladder/bowel symptoms. He worked in construction/landscaping and had no recent travel or insect/animal bites. He was a former smoker with occasional alcohol use and no illicit drug use. He had a past medical history of Hashimoto's disease, diagnosed 1 year prior. His mother and brother had hypothyroidism. He took daily cholecalciferol and levothyroxine as instructed. Physical examination revealed fever (38.4 C); other vitals were stable. He was jaundiced and had right lung crepitation. Studies revealed hypokalemia (2.8 mEq/L), leukocytosis (12.0 billion/L), thrombocytopenia (96,000 billion/L), acute renal failure (BUN 42 mg/dL, creatinine 2.11 mg/dL), hyperbilirubinemia (total 11.7 mg/dL; direct 6.7 mg/dL), and rhabdomyolysis (CPK 3,099 mcg/L). Abdominal CT and ultrasound were unremarkable. CT chest revealed bilateral ground-glass pulmonary opacities, suspicious for hemorrhage or unusual infection. Ceftriaxone and doxycycline were initiated for suspected community-acquired pneumonia. Tests for most infections, autoimmune hepatitis, hemolytic anemia, and vasculitis were negative. The patient recovered in 3 days and was discharged on doxycycline. Post-discharge, leptospirosis PCR from both urine/blood were positive. On follow-up, the patient’s symptoms resolved with 3 weeks of doxycycline.

IMPACT/DISCUSSION: Hyperbilirubinemia without biliary obstruction yielded a differential of babesiosis, leptospirosis, Lyme disease, syphilis, HIV, hepatitis, and vasculitis. Our patient's hyperbilirubinemia with acute renal failure, thrombocytopenia, and pulmonary hemorrhage represents Weil’s disease, a severe form of leptospirosis. Treatment consists of doxycycline for mild cases and penicillin G/ceftriaxone/cefotaxime for severe cases (10-15% mortality rate). Leptospirosis occurs mainly in tropical/subtropical regions. The USA has 100-200 annual cases, with the majority in Puerto Rico/Hawaii and only 5-15 in the temperate-zone Mid-Atlantic. Cases are underrecognized due to mild/non-specific symptoms and fewer cases in temperate zones. Improvement in recognition is needed as leptospirosis cases are anticipated to increase via urbanization and climate change (increased rainfall/floods) with leptospire survival in warmth and humidity. Exposure to water contaminated by infected animal bodily fluids (via recreation, construction/landscaping, sanitation/plumbing, military, or animal-related fields) may be key to diagnosis.

CONCLUSION: Leptospirosis may present with fever, hyperbilirubinemia, pulmonary hemorrhage, thrombocytopenia, acute renal failure, hypokalemia, cardiovascular failure, or neurologic changes. Leptospirosis is anticipated to increase outside of tropical zones and warrants a high degree of clinical suspicion, especially with occupational or recreational exposure to contaminated water.

LET IT PASS: A CASE OF SHIGELLA FLEXNERI CAUSING TOXIC MEGACOLON

Tatyana Nguyen¹; Hannah Nguyen²; Sayari Patel¹; Pranay Sinha³. ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Chobanian & Avedisian School of Medicine, Boston University, Boston, MA; ³Infectious Disease, Boston Medical Center, Boston, MA. (Control ID #4057739)

CASE: A 44-year-old man with high-risk sexual activity (MSM) on Emtricitabine/Tenofovir for pre-exposure prophylasix presented with ten episodes of watery diarrhea daily for two weeks, associated with diffuse progressively worsening abdominal pain and nausea. He reported anal and oral receptive sex one week prior to the onset of symptoms. Initial labs were notable for leukocytosis of 19.2 K/UL, platelet 617 K/UL, and sodium of 120 mmol/L. A multiplex stool PCR detected Shigella species without Shigatoxins 1 and 2. He was initially treated with 3 days of azithromycin, then 3 days of ceftriaxone before stool culture-confirmed XDR Shigella flexneri. He received 3 days of ertapenem and was discharged with 4 days of fosfomycin. Alongside antibiotics, he received loperamide 16mg/day for symptom control which he took liberally. He returned within a week with worsening abdominal pain, distension and was found to have toxic megacolon. His blood work was unremarkable, there was no leukocytosis. His stool PCR of common gastroenteric bacteria and viral, stool oval, and parasite were all negative. Obstipating agents were discontinued, a rectal tube was placed for 24 hours to decompress the distention, and he received 5 days of ertapenem with good effect. He was then discharged home.

IMPACT/DISCUSSION: In recent years, there is increased incidence of XDR Shigella species causing severe diarrheal illness complicated by bacteremia and even toxic megacolon in immunocompetent adults. Given the potential for severe complications, testing for drug-resistance through culture-based method is important, as there is increasing resistance to third generation cephalosporins, fluoroquinolones and macrolides. However, in patients with severe Shigellosis without stool culture, data from an epidemiological study in the UK suggests treatment with a carbapenem in hospitalized patients and fosfomycin for step down treatment. In this case, the culture showed susceptibility to meropenem, inferring susceptibility to ertapenem. The patient was treated accordingly and transitioned to fosfomycin when discharged.

Loperamide was prescribed for symptomatic management. However, as he presented the second time with colonic distention and unremarkable studies, it is thought that the toxic megacolon was resulted from the use of antimotility agents that reduced bacterial clearance from the colon, prolonging the inflammation, particularly before he received effective antibiotics. We speculated that this likely allowed the bacteria to invade the colonic mucosa and smooth muscle layer, reducing peristalsis and leading to colonic dilation.

CONCLUSION: Given the increase in XDR Shigella species and the potential for severe complications, testing for drug resistance through culture-based measures is important. Further, even in toxin-negative species of Shigella, antimotility agents should be used sparingly.

LETTING THE CAT OUT OF THE BAG: SUBACUTE ENDOCARDITIS PRESENTING WITH EYE PAIN AND WEIGHT LOSS

Roger Tieu¹; Ilias Christodoulou²; Zhexi Lu²; Alyssa Kelder²; Jennifer A. Corbelli¹. ¹Medicine, University of Pittsburgh Department of Medicine, Pittsburgh, PA; ²Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4063508)

CASE: A 42-year-old man with history of surgically-repaired tetralogy of Fallot, Strep endocarditis, bioprosthetic pulmonary valve and positive lupus anticoagulant not on anticoagulation presented with two months left conjunctivitis, malaise, and unintentional 30lb weight loss. He was afebrile without lymphadenopathy. A 3/6 pan-systolic murmur at left upper sternal border was noted. His was WBC 16.3, and blood cultures were persistently negative. TEE showed an 11mm mass on the pulmonic prosthetic valve and a 7mm mass on the tricuspid. CTA showed chronic PE and a new 6mm left-lung nodule concerning for septic embolus. Ophthalmology attributed this conjunctivitis to mechanical irritation. Antibiotics were deferred initially given clinical stability and persistently negative blood cultures. Vegetation extraction was not pursued due to his complex cardiac anatomy. Valve thrombosis was deemed less likely given the thrombi’s location in high blood flow areas. Doxycycline, daptomycin, and ceftriaxone were started. Within 24 hours, improvement of eye pain, and malaise, was noted. On day 12, labs resulted a positive IgG to Bartonella, and gentamicin was added per AHA guidelines. Further history revealed that the patient owned three cats and had flea infestation of his home two months before symptom onset. PCR resulted Bartonella henselae. The final diagnosis is Bartonella endocarditis with cats as the vector. He remained medically stable and was discharged home with antibiotics and close follow-up including consideration of future replacement of his prosthetic pulmonic valve.

IMPACT/DISCUSSION: We describe the development of infective endocarditis in a patient with an extensive cardiac surgical history after Bartonella exposure. In the setting of new vegetations on right-sided heart valves, CTA demonstrating chronic PE, and positive Lupus anticoagulant, our differential was broad, including thrombi vs bacterial vs fungal vegetations. Given the location of vegetations in high flow areas, subacute bacterial endocarditis seemed more likely despite persistently negative blood cultures. In retrospect, our patient’s left ocular symptoms which quickly improved with antibiotics likely represented a component of Parinaud's oculoglandular syndrome, an atypical form of cat scratch disease from Bartonella infection. This case stresses vigilance for endocarditis in at-risk individuals, urging broad antibiotic use for culture-negative cases to target various organisms. It also demonstrates how cat scratch disease can manifest systemically with multi-organ involvement, as compared to the regional lymphadenopathy alone which is more classic and well-known.

CONCLUSION: Fastidious organisms, including Bartonella, should be considered in patients with indolent infective endocarditis and negative blood cultures. Ocular findings should raise suspicion for cat-scratch disease.

Bartonella endocarditis is diagnosed with serum antibody testing and PCR confirmation and is treated with gentamicin with doxycycline.

LITHIUM INDUCED HYPERCALCEMIA?: ASSESSING THE DIFFERENTIAL DIAGNOSES OF HYPERCALCEMIA

Abbie West, Nirosha Adepu. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4057650)

CASE: 59 y/o female with Alzheimer’s, chronic kidney disease, and schizoaffective disorder admitted for hypercalcemia. Initial corrected calcium was 14.7mg/dL. History unobtainable due to Alzheimer's. She resided at a facility, where staff reported she had been less interactive. Admitting labs showed creatinine of 3.87mg/dL, baseline ~1.5mg/dL. She was treated with intravenous fluids, calcitonin, and bisphosphonates. Endocrinology and nephrology were consulted. Workup revealed normal parathyroid hormone (PTH), normal parathyroid hormone related peptide (PTHrP), and normal serum/urine protein electrophoresis. Imaging included a negative parathyroid sestamibi scan and MRI neck for parathyroid adenoma or malignancy. Further workup showed mildly elevated angiotensin converting enzyme (ACE) of 108U/L and elevated 1,25-OH Vitamin D3 at 102pg/mL, concerning for sarcoidosis. CT chest showed mildly enlarged mediastinal lymph nodes. Lymph node biopsy was attempted but consent was unobtainable, so she was empirically started on 40mg of oral prednisone for possible sarcoidosis. Calcium improved but slower than expected, leading to consideration of other differentials like primary hyperparathyroidism due to non-suppressed PTH levels. Cinacalcet was started. As calcium improved, she became more alert and interactive, later discharged back to her care facility with endocrinology follow up.

IMPACT/DISCUSSION: This case demonstrates the importance of considering multiple differential diagnoses when caring for patients, especially those with cognitive concerns. One of the first differentials was hypercalcemia of immobility due to Alzheimer’s. Others included hypercalcemia of malignancy, multiple myeloma, and primary hyperparathyroidism, for which workup was unrevealing. Sarcoidosis was considered but given slow response to steroids and inability to obtain biopsy, primary hyperparathyroidism was thought the next most likely diagnosis due to non-suppressed PTH. Medication induced causes were also investigated. Chart review noted prior lithium use for schizoaffective disorder but discontinued in 2009 due to supratherapeutic levels. From literature search, we discovered lithium can cause permanent parathyroid gland changes, leading to hypercalcemia even with normal PTH. Final diagnosis was hypercalcemia from prior lithium use and suspected primary hyperparathyroidism. Working through this multitude of differentials shows the importance of not anchoring on any one specific finding but considering all clinical components when formulating a final diagnosis and treatment plan.

CONCLUSION: In conclusion, this case shows the importance of having a wide range of differential diagnoses and always considering other possibilities if clinical workup does not initially fit with the leading diagnosis.

LOW-DOSE INITIATION OF BUPRENORPHINE IN A HOSPITALIZED PATIENT WITH ACUTE PAIN

Kaila Cohen¹; Mahnoor Khurshid³; Daniel Wesley²; Sumitha Raman¹; Jillian S. Catalanotti¹. ¹Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; ²Psychiatry, Saint Elizabeth's Hospital, Washington, DC; ³Edward Via College of Osteopathic Medicine, Blacksburg, VA. (Control ID #4028127)

CASE: A 34-year-old woman who injects opioids presented with leg pain, weakness, incontinence and inability to walk. Six weeks prior, she was hospitalized for MRSA osteomyelitis but left before completing antibiotics. MRI revealed epidural abscess with cord compression requiring surgery. Pain control was difficult given severe infection, high tolerance, and hyperalgesia. We maximized non-opioids and gave hydromorphone (HM). She expressed interest in MOUD. While maintaining a constant dose of HM, we started buprenorphine-naloxone 0.5-0.125mg SL daily with up-titration per 7-day protocol to 8-2mg SL BID. Day 8, we stopped HM and increased buprenorphine-naloxone to TID. She did not show signs of withdrawal and achieved adequate pain control. We sought discharge to a skilled nursing facility (SNF); they declined due to MOUD. We provided education and resources to SNF and she was accepted. She was discharged to complete rehabilitation and antibiotics while continuing MOUD.

IMPACT/DISCUSSION: Our patient’s OUD was initially untreated - withdrawal likely led to unplanned discharge and inadequately treated infection. In one study, people who inject drugs (PWID) were 4x more likely to have unplanned discharges, with poorer outcomes upon re-admission. On re-presentation, risk for unplanned discharge was high. Withdrawal mitigation and pain control were crucial components in her infection care.

Traditionally, initiating MOUD requires 12 hours of opioid abstinence and symptoms of moderate withdrawal - a barrier for patients with underlying pain. Low-dose initiation is an alternative that allows patients to continue full-agonist opioids, attempting to avoid withdrawal while slowly replacing full-agonist mu-receptor ligands with buprenorphine. Hospitalists treating patients with coexisting OUD and pain should feel empowered to use this method.

Hospitalization is a critical time to engage patients in MOUD initiation, but discharging patients newly initiated on MOUD to SNF can be challenging due to stigma, discrimination and lack of knowledge. As of 2022, any provider with a full DEA license may prescribe MOUD. Educating hospital and SNF case managers may improve willingness to accept those discharged on MOUD. SNFs in our area do not regularly stock MOUD, however patients can be transferred from the hospital with a 30-day prescription or medication supplied before discharge. Pharmacies with courier services have also delivered MOUD to SNFs. Discharging with information to book MOUD follow-up may ease concerns about transition on the back-end.

CONCLUSION: Because many patients with OUD do not access regular care, initiating MOUD inpatient with linkage to follow up is considered best practice. Low-dose MOUD initiation can be effective for inpatients requiring opioids for acute pain. Open discussion, education and resource sharing with local SNFs may improve their willingness to admit MOUD patients and ease care transitions.

LUMPS, BUMPS, AND…NOT MUMPS? AN ATYPICAL PRESENTATION OF NONRADIOGRAPHIC ANKYLOSING SPONDYLITIS

Alyssa Kelder¹; Aimee N. Pickering². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4057939)

CASE: A 27-year-old male with a history of psoriasis and migraines initially presented with intractable neck pain, headache, and fever for one week. Labs were notable for WBC 12.2, CRP 7.9, ESR 45. Lumbar puncture demonstrated WBC 26, RBC 82, protein 64.8, glucose 66, negative gram stain. MRI demonstrated leptomeningeal enhancement concerning for meningitis and the patient was empirically started on IV acyclovir. Infectious work-up for aseptic meningitis was negative aside from HSV PCR and viral culture which never resulted. On day two of admission, the patient developed ankle and back pain, which prompted a shift in focus to a rheumatologic work-up. The patient had a positive ANA 1:1280, but work-up was negative for RF, SLE, vasculitis, sarcoidosis, and HLA B27. Though the patient’s MRI was atypical for HSV encephalitis, his marked improvement on IV acyclovir and lack of alternative etiology led us to discharge him with a 21 day course of valacyclovir.

The patient then re-presented three days later with fever, polyarthralgia, low back pain, parotitis, epididymitis/orchitis, and anterior uveitis. Initial concern was for mumps, but serology was negative. Pelvic MRI was performed due to concern for ankylosing spondylitis and was negative. Ultimately, his syndrome was attributed to seronegative spondyloarthropathy, specifically nonradiographic ankylosing spondylitis. He improved clinically without intervention and was discharged with rheumatology follow-up.

IMPACT/DISCUSSION: The main consideration in our initial approach to this patient was whether the etiology of his aseptic meningitis was infectious or noninfectious. The patent was appropriately started on IV acyclovir according to the Reller Criteria, which recommends empiric acyclovir with any one of the following: CSF cell count >5, CSF protein >50, immunocompromise, or age <2. However, when he began to display signs of non-infectious etiology, we shifted our focus toward rheumatologic causes. Seronegative spondyloarthropathy became the leading diagnosis after the patient re-presented with uveitis, orchitis, and parotitis, which are uncommon but possible presenting signs of seronegative spondyloarthropathies. This case demonstrates the importance of avoiding premature closure and considering non-infectious etiologies when faced with aseptic meningitis.

CONCLUSION: Rheumatologic diseases are an important and often-forgotten cause of aseptic meningitis.

Though aseptic meningitis has a variety of non-infectious causes, HSV meningoencephalitis has a high mortality rate if left untreated and IV acyclovir should be started early if clinical suspicion is present.

LYSIS CRISIS: INTRAMEDULLARY HEMOLYSIS IN SEVERE VITAMIN B12 DEFICIENCY

Farhana Begum¹; Harrison Labban²; Awais Paracha¹; Mohammed M. Islam¹. ¹Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; ²Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY. (Control ID #4047755)

CASE: 60 yo M with no PMH was admitted due to anemia who reported loss of appetite, dyspnea on exertion, nocturia, lightheadedness, fevers, and a 6lb weight loss over 2 months. His primary care physician identified a hemoglobin level of 5 and recommended ED evaluation.

Initial Vital Signs notable for tachycardia (HR=110). Physical examination was notable for mild scleral icterus. Laboratory findings demonstrated pancytopenia with a hemoglobin level of 5.3 (MCV 120), WBC count of 3.21, and platelet count of 55. Hemolysis markers were elevated (LDH at 3111, haptoglobin <20, positive direct Coombs), while ferritin levels were normal. Despite unclear iron studies due to post-transfusion status, AST was elevated at 67, and total bilirubin was 1.6. Negative tumor lysis labs were reported, and CT A/P with IV contrast revealed short-axis retroperitoneal and mesenteric lymph nodes.

The patient received 3 units of pRBCs, experiencing rapid symptom improvement. A single dose of IVIG was administered for potential ITP. Subsequent tests revealed normal folate levels but severely low B12 levels (<150). Elevated homocysteine (96.8) and methylmalonic acid (15,383) levels, along with positive intrinsic factor and mildly positive parietal cells antibodies, confirmed a diagnosis of pernicious anemia. IVIG treatments were discontinued, and the patient commenced high-dose B12 injections for seven days, maintaining stable Hgb levels at 8 upon discharge, with a lifelong B12 injection plan in place.

IMPACT/DISCUSSION: While mild B12 deficiency manifests as megaloblastic anemia and demyelination-related neurological symptoms, severe deficiency can present with hemolysis and pancytopenia, mimicking conditions like TTP or leukemia.1 Unique characteristics of B12-associated pancytopenia include a low reticulocyte count and markedly elevated LDH levels, indicative of the intramedullary hemolysis observed in both pernicious anemia and diet-related B12 deficiency cases. The thrombocytopenia and leukopenia can also be explained by the fact that Cobalamin has a central role in in DNA synthesis, and thus hematopoiesis.2

Advanced B12 deficiency induces intramedullary hemolysis, leading to peripheral pancytopenia. Fragile RBCs are prone to shearing, producing schistocytes, while the lack of B12 inhibits erythropoiesis, resulting in a low reticulocyte count, distinguishing it from other hemolytic anemias.2

Hyperhomocysteinemia secondary to B12 deficiency may also contribute to hemolysis via cytotoxicity, inducing oxidative stress and endothelial damage. This oxidative stress leads to RBC shearing and further contributes to hemolysis.2 In summary, assessing B12 levels should be a part of the routine hemolysis and pancytopenia workup.

CONCLUSION: Severe B12 deficiency should be considered in hemolytic anemia cases with elevated MCV and low reticulocyte count.

MAGNESIUM MATTERS: RENAL WASTING AND NOVEL MANAGEMENT STRATEGIES

Aditi Kothari, Lakshmi Prasanna Vaishnavi Kattamuri, Shivangini Duggal, Sparsha Reddy Duvvuru, Angelica Lehker. Internal medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX. (Control ID #4065003)

CASE: 47-year old male with a significant past medical history of decompensated cirrhosis due to alcohol use disorder presented with seizures. He was hemodynamically stable at presentation. Blood work was unremarkable except for hypomagnesemia. Patient was started on intravenous levetiracetam and lacosamide for seizures and lactulose for hepatic encephalopathy. Persistent hypomagnesemia and hypokalemia were noted. Hypomagnesemia was attributed to be multifactorial from diarrhea due to lactulose use, proton pump inhibitor (PPI) for duodenal ulcer and chronic alcoholism. Despite correcting for all of the above factors, hypomagnesemia persisted. PPIs were discontinued and he was switched to famotidine. Upon further investigation, 24 hour urinary magnesium was elevated (500 mg/g). The patient’s serum magnesium remained low despite regular oral and intravenous replacement. In view of severe intracellular magnesium depletion and renal magnesium wasting, the patient was started on an intravenous magnesium drip for 24 hours for slow replacement, followed by oral magnesium supplementation. Amiloride and empagliflozin were added to reduce renal magnesium wasting. Patient clinically responded and magnesium levels improved

IMPACT/DISCUSSION: Hypomagnesemia is common in alcoholic patients with a prevalence of 30% and is due to secondary urinary excretion from the tubule dysfunction induced by alcohol. The diagnosis hinges on whether magnesium (Mg) losses stem from renal (urinary) or gastrointestinal sources. Serum Mg level measurement is not routinely conducted in everyday clinical practice but is selectively employed in arrhythmias, neuromuscular disturbances, malabsorption disorders, nutritional deficiencies, chronic alcohol use, or unexplained hypokalemia or hypocalcemia. However, serum Mg has its limitations in correlating with intracellular and total body magnesium stores. A 24-hour urine mg value exceeding 2 mEq or a fractional excretion greater than 3-4% indicates renal mg wasting, while lower values suggest insufficient magnesium intake or gastrointestinal losses. The fractional excretion of Mg (FEMg) is sometimes calculated to distinguish between renal and non-renal causes. In addition to common medications such as proton pump inhibitors, uncommon genetic syndromes, such as Gitelman syndrome, can lead to renal magnesium wasting. For asymptomatic chronic hypomagnesemia, oral Mg preferably in sustained-release formulations, it’s the preferred therapy to ensure slow absorption, preventing a rapid increase in blood concentration and maintaining a favorable gradient for reabsorption in the limb of Henle. Intravenous Mg indicated in life-threatening and severe hypomagnesemia. Amiloride and SGLT-2 are promising options for reducing renal wasting of Mg.

CONCLUSION: An overlooked electrolyte disorder necessitates thorough investigation to uncover its etiology and ensure proper treatment.

MASQUERADING HYPERFERRITINEMIA: A MYSTIFYING CASE OF RECURRENT HLH

Samira M. Samant. Internal Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA. (Control ID #4064993)

CASE: A 40 year old male with a history of gout and hypertension presented to the ED with 3 weeks of dyspnea and fevers despite outpatient antibitoics. Labs revealed leukopenia to 3.2 K/uL, thrombocytopenia to 115 K/uL, and transaminitis with AST 641 U/L and ALT 405 U/L. Chest CT revealed a 1.7 cm right middle lobe nodule, thought infectious. A broad bacterial, viral, and fungal pneumonia workup, along with autoimmune screening, was negative. Given travel to Vegas and Hawaii, Bartonella, Coxiella, and Rickettisial antibodies were added. Inflammatory markers revealed ferritin 102,237 ng/mL, with LDH elevated to 5,365 U/L. Parasitic smears and parvoviral screen were sent to rule out hemolytic anemia; empiric doxycycline was started. A blood smear was without blasts or hemophagocytosis, however the negative infectious workup and hyperferritinemia were concerning for HLH. Triglycerides were found to be 776 mg/dL, and fibrinogen 429 mg/dL. Bone marrow biopsy revealed hemophagocytosis, and ruxolitinib and dexamethasone were initiated. CSF flow cytometry and liver biopsy were negative for malignancy, and he was discharged on ruxolitinib and a prednisone taper.

He returned 16 days later with fever of 102.2 F, thrombocytopenia to 76 K/uL, and worsening transaminitis with AST 1228 U/L and ALT 794 U/L. Ruxolitinib was transitioned to etoposide with high-dose steroids. Normalizing ferritin suggested depleted macrophages and worsening disease. A negative genetic panel indicated secondary HLH, and IR biopsy of the lung nodule revealed Hodgkin’s lymphoma. His multiorgan failure necessitated ICU transfer for CRRT, and he developed neurologic collapse due to a large necrotic anterior lobe CNS lesion concerning for intracranial HLH with associated herniation, which proved fatal.

IMPACT/DISCUSSION: Immune hyperactivation in HLH results in persistent activation of cytotoxic T cells, macrophages, and natural killer cells, creating a cytokine storm that produces multiorgan dysfunction and mimics other systemic illnesses, masking the true diagnosis. Elevated ferritin and triglycerides, with low fibrinogen, are classic markers. Primary (familial) HLH is treated with chemotherapy as a bridge to stem cell transplantation; secondary HLH requires immunosuppression and management of the underlying disease. Unfortunately, HLH is so catastrophic that even despite timely diagnosis and treatment it is often fatal; more than 10% of patients die within the first two months of diagnosis due to neutropenic infection, coagulopathy, or multiorgan failure.

CONCLUSION: HLH is a rare but extraordinarily dangerous hyperinflammatory syndrome in which uncontrolled immune activation produces a cytokine storm, precipitating fevers, cytopenias, hepatosplenomegaly, coagulopathy, and often death from superimposed infections or multiorgan failure. As it may be genetic or secondary, and involves such a variety of organ systems, diagnosis is incredibly challenging, and outcomes often calamitous even with aggressive intervention.

MEDICAL ERRORS: ARE THEY PREVENTABLE?

Prasana Ramesh¹; Kirti Joshi²; Reva Kleppel²; Pranav S. Ramamurthy¹; Abdul Arham¹; chidubem Ezenna¹. ¹Internal Medicine, Baystate Medical Center, Springfield, MA; ²Department of Medicine, Baystate Medical Center, Springfield, MA. (Control ID #4062838)

CASE: A 73-year-old female with a history of multiple co-morbidities including type II diabetes mellitus on Insulin and Dapagliflozin presented with fall and euglycemic diabetic ketoacidosis for which she was placed on a hospital-approved DKA insulin drip protocol in the intermediate care unit. Her anion gap closed, and she was improving. Unfortunately, the patient’s drip was held for an unknown reason by nursing staff overnight despite having orders in the EMR and the patient went back into diabetic ketoacidosis. The medicine overnight team was contacted, and the patient's drip was resumed. During the evaluation of this medical error by medicine residents during a quality improvement rotation under the supervision of Department of healthcare quality through a root cause analysis to understand the reason of holding the drip overnight, it was uncovered that there were two different hospital-based approved insulin protocol; one that was used in the critical care area which was an insulin drip protocol for glycemic control in the critical care unit and the other was an insulin drip protocol for management of diabetic ketoacidosis in non-critical units. The root cause identified that the nurse taking care of the patient in the intermediate care unit was a critical care nurse who was using the hospital-based insulin drip protocol for glycemic control that she was familiar with in the critical care areas and not the insulin drip protocol for diabetic ketoacidosis.

IMPACT/DISCUSSION: Medical errors are one of the most common causes of iatrogenic patient harm and account for ∼98,000 deaths per year in the United States. They are often preventable. The root cause analysis performed by residents helped identify the difference between the insulin protocols which played a small but very crucial role in the introduction of DKA protocol in the intensive care unit and nursing education to point out the differences. Physicians and pharmacists worked to adapt the DKA protocol from medicine intermediate care to the critical care unit. Root cause analysis can play an important role in identifying the cause of errors and helping providers find a solution for the reversible causes. An open-minded interdisciplinary approach that puts patient safety first is indispensable for identifying and preventing such errors. As our root cause analysis played an important role in quality improvement and patient safety, such studies must be encouraged more.

CONCLUSION: 1. Medical Error events though unfortunate and never events, when occurred they are a learning opportunity to improve systems to prevent future harm.

2. Root cause analysis is a structured method used to learn about and analyze serious or potentially serious adverse events to identify the causes that led to adverse events and analysis of the event can result in areas of quality improvement and implementation of improvement work as in this case the differences of protocols were identified and a new protocol was implemented.

MEGESTROL- INDUCED POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES)

Grace Lee. Internal Medicine, Boston Medical Center, Boston, MA. (Control ID #4063499)

CASE: A 51-year-old woman with end stage kidney disease on peritoneal dialysis, Crohn’s disease, and poor appetite treated with megestrol presented to the emergency department (ED) for sudden onset confusion and altered mental status (AMS). In the ED, the patient had seizure-like activity with tonic-clonic movements. Computed tomography of the head did not show any acute intracranial abnormalities. Labs were notable for serum blood urea nitrogen of 68 mg/dl and calcium of 15.9mg/dl, which was attributed to calcium gluconate administration for presumed hyperkalemia. The patient underwent urgent hemodialysis and her presentation was attributed to metabolic derangements; however, her confusion persisted despite correction of her azotemia and electrolyte abnormalities. Electroencephalogram was negative for epileptiform discharges or seizures, but the patient was noted to be persistently hypertensive above 180/90. Magnetic resonance imaging showed T2/FLAIR hyperintensity in the parieto-occipital white matter, which is nonspecific but can suggest posterior reversible encephalopathy syndrome (PRES). Upon further review, it was discovered that the patient had recently completed a one-week course of daily megestrol for appetite stimulation, which is known to cause hypertension. Therefore, the impression was that the patient’s acute onset hypertension and AMS were secondary to drug-induced PRES. The patient’s blood pressure and mental status improved gradually to baseline without additional intervention.

IMPACT/DISCUSSION: Megestrol is a progesterone analog used for appetite stimulation. The drug is metabolized by hepatic cytochrome P450 and UDP- glucuronosyltransferases and is mostly excreted in the urine (66%). This patient was taking a substantially reduced dose of 20mg/day (400-800mg daily is common), and yet still experienced an adverse effect of extreme and sudden increase in blood pressure. This is presumably because drug clearance is significantly reduced in peritoneal dialysis compared to hemodialysis. The exact mechanism of why megestrol causes hypertension is not completely understood, but there is a suggestion that the drug binds more strongly than cortisol to glucocorticoid receptors, causing Cushing-like symptoms. Acute hypertension with autoregulatory failure can be associated with endothelial damage and extravasation of blood into the brain parenchyma. This can result in the clinical and radiological findings that are associated in the diagnosis of PRES. Drug-induced PRES has been established in antineoplastic and immunomodulating agents; however, there is a lack of documentation in progesterone analogs.

CONCLUSION: This case highlights megestrol as a cause of drug-induced PRES, and emphasizes the risk associated with using medications with renal clearance in patients with reduced kidney function, especially in peritoneal dialysis.

METASTASIS OF UNKNOWN ORIGIN

Sarah Grant. Internal Medicine Residency Program, East Alabama Medical Center, Opelika, AL. (Control ID #4046096)

CASE: A 60-year-old female with COPD presented to her oncologist after an incidental discovery of a right middle lung nodule found on chest x-ray originally obtained for an evaluation of a COPD exacerbation in the emergency room six weeks prior. Follow-up chest CT seven days later showed a 1.5 x 1.0 cm spiculated nodular density in the upper right middle lobe along with subtle nodular densities in the inferior right middle lobe with no abnormal lymphadenopathy. A subsequent PET scan three weeks later showed hypermetabolism of the same nodules noted in the chest CT with no other areas of increased uptake.

Two weeks later she had a bronchoscopy with washing, with a cytology report negative for malignancy. One week later a CT guided lung biopsy was performed, with the pathology report positive for metastasis with an 85% probability of small intestinal adenocarcinoma. Immunohistochemistry (IHC) was positive for CAM 5.2, CD-X2, Synaptophysin, CD 45, Cytokeratin 5, 6, 7, and 20. TTF-1, p40, GATA-3, PAX-8, CD 56, and Chromogranin were all negative. The results suggested gastrointestinal and pancreaticobiliary cells of origin including the possibility of a neuroendocrine tumor of gastrointestinal origin.

During her initial oncology visit the patient was asymptomatic, gaining weight, and feeling reasonably well. Tumor markers including CEA, alpha-fetal protein, CA 19-9, and CA 125 were all negative. Molecular tissue testing was not feasible due to insufficient sampleable tissue. Radiation and surgical excision were discussed as initial treatment options until a more definitive tissue origin could be identified. The patient did not want surgical removal and the option of radiation is still being discussed. The case was further discussed during the tumor board and due to no identifiable gastrointestinal source appreciable on the PET scan and insufficient amount of sampleable tissue a pill cam was ordered to see if any lesions could be seen for possible biopsy.

IMPACT/DISCUSSION: This case shows the complexity of identifying the origin of metastasis when there is limited tissue. A PET scan, biopsy, and IHC are starting points for diagnosing the primary origin and tissue molecular assays can be used if additional testing is needed. Resection of solitary lesions of metastasis with no evidence of additional metastasis, is recommended if location and tumor burden allows. Local radiation is recommended the location is not surgically favorable. Adjunct therapy is reasonable based on predicted tumor type and empiric chemotherapy is reasonable if poorly undifferentiated. However, if a primary origin is uncovered then the treatment should follow guidelines based on the origin.

CONCLUSION: This case shows how resection and/or radiation based on shared decision making can be used for patients with favorable prognosis and low tumor burden.

It also highlights the complexity of identifying the primary origin for targeted therapy and the added advantage of utilizing a multi-disciplinary team such as a tumor board.

METASTATIC LUNG ADENOCARCINOMA WITH BRCA1, EGFR EXON 19 DELETION CAUSING PANCREATITIS IN 43-YEAR-OLD MALE

Stephen J. Susman¹; Gianna Libonate¹; Jay Anderson². ¹Internal Medicine, Riverside Methodist Hospital, Columbus, OH; ²Medical Education, OhioHealth, Columbus, OH. (Control ID #4063856)

CASE: A 43-year-old man with a 2-year history of diffusely metastatic lung adenocarcinoma presented with three days of progressive nausea, vomiting, and epigastric abdominal pain. His adenocarcinoma was positive for BRCA1 mutation and EGFR exon 19 deletion. Laboratory studies showed an elevated lipase of 140 U/L, alkaline phosphatase of 302 U/L with otherwise normal liver function testing, carcinoembryonic antigen (CEA) of 18.5 ng/mL, and cancer antigen 19-9 (CA 19-9) of 209.6 U/mL. Computed tomography of the abdomen and pelvis demonstrated a 4.2 x 3.8 cm new soft tissue mass in the pancreatic head with findings concerning for acute cholecystitis and acute pancreatitis. Abdominal ultrasound showed dilation of the common bile duct to 7.9 mm. Fine needle aspiration of the pancreatic mass via endoscopic ultrasound revealed adenocarcinoma positive for thyroid transcription factor 1 (TTF-1) and napsin-A. Due to increasing abdominal pain and up-trending hyperbilirubinemia, a repeat endoscopy with retrograde cholangiopancreatography was performed. This demonstrated a severe 30 mm stenosis in the lower third of the main bile duct, and a 10 French by 6 cm covered metal stent was placed in the common bile duct. His symptoms improved and he was later discharged home to resume palliative chemotherapy.

IMPACT/DISCUSSION: We present a unique case of metastatic lung adenocarcinoma presenting as pancreatitis. Secondary pancreatic metastasis is a rare phenomenon, constituting only 4% of pancreatic masses. Of secondary tumors, lung adenocarcinoma comprise only 2.4% of cases. Moreover, pancreatic metastasis is often asymptomatic and found incidentally on imaging or autopsy. However, acute pancreatitis can result from invasion of the pancreatic duct. Diagnosis is established using endoscopic ultrasound with fine needle aspiration followed by histopathologic analysis. To distinguish between primary and metastatic adenocarcinoma, thyroid transcription factor 1 (TTF-1) and napsin A can be utilized as they are present in 76.7% and 81.0% of lung adenocarcinomas respectively. Treatment largely depends on the patient’s clinical picture. Surgery is the only potentially curative option but is often limited considering the advanced stage of disease in which pancreatic metastasis is identified. Overall prognosis remains guarded, with studies giving a median survival ranging between 5 and 8.7 months.

CONCLUSION: The pancreas is a rare location for lung adenocarcinoma metastasis and can present with pancreatitis, and is often in the context of extensive metastasis. TTF-1 and napsin A are specific histologic tumor markers for lung adenocarcinoma and aid in differentiating between primary pancreatic malignancy and metastatic disease. Our case serves to highlight one such case of metastatic lung adenocarcinoma due to its novel presentation.

METASTATIC OVARIAN CANCER AS PRESENTATION OF LYNCH SYNDROME

Rachel A. Rubel¹; David Bartfeld¹; Andreas Bub¹; Robert Babkowski²; Forugh Homayounrooz³. ¹Internal Medicine, Stamford Hospital, Stamford, CT; ²Stamford Hospital, Stamford, CT; ³Medicine, Stamford Health, Stamford, CT. (Control ID #4065111)

CASE: A 57-year-old female with history of hypertension presented to the Emergency Department with spasmodic abdominal pain, shortness of breath, and left shoulder pain. She described 40-pound unintentional weight loss and precipitous decline in functional status. Vital signs were significant for tachycardia to 120bpm and O2 saturation 86%. She had cachexia, a reducible ventral hernia, and right eye proptosis. She reported a family history of colon cancer in her father (50s) and paternal uncle (60s), uterine cancer in paternal aunt (50s), and ovarian cancer in paternal grandmother (60s). Her PREMM5 calculated risk of Lynch Syndrome (LS) was 28%. She had never had a colonoscopy. She had no recent pap smear or mammogram.

Laboratory analyses revealed hemoglobin 7.2g/dL, WBC 16.3x10⁹/L, TIBC 174 mcg/dL, ferritin 3168.8ng/mL, ESR 41mm/hr, and CRP 308.8mg/L. Multiple tumor markers were elevated, including breast CEA, CA-15-3, CA-125, and CA-19-9.

CT chest/abdomen/pelvis showed pulmonary masses, right sided pulmonary emboli, thrombi in the inferior vena cava and left renal vein, a large, heterogeneous right adnexal mass, an enlarged, lobular uterus, multiple bony lytic lesions, multiple liver, kidney, and adrenal lesions. Limited brain MRI showed a right orbit mass.

Ultrasound guided biopsy of a left chest wall mass showed poorly differentiated adenocarcinoma. Immunohistochemical work up found an immunoprofile consistent with metastatic ovarian carcinoma. There was insufficient tissue to perform microsatellite instability (MSI) testing. Several days later the patient suffered an acute stroke and was transitioned to comfort care. She expired with her family at bedside. Her family was counseled extensively to pursue genetic evaluation.

IMPACT/DISCUSSION: LS is an autosomal-dominant cancer predisposition syndrome caused by germline variants in the DNA mismatch repair (MMR) genes, leading to DNA microsatellite mutations and cancer. Testing for MSI in colon and endometrial cancer specimen is common practice but not for other LS associated cancers, such as ovarian, gastric, small intestine, biliary, urinary, prostate, brain, and soft tissue.

LS patients have an approximately 12-15% risk of ovarian cancer, usually of endometroid or clear cell morphology and typically presenting with synchronous/metachronous tumors and at younger age.

In patients with a suspicious family history or when tissue testing of current malignancy is impossible, risk models such as PREMM5 (Prediction Model for Gene Mutations) can screen for LS. PREMM5 uses age, sex, and personal/family history of Lynch-associated cancers to calculate the probability of an MMR gene pathogenic variant.

CONCLUSION: Lynch Syndrome can present as metastatic ovarian cancer. PREMM5 should be applied broadly to patients reporting personal or family history of LS associated cancers or for those in whom molecular testing of colorectal/endometrial cancer was not done. Patients with scores >2.5% should be promptly referred for genetic evaluation..

METASTATIC UVEAL MELANOMA INITIALLY DIAGNOSED AS HEPATOCELLULAR CARCINOMA: AN EXAMPLE OF ANCHORING BIAS

Navneet Kaur¹; Ravneet Kaur²; Jaskaranpreet Kaur¹. ¹Internal Medicine, North Alabama Medical Center, Florence, AL; ²Government Medical College Amritsar, Amritsar, Punjab, India. (Control ID #4031982)

CASE: A 66-year-old male with chronic hepatitis C and cirrhosis presents with left flank pain. Examination revealed stable vitals, benign abdomen and right eye blindness. Serum electrolytes and kidney and liver function tests were normal, except for an elevated total bilirubin level of 5.6 mg/dL. Initial imaging demonstrated an ill-defined 2.5 cm hypo-attenuating lesion in the right liver lobe with cirrhosis and splenomegaly.

Due to underlying risk factors, the clinical picture was attributed to hepatocellular carcinoma (HCC). However, alpha-fetoprotein was normal. Interestingly, the biopsy revealed nests of malignant plasmacytoid-appearing cells with brown pigment, which stained positive for SOX10 immunohistochemical stain and negative for arginase, HepPar 1 and cytokeratin AE1/AE3. The histological and immunohistochemical findings were consistent with melanoma. On further interviewing, he reported a history of right eye choroidal melanoma without metastatic disease three years ago, for which he underwent Iodine-125 brachytherapy.

Outpatient, the PET scan revealed multiple hyper-metabolic hepatic lesions and bony metastatic disease. Treatment was started with Ipilimumab and Nivolumab. Resection of liver masses was not offered due to multiple lesions. On the 6-month follow-up, he was tolerating immunotherapy with stable disease.

IMPACT/DISCUSSION: This simple case serves as a perfect example demonstrating the role of detailed history and tissue biopsy in achieving an accurate diagnosis. It also exemplifies anchoring bias, which occurs when physicians rely too heavily on the first piece of information available. Here, the liver lesions were initially diagnosed as HCC, given the history of cirrhosis and hepatitis C (anchor). However, biopsy and past medical history played a crucial role in confirming the diagnosis of metastatic malignant melanoma.

It also highlights the impact of timely initiation of treatment. The incidence of uveal melanoma is around 4 per million. About 50% of uveal melanoma cases develop hepatic metastasis within five years, with numbers reaching as high as 70-80% in 10 years. Where late detection is associated with poor prognosis, early diagnosis and the presence of lesions amenable to surgical resection have a much better prognosis.

CONCLUSION: 1. Anchoring bias should be recognized early as it can result in delayed and inappropriate treatment. When a patient with a history of melanoma presents with new liver lesions, it is imperative to consider metastasis, regardless of any chronic hepatic disease.

2. Uveal melanoma patients should be closely followed to allow prompt detection of disease recurrence. Correct and early identification ensures appropriate and timely treatment, leading to better outcomes.

3. The presence of metastatic lesions does not always mean hospice care. With the advancement in immunotherapy and chemotherapy, there is an improvement in median survival time, and patients can continue to have a meaningful life.

METHEMOGLOBINEMIA FROM TOPICAL ANESTHETICS: A DIAGNOSIS NOT TO BE MISSED

Ashley Pekera¹; Emily E. Sullivan¹; Stephanie Braunthal². ¹Hospital Medicine, Care New England Health System, Providence, RI; ²Medicine, Brown University, Providence, RI. (Control ID #4064256)

CASE: A 26 year old woman pregnant at 7 weeks with a history of asthma presented with generalized weakness, myalgias, chills, cough, sore throat, and chest pain. She was diagnosed with Influenza B and Respiratory Syncytial Virus. Initial vitals: temperature 37.4C, blood pressure 121/75 mmHg, heart rate 81 bpm, respiratory rate 18 breaths/min, SpO2 98% on room air. Exam was significant for retching and paraspinal tenderness. The remainder of the exam and diagnostic workup (CBC, electrolytes, troponin, BNP, EKG) were unremarkable. CT angiography did not reveal pulmonary embolism or any other acute pathology. She received pain control, antiemetics, Oseltamivir, and topical benzocaine spray. Soon after admission she became febrile and mildly hypoxic, requiring 2L nasal cannula to maintain SpO2 95%, the desired goal for fetal perfusion. She then received acetaminophen, a lidocaine patch, and benzocaine spray for symptom relief. Three hours later she suddenly required 15 L O2 via non-rebreather, weaned to 3L after repositioning, albuterol, and mucolytics. Several hours later she became lethargic, more hypoxic, and reported feeling cold shortly after another benzocaine spray, ultimately requiring non-invasive positive pressure ventilation. Labs were significant for new anemia (Hb 12 g/dL to 10.4 g/dL), arterial blood gas (ABG) that was blue-purple, with PaO2 432 mmHg while FiO2 100% and SpO2 ~90%. Methemoglobin was elevated to 20.2%. The cause of hypoxia was deemed to be methemoglobinemia, most likely from topical benzocaine and lidocaine, which were discontinued. She recovered in the ICU, and did not receive methylene blue or ascorbic acid. Prior to discharge, methemoglobin level was undetectable, hemoglobin remained stable, G6PD level was obtained (normal), and she was oxygenating on room air. She remains pregnant, with ongoing multidisciplinary prenatal care.

IMPACT/DISCUSSION: Acquired methemoglobinemia is a rare but potentially fatal side effect of topical anesthetics; this case highlights the need for patient and provider awareness. It must be considered in the setting of cyanosis, abrupt hypoxia, or hemolysis following their use. ABG may show normal or high PaO2 in the presence of tissue hypoxia and the blood’s hue may be blue or purple. Other causes include antimalarials, nitric oxide, nitrites, nitrates, metoclopramide, sulfonamides, and acetaminophen. Severe elevations (>30%) or significant symptoms may be treated with methylene blue or ascorbic acid. Avoid methylene blue in patients with G6PD deficiency (hemolysis), on SSRIs (serotonin syndrome), and when possible, in pregnancy.

CONCLUSION: Acquired methemoglobinemia can cause abrupt, resistant hypoxia, and providers should be familiar with common causative agents.

Obtain a thorough medical history prior to deciding to administer methylene blue.

METHOTREXATE-INDUCED PHOTOSENSITIVITY REACTIONS

Harveen Kaur¹; David A. Feldstein²; Linda Baier Manwell³; Michael Houghan⁴. ¹Internal Medicine, University of Wisconsin-Madison, Madison, WI; ²Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; ³Department of Medicine, Division of General Internal Medicine, University of Wisconsin-Madison, Madison, WI; ⁴Department of Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4061878)

CASE: A 73yo female with Sjogren's Syndrome, psoriatic arthritis on etanercept and methotrexate, chronic oral ulcerations on colchicine, and chronic migraines was admitted for fall, acute kidney injury, and diffuse skin sloughing. Two weeks prior, she had increased sun exposure on vacation and noted upper extremity rash despite sunscreen use. Cephalexin was prophylactically prescribed by her doctor due to a history of cellulitis she initially thought was similar. On presentation BP was 97/64. Exam revealed desquamation over bilateral extensor upper extremities, knees, and dorsiflexor portion of feet and ankles. Labs notable for WBC 1.1 with monocytopenia and lymphopenia, platelets 154, Creatinine 1.87, eGFR of 28, LDH 326, CRP 16, ESR 50, and haptoglobin 243. Chest x-ray, obtained due to increasing oxygen needs and fevers, showed organizing pneumonia. Hematology and Dermatology diagnosis was photo dermatitis from methotrexate toxicity, in the setting of sepsis and acute kidney injury, leading to delayed clearance of methotrexate and profound marrow suppression. Methotrexate and etanercept were held. An infectious work-up was negative. Predominant lymphocytes on bronchoscopy indicated probable drug induced pneumonitis. All symptoms resolved and she was discharged on leflunomide with rheumatology follow up.

IMPACT/DISCUSSION: Methotrexate is a folate antagonist known to cause multiple side effects, most commonly nausea and stomatitis. However, adverse effects are wide ranging: leukopenia, GI ulcerations, alopecia, and multiple organ toxicities. Skin reactions are established but uncommon; the incidence is unclear, but multiple studies describe acral erythema, cutaneous ulceration, and photosensitivity despite use of folic acid. A recent case-control study explored methotrexate as possible cause of increased risk of skin carcinomas. Etiology of the skin reaction in this particular case is not understood. It may have been a “photoreactivation reaction”, due to UV light exposure and administration of methotrexate 2-5 days after. Patients should be informed of the risk of sun exposure when undergoing methotrexate treatment. The risk of using other drugs known to cause adverse skin effects (cephalexin, etanercept) should also be considered. The above case brought to light the possibility of photosensitivity and what added factors can provoke severe skin reactions.

CONCLUSION: Methotrexate-induced toxicity can manifest as pancytopenia, renal and lung toxicities, and photosensitivity reactions

Photosensitivity reactions with methotrexate can be exacerbated by concurrent drugs, underlying renal disease, and UV light exposure despite dosage

Patients should be educated about the manifestations of photosensitive reactions to avoid delays in care and possible progression to secondary infection

MORE THAN SKIN DEEP – SKIN MANIFESTATION OF ALK NEGATIVE LARGE CELL LYMPHOMA IN A POST-TRANSPLANT PATIENT

Debbie Marie R. Fermin, Forough Hakimzada, Tamara Goldberg. Internal Medicine, Mount Sinai St. Lukes West, New York, NY. (Control ID #4064259)

CASE: A 57-year-old male with a history of ESRD s/p right kidney transplant in 2006 on immunosuppressive therapy presented to the hospital with three months of left leg swelling and mildly painful, round, raised, umbilicated, ulcerated skin lesions. The non-pruritic skin lesions initially started in the left inguinal area, then progressed in number and size with distal spread to the knee. He denied having fevers, chills, night sweats, or unintentional weight loss. Medications included Tacrolimus, Prednisone and Nifedipine. He denied any recent travel, hiking, cave exploration, or animal exposure. Physical exam revealed numerous firm raised annular plaques, some with central crusting, with smooth rounded borders on the left thigh, 1—2 cm left inguinal lymphadenopathy and leg edema. Labs were remarkable for mild normocytic anemia. HIV, AFB tissue culture and smear, EBV Ag & Ab, urine Histoplasma Ag, serum Fungitell, Galactomannan, Blastomyces antibody and HTLV antibodies were all negative. Subsequently, patient underwent a skin biopsy, which was sent for histopathology and bacterial/fungal culture. Tissue culture revealed light growth of S. aureus (oxacillin-susceptible) and coagulase negative Staph species. The patient completed a 7-day course of Doxycycline. Histopathologic findings were positive for CD30+ T-cell lymphoma, consistent with ALK-negative anaplastic large-cell lymphoma. Patient was referred to Oncology and was seen outpatient for staging and treatment.

IMPACT/DISCUSSION: ALK-negative anaplastic large cell lymphoma (ALK-ALCL) is a rare subtype of CD30+ T-cell lymphoma which comprises only ∼5.5% of peripheral T-cell lymphomas. (1) ALK-ALCL primarily impacts adults aged 40 to 65, with a 1.5:1 male-female ratio. Patients typically exhibit adenopathy and B symptoms. At diagnosis, 49% of cases involve the lymph nodes, while 20% are extra-nodal sites. This case highlights the importance of maintaining a broad differential for skin lesions, since although rare, ALK-ALCL can manifest in diverse locations, including the skin. (2) Insufficient data currently exists to establish a clear association between ALK-ALCL occurrence in immunocompromised patients. (3) No established optimal therapy exists for ALK-ALCL due to its rarity, varied clinical presentations, and the absence of dedicated randomized trials. It often responds to doxorubicin-based chemotherapy, such as CHOP as the standard first-line treatment, however relapses are frequent. Patients with ALK-ALCL have a 5-year overall survival rate of 49%. (2)

CONCLUSION: ALK-ALCL typically manifests with adenopathy and B symptoms and can have extra-nodal site involvement such as the skin.

There is insufficient data to establish an association between ALK-ALCL and immunocompromised status. Further studies are needed to investigate for any correlation.

MULTIFACETED CHALLENGES: THE COMPLEX CASE OF A PATIENT PRESENTING WITH FALL.

Grace Buckley¹; Samia Nadeem²; Kirti Joshi². ¹Internal Medicine-Pediatrics, Baystate Medical Center, Springfield, MA; ²Internal Medicine, Baystate Medical Center, Springfield, MA. (Control ID #4064109)

CASE: 58-year-old male with history of epilepsy not on anti-seizure medications presented to the ED with unwitnessed fall. Initial laboratory tests revealed leukocytosis (21.4k/mm3), high lactate (3.1mmol/L) and high creatinine kinase (10,628units/l). Neurological exam showed confusion, right upper extremity weakness, wrist drop and numbness. Further examination showed hyperreflexia, dysmetria, ataxia and bilateral positive-Babinski sign. Patient was started on levetiracetam and admitted for probable seizure with new upper motor neuron findings. MRI showed multifocal T2 enhancing lesions in the pons, ventral medulla, cerebral white matter and upper cervical spinal cord compatible with demyelinating disease and sub-acute combined degeneration (SCD). Full SCD work-up remarkable for low vitamin B12 (<150pg/ml) and folic acid (2.9ng/ml). Further history demonstrated diet with little source of B12. Positive intrinsic-factor antibodies thereafter confirmed diagnosis of autoimmune pernicious anemia. Consequently, the patient was initiated on vitamin B12 and folic acid replacement.

IMPACT/DISCUSSION: Falls are the leading cause of injury-related visits to emergency departments in the United States. A fall may be a non-specific presentation of an acute illness, or it may allude to an exacerbation of a chronic disease. Falls in the elderly are described extensively in literature. However, falls in younger patients are less reported. Here we present a case of a middle-aged patient presenting initially with ‘fall’, subsequently found to have a B12-deficiency causing upper-motor neuron pathology. In this case, the patient’s presentation was initially attributed to his history of epilepsy. However, a comprehensive neurological examination revealed upper-motor neuron processes. This case further shows that even with low levels of dietary vitamin intake, malabsorptive conditions must also be investigated. Furthermore, work-up of common presentations such as unwitnessed fall can reveal a complex interplay of both acute and chronic etiologies which can be reversible and treatable if caught early.

CONCLUSION: 1. Events such as fall and long-lie are common presentations in the older population but can occur in younger and middle-aged populations, thus a careful focus must be given to complete and thorough clinical evaluation to assess all potentially contributory organ system and patient factors, both medically and socially.

2. Severe nutritional deficiencies can result from very poor nutritional intake, however full work-up for contributory malabsorptive conditions and autoimmune disorders is also warranted in all cases

MULTIFOCAL LEIOMYOMAS IN A YOUNG MAN WITH AIDS - THE ROLE OF INTERNISTS AND THE CHALLENGES OF MEDICAL DECISION-MAKING IN RARE DISEASES

Juana Martinez, Maria G. Parra Riveros, Alberto Busmail Haylock, Erin Feliciano, Julie Kanevsky. Elmhurst Hospital Center Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4064808)

CASE: A 36-year-old man with AIDS (CD4 <10 cells/mm^3) presented with five months of progressive headaches, vision loss, and shortness of breath. The headaches were left-sided and occipital, throbbing, and worsened with straining. The patient previously had well-controlled HIV but stopped ART two years ago due to depression following the loss of his partner to COVID-19. Exam was notable for oral thrush and several abnormal findings in the left eye: proptosis, decreased visual acuity, large afferent pupillary defect, decreased color perception, and extra-ocular movement restriction. CT of the head, chest, abdomen, and pelvis showed a left temporal lobe mass causing mass effect on the left optic nerve, a left lung mass with multiple small lung nodules suspicious for metastasis, a left renal mass with invasion of the renal vein, and bilateral adrenal masses. Biopsies of the left adrenal mass and left lung revealed EBV-positive leiomyoma. After an interdisciplinary conversation between infectious disease, oncology, neurosurgery, and oculoplastics teams, surgical intervention (including brain biopsy) was considered too high risk due to the location of the mass. The team debated initiating ART considering the risk of immune reconstitution inflammatory syndrome (IRIS) and eventually chose to start ART, deferring surgical interventions. Symptoms showed improvement after two weeks of ART, though left eye vision remained poor. The patient was discharged but lost to follow-up despite multiple attempts to reach him. Five months later, the family reported the patient's demise without providing further details.

IMPACT/DISCUSSION: Diagnosing EBV-associated leiomyomas requires a high index of suspicion in AIDS patients with nonspecific symptoms and mass lesions on imaging. Early biopsy with EBV testing is recommended. EBV smooth muscle tumors (SMT) should be considered in the differential for brain masses since intracranial leiomyomas, a common type of EBV-SMT, can mimic meningiomas. An immunodeficiency should be suspected when an EBV-SMT is found in a previously immunocompetent patient. Optimal treatment remains uncertain, previous reports describe improvement with ART and note that remission rates correlate with CD4 count recovery. Surgical excision, radiation therapy, and chemotherapy have also been reported. Assessing treatment options is challenging in the absence of clinical trials and few reported cases. Internists play a central role in interdisciplinary approaches when consultants lack consensus. Mental health impacts treatment outcomes, as illustrated by medication non-adherence, highlighting yet another challenge to be managed by the internist while orchestrating complex care.

CONCLUSION: Diagnosing EBV-associated leiomyomas requires early biopsy in immunocompromised patients with nonspecific symptoms. Treatment decisions remain uncertain, with ART showing promise. Internists play a central role in coordinating interdisciplinary approaches and guiding the patient in shared decision-making.

MULTIPLE INFECTIOUS ANEURYSMS OF THE THORACIC AORTA ASSOCIATED WITH PASTEURELLA MULTOCIDA BACTEREMIA

Nicholas Massanet¹; Bansi Savaliya¹; Daniel Mendoza¹; Arun Sunny²; Ambika Eranki². ¹Internal medicine, University of South Florida, Tampa, FL; ²Infectious Diseases, University of South Florida, Tampa, FL. (Control ID #4061205)

CASE: An 86-year-old woman was admitted for acute chest pain and shortness of breath. Her history was remarkable for hypertension, hyperlipidemia, osteoarthritis, fostering of 5 cats at home, a remote episode of cat scratch disease, and a thoracic aortic aneurysm (4.6cm) incidentally diagnosed one month prior. Initial assessment revealed signs of sepsis including tachypnea, leukocytosis, and lactic acidosis. An urgent computed tomography (CT) scan showed multiple saccular pseudoaneurysms with the largest (7.4cm,) having ruptured. Immediate management with intravenous fluids, antibiotics and emergent endovascular repair. Blood cultures soon grew Pasteurella multocida. She was started on prophylactic antibiotics and counselled to avoid kittens. Follow-up showed symptomatic resolution and successful repair of her aneurysm on CT imaging.

IMPACT/DISCUSSION: This patient differed from many patients with thoracic aneurysms as she is a female, a lifelong non-smoker, and had saccular rather than fusiform aneurysms. The clinical picture of a rapidly expanding, saccular, descending aortic aneurysm that ruptured in the presence of severe sepsis due to P. multocida bacteremia strongly suggests an infected aortic aneurysm (IAA). Other CT findings that were not present but would support IAA are peri-aneurysmal gas, abscess, stranding or generalized inflammation and lymphadenopathy. In a literature review of previous cases of ruptured aortic aneurysms, we found just 10 reported aortic aneurysms associated with P. multocida. Of these 10, only 2 reported on thoracic aneurysms associated with P. multocida bacteremia.

Immediate CT imaging in concordance with sepsis treatment and, upon discovery of the aneurysm, emergent vascular referral are essential to the initial management of any suspected IAA. The overlap of sepsis due to a bacterial infection and systemic inflammatory response syndrome (SIRS) due to acute illness from aneurysmal rupture or dissection can be confounding in cases such as this. Prompt recognition of sepsis with treatment including intravenous fluids, early blood cultures and antibiotics improves outcomes.

After repair, patients with IA may be considered for further resection and reconstruction, or put on secondary prophylaxis depending on their individualized risk and benefits. They should also be counseled on risk factors that may predispose them to infection such as immune-suppression, elderly age, and interaction with animals or other vectors of infection.

CONCLUSION: This case represents an exceedingly rare condition in a seemingly unlikely host. Emergent surgical or endovascular repair is warranted, but investigation into an acute underlying pathology can and should also be performed. Prompt recognition of severe sepsis with early blood cultures, fluids, and antibiotics may have made the difference for this patient's positive outcome. Post-operatively it was essential this patient was counselled on her risk by fostering animals that can further expose her to P. multocida.

MULTIPLE LEVEL SPINAL ABSCESSES MASQUERADING AS SCIATICA

Damaris Figueroa, Tigran Kakhktsyan, Kadijha Merchant. Capital Health Regional Medical Center, Trenton, NJ. (Control ID #4019183)

CASE: A 58-year-old healthy female, visited Emergency Department (ED) with low back pain radiated to right leg. She denied traumas and blamed the discomfort on exercising. On examination she was afebrile, sensation, strength and deep tendon reflexes were normal, the straight leg raise test was positive. She was diagnosed with sciatica and managed for pain on ED and by Orthopedic a week after. She then returned with severe shooting pain in her neck and lower back, radiated to upper and lower extremities. Accompanied of antalgic gait, inability to lie flat, and trouble passing urine. She remained afebrile without neurological deficit. Severe pain noted on active and passive movement. Blood work showed white blood cell count of 33.06 x 10^3/uL, an erythrocyte sedimentation rate of 120, and a C-reactive protein of 43.8 mg/dL. Magnetic Resonance Imaging (MRI) with and without contrast of cervical, thoracic, and lumbar spines revealed extensive and diffuse leptomeningeal enhancement along the cervical spinal cord. A 5 mm x 2 cm ventral subdural empyema. Extensive spinal meningitis with a dorsal subdural empyema causing mild cord compression at the T6 level, along with extensive spinal meningitis in the lumbar spine. A large dorsal empyema severely compressed the thecal sac at the L3, L4, and L5 levels. Blood cultures and surgical specimens revealed Streptococcus intermedius. She was started on a 6-week course on Ceftriaxone and underwent a C3-C7 Posterior Cervical Laminectomy and L2-L5 Posterior Lumbar Laminectomy with spinal cord decompression and Cauda Equina Decompression. A new MRI showed resolution of the abscess, cord compression, improved dural enhancement.

IMPACT/DISCUSSION: Spinal epidural abscesses (SEAs) are severe infections of the central nervous system afflicting the epidural space. Despite widely accessible diagnostic tools, they still pose a threat to the diagnosis skills of doctors, given their subtle presentation and insidious growth. With a high digree of misdiagnosis at presentation. We show a case of multiple levels of spinal abscesses leading to cauda equina compression. Caused by Streptococcus intermedius in a person who was previously healthy but had a dental procedure. This case highlights an unusual presentation that initially confused healthcare providers that missed dental procedure in the history, resulting in a misdiagnosis of sciatica, delaying interventions.

CONCLUSION: SEA incidence has increased with the distribution of modern imaging techniques. Still early clinical diagnosis remains challenging, requiring a vigilant and suspicion-driven approach. Failure to identify and intervene in these cases, where recent dental procedure is a key historical factor, can lead to severe consequences.This case underlines the difficulty clinicians’ face in distinguishing spinal epidural abscess from radiculopathy and highlights the pivotal role of thorough and rigorous history-taking. This can notably reduce the risk of misdiagnosis, treatment delays and complications.

MYCOPLASMA PNEUMONIAE-INDUCED RASH AND MUCOSITIS (MIRM) & ADENOVIRUS CO-INFECTION: RARE CASE IN A YOUNG ADULT

Jeffrey Li, Natalie Bouri, Inderpreet Saini. Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4064464)

CASE: A 20-year-old male without past medical history presented with fever, sore throat, and dyspnea. Chest X-Ray showed evidence of pneumonia. Levofloxacin was started, but bilateral conjunctivitis and oral ulcers developed, concerning for Stevens-Johnson Syndrome (SJS). However, the lack of skin blistering with positive adenovirus PCR was more suggestive of reactive infectious mucocutaneous eruption (RIME). Patient was discharged with oral corticosteroid taper. At follow up, large conjunctival defects were found and patient was instructed to return.

On readmission, patient presented with blurry vision, painful oral and genital lesions. Exam was notable for bilateral conjunctivitis and blistering lesions at the mouth, penis, and scrotum. Vital signs were unremarkable and labs were significant for mild leukocytosis. Patient underwent bilateral amniotic membrane transplantation and received methylprednisolone therapy but continued to have mucositis and developed small macules on bilateral feet. Mycoplasma pneumoniae serology was positive, suggestive of mycoplasma-induced rash and mucositis (MIRM). Patient received azithromycin, cyclosporine, and etanercept injection, in addition to adjunctive topical therapy for symptomatic relief. Patient improved and was discharged on oral cyclosporine taper.

IMPACT/DISCUSSION: Mycoplasma pneumoniae, a classic cause of atypical pneumonia, can lead to epidermolytic dermatopathies. Most cases occur in children, but a few adult cases have been reported. While initially considered “atypical/incomplete SJS,” a recent study defined MIRM as its own syndrome with a classic triad: <10% skin detachment, presence in at least 2 mucosal sites (ocular, oral, genitourinary), and evidence of atypical pneumonia. Other viruses have also been found to cause similar pathology, resulting in the broader term RIME that includes MIRM. MIRM/RIME mucocutaneous lesions do not have differentiating histopathologic features from SJS/TEN. Mucositis-dominant exam findings should increase suspicion for MIRM/RIME whereas cutaneous-dominant involvement suggest SJS/TEN.

Our patient initially tested positive for adenovirus and was only later found to have a Mycoplasma co-infection. His disease progressed with treatment of suspected adenovirus-induced disease but showed improvement with azithromycin and immunomodulators. In other cases of MIRM, patients also responded well to macrolides. While steroids and IVIG have commonly been used, cyclosporine was only used in a case series that resulted in shortened hospitalization. To our knowledge, this is the first documented use of etanercept as an adjunctive therapy in an adult patient. While further investigation is needed, this case may provide insight into the proposed T-cell mediated pathophysiology of MIRM/RIME.

CONCLUSION: It is crucial for the clinician to differentiate MIRM/RIME from SJS/TEN. The course of this case may highlight the importance of accurate microbiology in guiding management.

MYELIN OLIGODENDROCYTE GLYCOPROTEIN ANTIBODY-ASSOCIATED DISEASE (MOGAD) INITIALLY MASKED AS A MIGRAINE

Christine Li¹; Mridula Sree Naagendran¹; Moshe Zutler². ¹Medicine, UConn Health, Farmington, CT; ²Pulmonary/Critical Care, Hartford HealthCare, Hartford, CT. (Control ID #4058163)

CASE: A previously healthy 19 year-old female reported a week-long history of headache with progressive left eye vision disturbance. Her symptoms improved with Fioricet, so she was diagnosed with migraines and sent home. She returned within a week for complete left vision loss. Physical examination revealed no light perception of her left eye and absent visual fields. Her right eye was normal and reactive to light with intact visual fields and extraocular movements. Labs showed normal white blood cell count and inflammatory markers. CT scan of head showed no hemorrhage or infarct. MRI of the brain and orbits showed asymmetric diffuse enlargement of the left optic nerve with symmetric contour and signaling intensity of surrounding intraorbital structures. MRI of cervical and thoracic spine showed no evidence of demyelinating processes. Lumbar puncture showed clear and colorless fluid with glucose of 93, protein of 28, normal IgG levels, minimal neutrophils and absent oligoclonal bands. Cytology showed reactive lymphocytes, rare histiocytes and frequent degenerative mononuclear cells. There were no malignant cells or anti-MOG antibodies in the cerebrospinal fluid. Notable negative lab findings include: ANA screening, serum ACE levels, syphilis antibodies, and aquaporin-4 antibodies. Neurology recommended intravenous Solu-Medrol 1 gram for 5 days, followed by plasmapheresis every other day for 5 courses. She had gradual improvement of her vision over the week. She was transitioned to oral prednisone 60 miligrams daily with a 10 miligrams taper every week until 10 miligrams daily was reached. She had complete resolution of her symptoms with no recurrence to date.

IMPACT/DISCUSSION: This case highlights the importance of keeping a broad differential of a seemingly simple case as the severity of disease can vary. MOGAD is not typically high on differentials as it has an incidence of 1.1-2.4 per million people. Being able to recognize typical presentations is key to making an accurate diagnosis. Typical presentations of MOGAD include unilateral or bilateral optic neuritis with vision loss, encephalomyelitis, and transverse myelitis. High-dose steroids and plasmapheresis are used to treat acute attacks. MOGAD is commonly monophasic, though recurrence occurs in 50-60% of cases. Oral immunosuppressants and infusion therapy are reserved for refractory cases.

CONCLUSION: Typical presentations of MOGAD include optic neuritis with vision loss, encephalomyelitis, and transverse myelitis. Acute attacks are treated with high-dose steroids and plasmapheresis, if refractory. Oral immunosuppressants and infusion therapy are indicated in relapsing disease.

MY IMMUNE SYSTEM IS SO DEPRESSED.

Karla De Jesus Nunez. Medicine, Montefiore Wakefield Campus, New York, NY. (Control ID #4064859)

CASE: A 39-year-old man with no past medical history presented with malaise and sudden onset bilateral hearing loss for three days. Review of systems was positive for persistent cough and 40 pounds weight loss. On exam, he had decreased hearing and right upper lung field coarse breath sounds. Initial chest x-ray revealed interstitial and patchy opacities present at the right upper lobe and left midlung. The respiratory panel was positive for COVID-19 infection. Laboratory findings were remarkable for normocytic normochromic anemia, hyponatremia, and transaminitis. He was treated with nirmatrelvir/ritonavir for COVID infection and prednisone for sensorineural hearing loss (SNHL) . However, despite receiving treatment, he continued spiking fevers. Repeat chest x-ray displayed progression of right lung opacities with extension to the lung. Acid-Fast Bacillus smear was positive for M. Tuberculosis. Chest computed tomography revealed severe tuberculosis infection: large cavitary lesions replaced almost all normal lung parenchyma, with calcified granulomas, worse after steroid use. Immune reconstitution inflammatory syndrome (TB-IRIS) was diagnosed. After treatment with anti-tuberculosis therapy, steroids were resumed to preserve the remaining lung tissue with a favorable response.

IMPACT/DISCUSSION: Corticosteroids are the first line of treatment for COVID-19-induced sensorineural hearing loss by targeting and suppressing cytokines release, but the full clinical picture should be taken into consideration when deciding to prescribe these potent immunosuppressive drugs, as treatment with moderate to high dose glucocorticoids is associated with an increased risk of activation of latent tuberculosis. Steroid doses commonly used to treat asthma exacerbation can trigger miliary tuberculosis. In our case, a steroid dose used to treat SNHL caused tuberculosis reactivation complicated with immune reconstitution syndrome after antituberculous therapy was started.

The commencement of tuberculosis therapy for pulmonary tuberculosis could be followed by worsening pulmonary infiltrates, persistent fever, malaise, and weight loss in the absence of human immunodeficiency virus, known as immune reconstitution syndrome. Treatment is based on steroids to alleviate the severe inflammatory reaction around the granuloma formation and to preserve the remaining lung tissue. Steroids are not contraindicated in tuberculosis, evidence shows no difference when used along with antituberculous therapy or as a part of immune reconstitution syndrome therapy, however, when used alone can cause immunosuppression and tuberculoid dissemination.

CONCLUSION: Steroid use in pulmonary tuberculosis is controversial. However, if patient is already on antituberculous therapy and there is significant lung destruction with persistent fevers, steroids are recommended to preserve the remaining lung tissue and to treat drug induced fever even in the absence of human immunodeficiency virus infection.

MYOTONIC DYSTROPHY AND A THROMBOEMBOLIC MYSTERY

Karen Ha, Simran Gupta, Dominick Tammaro. Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI. (Control ID #4057080)

CASE: A 44-year-old male with myotonic dystrophy type II and a history of DVT in 2021 presented to the emergency room with acute onset of numbness in his left arm and blurry vision in his left eye. He reported severe chest pain a few days prior associated with dyspnea that had since self-resolved. He stated he was no longer taking his apixaban since being instructed to stop taking it by a physician a few months prior. Physical exam at presentation was notable for poikilothermia and pallor of his left arm with absence of distal pulses by Doppler ultrasound. Marked weakness of all extremities were noted in the setting of the patient’s known fluctuating muscle weakness.

CTA chest revealed extensive emboli in bilateral pulmonary arteries, segmental branches, and subsegmental branches, as well as pulmonary and renal infarcts. He was promptly admitted to the ICU for a high intensity heparin drip with clinical improvement of his upper extremity symptoms. Lower extremity ultrasound revealed further thrombi in the distal femoral, popliteal, and peroneal veins of the left leg. Echocardiography showed evidence of severe right heart strain and an urgent mechanical thrombectomy of the pulmonary embolism was performed successfully. A bubble study confirmed a patent foramen ovale (PFO) and the patient was discharged on warfarin therapy with plans for PFO repair in the outpatient setting.

IMPACT/DISCUSSION: This vignette highlights a unique case in which diverse risk factors converged to cause the development of paradoxical emboli (PDE) in a patient with myotonic dystrophy (MD), resulting in concomitant submassive pulmonary embolism, upper limb ischemia, and solid organ infarcts. The mechanism of PDE formation in the setting of a PFO has been well characterized, though the current literature surrounding thromboembolic complications in MD is sparse. This case offers an example of the multitude of factors at play that led to the near loss of this patient’s limb and life.

The progressive nature of MD provides a challenge to the timely identification of life-threatening complications such as DVT and acute limb ischemia. The greater incidence of thromboembolic complications in those with MD is believed to be secondary to their inevitable progressive immobilization. It has also been postulated that there may be a predisposition for hypercoagulability inherent to MD, though further investigation into the exact pathophysiology is required. Nevertheless, it is critical to be vigilant for thromboemboli in patients with MD and of the ways in which these complications may manifest.

CONCLUSION: 1. Paradoxical emboli present with diverse features that require rapid recognition and management to prevent permanent organ damage, limb amputation, and mortality.

2. Patients with myotonic dystrophy should be monitored with an increasing index of suspicion for thromboembolic events as mobility is progressively lost.

MYSTERIOUS CASE OF DELIRIUM FROM SKIING ACCIDENT

Marina Knysheva¹; Luisa Rusta²; Meenu Singh³; Zach Rubnitz⁴. ¹Spencer Fox Eccles School of Medicine, University of Utah Health, Salt Lake City, UT; ²Spencer Eccles Fox School of Medicine, University of Utah Health, Salt Lake City, UT; ³Internal medicine, University of Utah Health, Salt Lake City, UT; ⁴Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4061488)

CASE: A 79-year-old male with a history of hypertension and hyperlipidemia presented as a trauma patient after a skiing accident. He was unable to move his right arm and leg due to pain. He was wearing a helmet at time of the accident and denied head injury or loss of consciousness. Vitals included: RR 22/min, 2L O2 requirement, BP 158/80 mmHg. Physical exam pertinent for right forearm and left thigh swelling, with pain and restricted ROM. Pertinent labs included high WBC (20.85), low HgB (12.9), low CO2 (19). Imaging showed displaced right radial fracture, left midshaft femur, displaced acetabular and pubic ramus fracture. On day 2 of hospitalization, prior to surgery, patient was intermittently, mildly confused, stating incorrect location, but quickly correcting himself, with mildly dysarthric speech. CTOH, CTA head and neck, EEG, B12, TSH, RPR, folate, thiamine, and urine drug screen were unremarkable. There was concern for delirium from pain and oxycodone (5-10mg). Patient had ORIF with nailing on day 3 with perioperative development of thrombocytopenia and AKI and postoperative acute hypoxic respiratory failure requiring 5L oxygen, worsening mental status, negative CTPE. The constellation of acute hypoxic respiratory failure, neurological changes, thrombocytopenia, and renal dysfunction led to suspicion of fat emboli syndrome (FES), although petechial rash was not present. MRI brain revealed “starfield” pattern strongly suggestive of FES. Patient was managed conservatively with IVF, tube feedings due to failed swallow evaluation, electrolyte replacement, and monitoring. He gradually improved to baseline by day 8 of hospitalization, able to tolerate regular diet, feeding tube was removed, and was discharged to inpatient rehabilitation.

IMPACT/DISCUSSION: Fat embolism syndrome (FES) is a clinical phenomenon associated with respiratory failure and neurologic impairment due of the release of marrow fat into the circulation. Fat embolism occurs in 95% of patients after fracture and invariably during reamed nailing of fractures. It is a subclinical phenomenon is most patients, but FES occurs in about 1-5% of patients. FES usually develops 24-72 hours after the fracture. Neurologic dysfunction may include seizures and/or focal deficits. The petechial rash is observed in 20-50% of cases. Less common findings include anemia, thrombocytopenia, and AKI. MRI brain finding of the starfield sign is usually reversible. FES is a clinical diagnosis with largely supportive treatment. There is evidence that early stabilization and fixation may reduce FES, though there are reports of FES with elective orthopedic procedures as well. Administration of systemic corticosteroids and heparin is controversial. Prognosis is good with most patients achieving full recovery within days to weeks, with reported mortality of 1.2 %.

CONCLUSION: FES is a less known cause of altered mental status. It is important to distinguish it from CVA or delirium, as management calls for early surgical treatment of fractures.

MYSTERY DIAGNOSIS IN A PATIENT PRESENTING WITH FAILURE TO THRIVE

Wendy Tong. Internal Medicine, McGaw Medical Center of Northwestern University, Chicago, IL. (Control ID #4062580)

CASE: A 69-year-old man with cirrhosis secondary to alcohol use, HTN, HFrEF, CKD, and COPD presented with BRBPR and failure to thrive (FTT). He reported fatigue, diarrhea, and mild right upper quadrant pain. He denied chest pain, shortness of breath, nausea, and vomiting. Physical exam was notable for cachexia, hepatomegaly, and ascites. Endoscopy showed duodenal ulcers and no varices. His bleeding self-resolved, but his course was complicated by hepatic encephalopathy and progressive dysphagia worsened by fluctuating mental status for which he ultimately underwent gastric tube placement. He subsequently developed hyponatremia, hyperkalemia, and non-anion gap metabolic acidosis (NAGMA). Lab abnormalities persisted after intravenous fluids, prompting further workup. Morning cortisol was low at 3.6 ug/dl. ACTH stimulation test showed a suboptimal response with a cortisol of 9.7 ug/dl sixty minutes after cosyntropin administration. Plasma renin was low at 0.18 ng/mL/h, aldosterone was low at <1 ng/dL, and ACTH was low at 7.1 pg/mL. A CT scan showed normal adrenals. The patient had no history of autoimmune disease, ischemia, head trauma, or pituitary dysfunction. A thorough medication reconciliation revealed prior use of lisinopril and ongoing use of spironolactone, opioids, and inhaled corticosteroids (ICS). Given his laboratory patterns and medication history, there was concern for central adrenal insufficiency (AI) with a concurrent Type 4 Renal Tubular Acidosis (RTA). The patient was started on methylprednisolone per endocrinology recommendations (chosen over hydrocortisone due to ease of once-daily dosing) with great improvement in mental status and oral intake. At a two-month outpatient endocrinology follow-up, he had gained 15 pounds. Months later, the patient recovered sufficient oral nutritional intake and his gastric tube was removed.

IMPACT/DISCUSSION: This patient was diagnosed with central AI, and his FTT greatly improved with appropriate treatment. Though low aldosterone and hyperkalemia raise concern for primary AI, the combination of low ACTH and intact adrenals with low renin and NAGMA in addition to culprit medications signifies a more likely diagnosis of central AI with a concurrent Type 4 RTA. In central AI, renin and aldosterone are not affected because the renin-angiotensin-aldosterone system is intact and not regulated by the hypothalamic-pituitary-adrenal (HPA) axis. In the absence of pituitary pathology, this patient’s central AI can be attributed to chronic opiate and ICS use, which can both suppress the HPA axis. His Type 4 RTA can be attributed to CKD exacerbated by use of spironolactone (via increased aldosterone resistance) and lisinopril (via decreased aldosterone production).

CONCLUSION: Renin and aldosterone are not regulated by the HPA axis and thus are not affected in central AI.

A concurrent Type 4 RTA may confound lab values used to differentiate primary and central AI.

Culprit medications associated with central AI include chronic opiate and ICS use.

MYXED UP: A CASE OF SEVERE HYPOTHYROIDISM CAUSING PSYCHOSIS

Amelia Clarke¹; Michelle Falconi¹; Valerie Gobao¹; Carla Spagnoletti². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4062675)

CASE: A 62-year-old woman with papillary thyroid cancer and well controlled bipolar disorder without psychotic features on valproic acid presented from a skilled nursing facility six weeks after total thyroidectomy. She experienced paranoia, delusions of persecution, and both auditory and visual hallucinations. She refused levothyroxine and other medications due to the belief that the facility’s staff were trying to hurt her. She reported seeing and hearing staff murder kittens. She endorsed mild fatigue, but denied cold intolerance, constipation, and dry skin.

Vitals were within normal limits. Exam was notable for circumstantial speech, paranoid delusions, and ongoing visual hallucinations. Labs were notable for TSH 84.6, Free T4 0.82. Electrolytes, creatinine, vitamin B12, folate, syphilis screen, and valproic acid level were within normal limits. Urinalysis was negative. MRI brain was unremarkable. Psychiatry and Endocrinology were consulted. She was treated with a loading dose of levothyroxine 250mg followed by 400mg/daily for three days, ending with a maintenance dose of 200mg/daily. Mental status improved and psychotic symptoms resolved after one week with normalization of TSH and free T4 at discharge.

IMPACT/DISCUSSION: Thyroid hormone, via T3 receptors in the brain, helps regulate mood and cognition. Hypothyroidism is a common disorder that can manifest with psychiatric and cognitive symptoms, the most common being depression. Rarely, severe hypothyroidism presents as hallucinations and paranoia. This syndrome, colloquially termed “myxedema psychosis,” is characterized by persecutory delusions and visual hallucinations. It often lacks other “classic” features of severe hypothyroidism. Given the severity of symptoms, myxedema psychosis can be easily misdiagnosed as a primary psychiatric disorder. It is treated with levothyroxine and temporary anti-psychotics. About 90% of patients make a full recovery.

As demonstrated by our patient, severe hypothyroidism is an important part of the differential for new onset psychosis. The differential includes primary psychiatric disorders, infection, mass lesions, toxins, electrolyte abnormalities, and vitamin deficiencies. While our patient’s recent thyroidectomy increased our suspicion for hypothyroidism, she lacked other disease-specific features. We questioned if her symptoms could be a new psychiatric diagnosis or part of her existing bipolar disorder. In this case, consultant expertise guiding a broad differential diagnosis and thorough work up led to an accurate diagnosis and prompt treatment.

CONCLUSION: Psychosis is an uncommon presentation of severe hypothyroidism.

Work up for new psychosis should be broad and include myxedema psychosis.

NAVIGATING A COMPLEX CASE OF MYCOBACTERIUM XENOPI IN A PATIENT WITH BLUE RUBBER BLEB VENUS SYNDROME

Muhammad Umer Riaz Gondal¹; Zainab Kiyani²; Anthony Donato¹. ¹Internal Medicine, Tower Health, West Reading, PA; ²internal medicine, Islamabad Medical and Dental College, Islamabad, Pakistan. (Control ID #4032596)

CASE: A 40-year-old female with a history of Blue Rubber Bleb Venus Syndrome complicated by asthma and bronchiectasis presented to the Pulmonology clinic with two weeks of shortness of breath and cough. The patient was recently admitted for a bronchiectasis exacerbation but continued to have a worsening productive cough. She had been having low-grade fevers to (100° F). She was using ipratropium, fluticasone, and albuterol inhalers regularly with guaifenesin. A physical exam revealed diffuse rhonchi and wheezing. Her most recent CT chest showed interval stable right upper lobe fibrocavitary disease, demonstrating gradual progression over two years. She had occasional positive cultures for Mycobacterium Avium Complex and M. Xenopi 1 year ago, assumed to be a colonizer and not treated. Most recent hospital cultures were negative for bacteria, AFB smear, with unremarkable antifungal and immunoglobulin testing. Most recent pulmonary function testing revealed severe respiratory impairment with a decrease in FEV1 0.83 L (30 %) and FVC 0.99 (30 %), with FEV1/FVC ratio 83 %. She was sent to the emergency department for a bronchiectasis exacerbation, intravenous antibiotics, and systemic steroids. Sputum cultures revealed a negative AFB smear. She returned to the pulmonology clinic six weeks later, as two sputum cultures grew M. Xenopi. It was decided to treat M. Xenopi as this was likely the cause of her cavitary lung lesion and frequent respiratory infections. She was started on azithromycin, rifampin, and trimethoprim/sulfamethoxazole (TMP/SMX). She did not tolerate TMP/SMX, and intravenous amikacin was added in its stead. In the interim, she had episodes of hemoptysis and was referred to cardiothoracic surgery for a right upper lobectomy. After months of coordination between various specialties, she finally had a right partial lung resection done after one year, with her amikacin switched to nebulization. She was on and off antibiotics for M. Xenopi for approximately three years with various interruptions with negative repeat cultures for non-tuberculous mycobacteria (NTM).

IMPACT/DISCUSSION: M. Xenopi is often a commensal organism. NTM pulmonary disease is diagnosed by nodular or cavitary opacities on chest imaging with positive cultures from at least two sputum samples according to guidelines, such as our case. Due to the high mortality of M. Xenopi infections (which can be as high as 69 %), treatment of at least 12 months is recommended. Blue Rubber Bleb Venus Syndrome is a rare disorder of venous malformations, with around 200 cases reported, and requires close follow-up. To our knowledge, this is the first case reported of M. Xenopi in a patient with Blue Rubber Bleb Venus Syndrome.

CONCLUSION: -The decision to initiate treatment for NTM infections is often challenging.

-Lifetime monitoring is required in patients with Blue Rubber Bleb Venus Syndrome.

-M. Xenopi has the highest mortality among NTM infections and requires at least 12 months of treatment

NAVIGATING A RARE PRESENTATION OF PSEUDO-THROMBOTIC MICROANGIOPATHY SECONDARY TO SEVERE VITAMIN B12 DEFICIENCY IN THE SHADOW OF PERNICIOUS ANEMIA

Paulino J. Yanez²; Alisha Sharma¹. ¹Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; ²Medical School, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4063550)

CASE: A 66-year-old woman presented to the ED with generalized fatigue and leg cramps. At the time of her current presentation, labs were positive for anemia with a hemoglobin of 5.2, a reduced platelet count of 154 10e3/uL, leukopenia, haptoglobin < 10, elevated LDH 1728, and a mean corpuscular volume of 121fL. There were no signs of active hemorrhage. Schistocytes, tear drop cells, and hypersegmented neutrophils were seen on blood smear. A differential diagnosis was made of microangiopathic hemolytic anemia or folate/B12 deficiency. Vitamin B12 levels were low at < 150 and was thought to be the suspected cause of the macrocytic anemia and hemolysis. Folate levels were normal. Antibodies for intrinsic factor were positive and the diagnosis of pernicious anemia was made. Treatment with vitamin B12 was initiated and the patient’s symptoms improved. This case highlights a rare presentation of hemolytic anemia secondary to pernicious anemia presenting as pseudo-thrombotic microangiopathy.

IMPACT/DISCUSSION: Anemia due to B12 deficiency can present with laboratory findings suggestive of microangiopathic hemolytic anemia and easily be mistaken as TTP with the classic findings of hemolytic anemia, thrombocytopenia, and schistocytes. This can lead to delay in diagnosis and unnecessary plasmapheresis. The incidence of exhibiting a pseudo-thrombotic microangiopathy in patients with B12 deficiency has been reported to be as low as 2.5%. The low levels of B12 detected and antibodies against intrinsic factor is diagnostic for pernicious anemia. Vitamin B12 is necessary for effective DNA synthesis and deficiencies can lead to megaloblastic cells and subsequent intramedullary premature destruction of these abnormal developing cells causing ineffective erythropoiesis. The destruction of these erythrocyte precursor cells in the bone marrow is believed to be the cause for the elevated LDH levels seen with pseudo-thrombotic microangiopathy when compared to LDH levels in TTP and can be an important diagnostic tool. This patient’s low normal platelet count appears to be consistent with findings from other studies which report only slight reduction in the platelet count with pseudo-thrombotic microangiopathy compared to the more significant thrombocytopenia seen in TTP. It is important that pseudo-thrombotic microangiopathy be considered when presented with a clinical picture suggestive of microangiopathic hemolytic anemia and that an appropriate workup for potential pernicious anemia be conducted.

CONCLUSION: Pseudo-thrombotic microangiopathy is a rare manifestation of severe vitamin B12 deficiency. It can be misdiagnosed as thrombotic thrombocytopenic purpura (TTP), exposing patients to unnecessary plasma therapy. Here, we present a 66-year-old female with a hemolytic anemia presentation. A prompt and thorough investigation leading to the diagnosis of pseudo-thrombotic microangiopathy secondary to pernicious anemia, coupled with timely treatment, facilitated a swift and successful clinical recovery.

NAVIGATING DIAGNOSIS AND TREATMENT OF RAPIDLY PROGRESSING SERONEGATIVE MYOSITIS INDUCED INTERSTITIAL LUNG DISEASE

Grant A. Zydeck¹; Nina Brahmbhatt²; Momin Samad³; Dana Kabbani⁴. ¹School of Medicine, Wayne State University, Detroit, MI; ²Student, Wayne State University School of Medicine, Detroit, MI; ³Internal Medicine, Henry Ford Health System, Detroit, MI; ⁴Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4064585)

CASE: A 76 year old male with PMH of CAD, hyperlipidemia, GERD, and type II DM developed acute hypoxic respiratory failure and muscle weakness 2 weeks after receiving COVID-19 vaccination. 4 weeks later, the patient presented at an outside hospital for worsening acute hypoxic respiratory failure. Initial work up showed suspicion for cryptogenic organizing pneumonia or pulmonary fibrosis with no evidence of infection or autoimmune disease. CT scan showed ground glass opacities eliciting transfer to quaternary care center. Upon consultation with the interstitial lung disease (ILD) team patient was placed on steroid burst taper. Development of intermittent tachycardia and progressive hypoxia evoked workup for pulmonary embolism. CT significant for worsening diffuse lung disease. Patient experienced proximal muscle weakness which prompted subsequent autoimmune neurologic workup. MSAs yielded negative results. EMG findings showed proximal myopathy concerning chronic inflammatory demyelinating polyneuropathy. Lab work showed CPK, TSH/T4, Ca, folate, PTH, zinc, intrinsic factor, ANA, copper, gastric parietal cell antibody, HMG CoA within normal limits. Serum was positive for selenium 171, but negative for myelin associated glycoprotein antibody and ganglioside. Statin was discontinued and muscle biopsy was collected with myositis panel. Patient started on IVIG but was forced to stop due to O2 falling to the 60s and transfer to MICU. Five days later the patient received 5 IVIG infusions, unfortunately the patient passed due to worsening lung condition. The original muscle biopsy revealed randomly distributed necrotic muscle fibers without mononuclear cell infiltrates confirming inflammatory myopathy.

IMPACT/DISCUSSION: Rapidly progressive myositis associated ILD is correlated with worse survival, meaning early recognition and treatment plays a vital role in illness management. ILD can present prior to symptoms of myositis, therefore as other causes of ILD are ruled out myositis should be kept in the differential diagnosis and investigated early in disease progression. Negative serological testing warrants further workup and muscle biopsy since it is more common for patients with immune mediated necrotizing myopathy (IMNM) to present in this manner. Seronegative patients form a distinct subgroup with unique features within IMNM, showing higher rates of extramuscular disease activity. Treatment guidelines for rapidly progressive myositis are currently limited, especially rapidly progressive subtype. High dose steroids combined with azathioprine or mycophenolate, and tacrolimus is recommended for initial treatment. Finally, evidence for use of IVIG is limited but shows promising results in treatment resistant cases when implemented early, unlike our case.

CONCLUSION: 1) Myositis can present with extra muscular involvement with lung comprising the most common organ

2) Prompt multimodal immunosuppressive therapy is the treatment for myositis associated rapidly progressive ILD

NAVIGATING DIAGNOSTIC CHALLENGES IN CASES OF CHRONIC DIARRHEA FOR MULTIMORBID PATIENTS

Jacob G. Cox¹; Ingrid Lobo². ¹MSTP, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4056471)

CASE: 71-year-old male with type 2 diabetes, hypothyroidism, depression, coronary artery disease, hypertension, lung cancer in remission, and urothelial cancer in remission presented to non-PCP provider with non-bloody diarrhea for 4-6 weeks. He had no abdominal pain, weight loss, distension, vomiting, bleeding, foreign travel, and no recent antibiotics. The medication list was extensive. In an attempt to improve mood control venlafaxine was replaced with sertraline 2 months prior. Patient had a normal colonoscopy within the last year. On the initial visit medication side effects were suspected and CBC, TSH, and celiac disease reflex panel (IgA, TTG IgA) were performed. Sertraline, metformin, and dulaglutide were held stepwise over a series of three visits with no change in symptoms. C diff and Giardia were negative. Patient saw PCP on fourth visit - at that time, the patient had high blood glucose levels, was losing weight, his anxiety was worse, and had ongoing diarrhea. The patient was started on insulin for diabetes control. A full stool PCR tested positive for Y. enterocolitica. CT IVP showed bladder thickening with likely recurrence or urological cancer. Of note, his original presentation of his urothelial cancer was diarrhea. Anxiety worsened off of the sertraline and lower dose of Effexor. Diarrhea resolved with antibiotics.

IMPACT/DISCUSSION: Diarrhea is a leading contributor to health care use in the U.S. In adults’ bacteria accounts for >80% of severe diarrhea that last longer than 3 days. This can often be overlooked if other causes seem more apparent. In this case, the patient had just started sertraline, where diarrhea can be a side effect 20% of the time. Metformin and GLP1 agonists are also common culprits. Confounding the case was the patient’s original presentation of his urogenital cancer with diarrhea. In removing the sertraline, metformin, and dulaglutide in an attempt to calm the diarrhea, the patient’s diabetes and anxiety acutely worsened and contributed to him feeling unwell. It is unclear how much impact continuity of care contributed.

A presentation of diarrhea may be straightforward, but we must weigh diagnostic testing, history, medication contributions, and of course the dilemma that we cannot always be available to our patients. In this case, it is still not clear if his diarrhea cleared with a course of antibiotics, time for sertraline clearance, or with the diagnosis of his urothelial cancer. Finally, we must also continue to manage confounding chronic disease that may be affected by our treatment plan like diabetes or mood.

CONCLUSION: Although this case isn’t groundbreaking, this highlights a common dilemma internists face daily. With the ever-increasing usage of various pharmacologic treatments for diabetes and weight loss it’s important to not overlook common causes of GI upset. Additionally, it’s crucial to always keep patients’ chronic illnesses in mind even when managing acute presentations.

NAVIGATING THE ABYSS: UNRAVELING NONDIABETIC HYPOGLYCEMIA IN HEPATOCELLULAR CARCINOMA

Kevin Tong¹; Ricardo Cruz². ¹Internal Medicine, Boston Medical Center, Boston, MA; ²General Internal Medicine, Boston Medical Center, Boston , MA. (Control ID #4063700)

CASE: A 30-year-old male with history of hepatitis B and recent diagnosis of hepatocellular carcinoma presented with abdominal pain and distention, nausea, and hypoglycemia with fingerstick glucose of 39 mg/dL.

He denied other symptoms such as vomiting, diarrhea, dysuria, chest pain, or leg swelling. He was afebrile and tachycardic to 100s. Physical exam was notable for mild lethargy, firm upper abdomen, moderate abdominal distention with fluid wave, and diffuse abdominal tenderness. There was no asterixis or jaundice. Labs were significant for WBC 12.5, Hgb 7.5, AST 185, ALT 23, albumin 1.8, and glucose 101 after giving IV dextrose. Abdominal ultrasound showed moderate ascites.

Given nondiabetic hypoglycemia, a dextrose infusion was initiated. This resolved the nausea and lethargy. The infusion was discontinued and when glucose was <55 mg/dL, a nondiabetic hypoglycemia workup was initiated. Insulin, proinsulin, C-peptide, IGF-1, IGF-2, beta-hydroxybutyrate, insulin antibody, cortisol, and sulfonylurea hypoglycemia panel were collected. The hypoglycemia labs were notable for suppressed C-peptide, low proinsulin, and an elevated IGF-2 to IGF-1 ratio. Based on this, the patient was ultimately diagnosed with IGF-2-induced hypoglycemia related to his hepatocellular carcinoma.

IMPACT/DISCUSSION: Nondiabetic hypoglycemia is a rare cause of low blood glucose; most hypoglycemia cases occur from exogenous insulin. Clinical suspicion of symptomatic hypoglycemia should be high when Whipple’s triad is fulfilled, which includes symptoms of hypoglycemia such as diaphoresis, anxiety, lethargy, palpitations, hunger, and seizure, low plasma glucose concentration (<55 mg/dL), and resolution of symptoms after plasma glucose concentration is raised. The patient fulfilled this with adrenergic and neuroglycopenic symptoms of hypoglycemia, low plasma glucose, and symptom resolution with dextrose.

Nondiabetic hypoglycemia is divided into insulin-mediated and insulin-independent causes. Insulin-mediated causes include insulinoma, islet cell hyperplasia, and iatrogenic hyperinsulinism. Insulin-independent causes are broader; non-exhaustively this includes alcohol, liver failure, sepsis, adrenal insufficiency, medication/drug side effects, and paraneoplastic processes. Often, clinical history can reveal the cause by assessing for comorbidities. However, when etiology is unknown, as in this case, supervised testing can determine the underlying disorder.

CONCLUSION: Nondiabetic hypoglycemia is a rare cause of low blood sugar; it is important to recognize symptomatic hypoglycemia using Whipple’s triad to initiate the proper workup. While clinical history can often reveal the cause of hypoglycemia, clinicians should be aware of the broad workup for diagnosing the underlying etiology of nondiabetic hypoglycemia. This case highlights an example of recognizing nondiabetic hypoglycemia using Whipple’s triad and then executing its workup.

NAVIGATING THE HEPATIC HAVOC OF SICKLE CELL DISEASE: A CASE REPORT ON CHOLESTASIS IN SICKLE CELL CRISIS

Hannah J. Cushen¹; Maya Sayarath². ¹Internal Medicine, University of Minnesota Twin Cities, Minneapolis, MN; ²Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #4064065)

CASE: A 20-year-old man with a history of sickle cell disease (SCD) was admitted due to severe and unexplained epistaxis. Upon arrival, he presented with hypotension, tachycardia, lethargy, disorientation, and generalized abdominal tenderness.

Initial laboratory results revealed hemoglobin 4.3, white blood cell count 33.8, platelets 87,000, INR 4.54, reticulocyte count 12.2%,

creatinine 2.2, total bilirubin 41.3, direct bilirubin 38.2, alkaline phosphatase 506, AST 284, ALT 85, and albumin 1.8. A right upper quadrant ultrasound exonerated obstructive pathology but indicated diffusely coarsened hepatic echotexture. He stabilized following initiation of empiric vancomycin and piperacillin-tazobactam, along with transfusions of packed red blood cells, fresh frozen plasma, and Vitamin K.

Considering his history of SCD, substantial coagulopathy, and liver injury, both Hematology and Hepatology were consulted. Infectious, genetic, and autoimmune causes for his liver injury were ruled out. MRCP revealed only the previously noted coarsened hepatic echotexture.

As suspected, his Hemoglobin S (Hgb S) levels returned elevated at 37%, indicating a high risk of ongoing sickling. At this point the overall clinical picture aligned with a severe sickle cell crisis, resulting in intrahepatic cholestasis, and his subsequent liver failure. Per the mainstay of treatment, he underwent an emergent exchange transfusion.

Following the exchange, Hgb S down trended to 12%. Over the subsequent seven days he markeldy recovered. His encephalopathy progressively resolved. Transaminases and albumin showed gradual improvement. His INR improved to 1.2, platelets to 127,000, and creatinine to 0.7. His direct bilirubin decreased to 28 in an expected delayed manner. Given his encouraging trajectory, he was ultimately discharged home with close hematology follow-up.

IMPACT/DISCUSSION: It is well known that sickle cell disease can have complications affecting multiple organ systems. Intrahepatic cholestasis (IC) is a rare sequelae of SCD that can occur with acute vaso-occlusive crises, which can lead to delayed diagnosis as well as therapeutic management. In absence of early recognition of this complication, patients are at high risk for acute liver failure, which can ultimately lead to fatal outcomes. Diagnosis involves a comprehensive evaluation of the hepatobiliary system to exonerate additional diagnoses. This case emphasizes the significant importance of providers to recognize, diagnose and urgently manage sickle cell intrahepatic cholestasis with exchange transfusion and consideration of liver transplantation.

CONCLUSION: 1) Case demonstrates the importance of early providing recognition of intrahepatic cholestasis as a rare vaso-occlusive manifestation of sickle cell.

2) Case highlights the potential severe adverse consequence of delayed management of sickle cell intrahepatic cholestasis with exchange transfusion.

3) Case reviews the management of this rare sickle cell complication with exchange transfusion.

NEC-FASC?! THINK FAST! A CASE OF NECROTIZING FASCIITIS MISDIAGNOSED AS CELLULITIS

Aditya Joshi¹; Talal Alomar¹; Julien Bourgeois^1,2; Diego F. Kaune⁴; Sammy Alomar¹; Eliace Noory¹; Clarice M. Douille¹; David Solomon^1,3. ¹Creighton University School of Medicine Phoenix Health Sciences Campus, Phoenix, AZ; ²Department of Internal Medicine, Creighton University - Phoenix, Phoenix, AZ; ³Department of Hospital Medicine, Phoenix Children's Hospital, Phoenix, AZ; ⁴Johns Hopkins University, Baltimore, MD. (Control ID #4015595)

CASE: A 17-year-old male was transferred to an academic emergency department from a community hospital for right lower extremity cellulitis and suspected sepsis. Three days prior, he had noticed an itchy scratch on his shin which had progressively become swollen, erythematous, and tender. The patient denied any paresthesia or numbness.

Upon arrival, vitals were a temperature of 36.9°C, HR of 102 bpm, RR of 24 bmp and O² saturation of 94% on room air. Laboratory results showed elevated white blood cell count (26.7x11⁹/L) with neutrophilic predominance (90%). CRP was elevated at 33 mg/dL, and lactate was 2.2 mmol/L.

On examination, there was an 8x6cm exudative, ulcerated lesion with a violaceous base on his right lower leg. Surrounding this were scattered 1cm fluctuant lesions. The area was tender, with serous crusting and black necrotic tissue present at the ulcer edges. Prior CT showed subcutaneous edema consistent with cellulitis. Workup was deemed sufficient, and the patient was transferred to the floor.

Plastic surgery was consulted due to escalating pain and rapid progression of disease process concerning for necrotising fasciitis (NF), leading to immediate fasciotomy and debridement. Cultures grew multiple species of Group A Streptococcus and Staphylococcus. The patient was hospitalized for 10 days, received a 3-week-course of Cefazolin, and a underwent a meshed split-thickness skin graft. By the end of his hospital stay, he showed significant improvement.

IMPACT/DISCUSSION: NF is a life-threatening soft tissue infection that rapidly spreads along the fascial plane. Within hours to days, patients develop necrosis of soft tissue, potentially leading to irreversible limb damage, sepsis, and death.

NF manifests as erythema evolving into pustules, abscesses, and bullae, with edema, crepitus, and violaceous discoloration. Pain is described as 'out-of-proportion’ to appearance and escalates rapidly. MRI and CT can be used to detect gas in tissue, indicative of a necrotizing infection. Common sites include the abdominal wall, gluteal region, and extremities. Common pathogens include invasive Group A Streptococcus, Staphylococcus Aureus, and Clostridium, however cultures are positive only 40% of the time.

NF carries a high mortality rate of up to 34% and a 22% amputation rate. Swift surgical and medical intervention is crucial. Research shows that NF is misdiagnosed in 40-75% of cases, due to symptoms resembling cellulitis and other soft tissue infections. In cases of acutely worsening cellulitis with classic warning signs, physicians should have a low threshold for further evaluation, IV antibiotics, and surgical intervention.

CONCLUSION: -NF is a life-threatening, rapidly progressive infection of the skin and soft tissues that can lead to irreversible limb loss, sepsis and death.

-Clinicians should recognize the rapid progression, bullae, and crepitus characteristic of NF as immediate IV antibiotics and surgical intervention increases likelihood of survival.

NECROTIZING PANCREATITIS AND CHOLECYSTITIS IN A YOUNG PATIENT TAKING TIRZEPATIDE FOR WEIGHT LOSS

Mohammed Abdelsalam, James ". Walker. Internal medicine, Texas Tech University System, Lubbock, TX. (Control ID #4064018)

CASE: A 25-year-old female with medical history of obesity presented with intermittent episodes of severe epigastric pain radiating to the back and right upper quadrant abdominal pain along with nausea and vomiting for few days. She reported that she has been taking Tirzepatide weekly injections for weight loss and has lost 30 pounds over 6 months. She denied previous similar episodes, fever, diarrhea, hematemesis, melena and hematochezia. No history of smoking, drinking alcohol or family history of recurrent pancreatitis. Vital signs showed mild tachycardia. Physical exam revealed BMI of 45 kg/m2, Soft abdomen with tenderness to palpation in the epigastric and right upper quadrant area, positive murphy’s sign, no guarding, no rebound tenderness and hypoactive bowel sounds. Lab workup showed WBC of 27 27.7 x10e3/mcL with 86% neutrophils, hemoglobin of 17.2 gm/dL, Total bilirubin of 4 mg/dL, direct bilirubin of 3.21 mg/dL, lipase of 9000 units/L, amylase of 1300 units/L, triglycerides of 136 mg/dL, alkaline phosphatase of 95 units/L, calcium of 6.3 mg/dL and normal liver transaminases. CT abdomen and pelvis w/ contrast was remarkable for signs of Acute necrotizing pancreatitis. US abdomen exhibited distended gall bladder with pericholecystic fluid, multiple mobile gallstones and thickened gall bladder wall. MRCP showed Severe edema surrounding the pancreas, compatible with acute pancreatitis with necrotizing pancreatitis and no intra or extrahepatic biliary dilatation. Gallstones which were visualized on ultrasound were not visualized on mrcp. Patient was started on aggressive IV fluids and antibiotics. Cholecystectomy was planned.

IMPACT/DISCUSSION: Acute pancreatitis is associated with many etiologies including gallstones and alcohol use disorder which both account for two-thirds of cases. Acute pancreatitis has a mortality of 5 % and can increase up to 17 % in necrotizing pancreatitis. Drug-induced pancreatitis is rare (<5 %) with good prognosis and low mortality. Tirzepatide is a novel GIP receptor and GLP-1 receptor agonist that increases insulin secretion, reduces glucagon secretion, slows gastric emptying, and decreases food intake. A population-based matched case-control study by Singh et al and another observational study by Elashof et al revealed an increased risk of acute pancreatitis including necrotizing pancreatitis in patients taking GLP-1 receptor agonists. The mechanism is unknown, but these agents are thought to cause overgrowth of cells lining small pancreatic ducts, leading to hyperplasia, duct occlusion and subsequent pancreatic inflammation. Furthermore, a meta-analysis of numerous RCTs by Liyun et al found an association between GLP-1 receptor agonists and cholelithiasis, cholecystitis and cholangitis.

CONCLUSION: GLP-1 receptors agonists are associated with increased risk of pancreatitis and gall bladder diseases particularly in patients with other risk factors for pancreatitis and those with higher doses, longer duration of treatment and rapid weight loss.

NECROTIZING SWEET SYNDROME, A NOT-SO-SWEET POST-OPERATIVE COMPLICATION

Kimberly T. Diaz, Mariam Ansar, Aakhila Rameeza, Kathryn Haroldson. Internal Medicine, Cooper University Health Care, Camden, NJ. (Control ID #4058360)

CASE: A 55-year-old male with history of bilateral (b/l) degenerative hip joint disease presented for worsening serosanguinous drainage from b/l hip wounds one week after b/l hip replacement. He developed diaphoresis and chills, received cephalexin at an outside hospital although his wounds became increasingly inflamed and erythematous. He was febrile (102.9F) and tachycardic on admission. Labs significant for high ESR, CRP and WBC. CT scan revealed rim enhancing discrete fluid collections. Initially, differential diagnosis included abscess, diffuse edema, cellulitis and septic arthritis. He was started on broad spectrum antibiotics (vancomycin and cefepime) and he underwent aspiration of both hips. Infectious workup (deep wound and blood cultures) were negative, but the patient continued to have wound drainage and breakthrough fevers. Dermatology was consulted. Labs were negative for ANCA, myeloperoxidase ab, and proteinase 3 ab. Biopsy showed ulceration with necrosis, extensive acute inflammation and spongiosis. He was started on high dose-prednisone 80 mg with improvement in wound drainage and was discharged and followed up outpatient.

IMPACT/DISCUSSION: Necrotizing sweet syndrome (NSS), also known as acute febrile neutrophilic dermatosis, was first described by Dr. Sweet in 1964.

The major criteria for diagnosis of NSS includes abrupt onset of erythematous dermatological papules or nodules, often painful AND histopathological evidence of dense neutrophilic infiltrate with no evidence of leukocytoclastic vasculitis .

The minor criteria includes

1. ESR >20 mm/hr OR WBCs >70 OR Neutrophils > 70% OR Positive CRP

2. Temperature > 38° C

3. Clinical improvement to corticosteroids or potassium iodide

4. Association with autoimmune, malignancy, inflammatory disease, pregnancy, or preceded by an infection/vaccination

Currently, the criteria to diagnose NSS should include 2 major criteria and 2/4 minor criteria.

Our patient met all minor criteria and one of two major criteria. The biopsy revealed ulceration with marked inflammation, focal necrosis and spongiosis. However, there are reports of diagnosing NSS without this neutrophilic predominance, thus making diagnosis challenging.

The pathogenesis of NSS, is believed to be multifactorial influenced by circulating autoantibodies, immune complexes, and genetic susceptibility. The mainstay of treatment is oral corticosteroids with initial dose being 1mg/kg/day or 40-60 mg, tapered over a period of next four to six weeks. For patients who do not tolerate steroids, colchicine and potassium iodide can be used as a first-line therapy. If recurrence occurs, potassium iodide or dapsone can be used. Indomethacin, clofazamine, dapsone and cyclosporin can also be used as second-line treatment.

CONCLUSION: The criteria to diagnose NSS should include 2 major criteria and 2 out of 4 minor criteria.

There are reports of diagnosing NSS without neutrophilic predominance, making diagnosis challenging.

Importance to differntiate NSS from necrotising fasciitis.

NEPHROTIC SYNDROME IN PATIENTS WITH NON-HODGKIN LYMPHOMA

Yamundow Leigh¹; Shehryar Njeeb¹; revekka babayev¹; Forugh Homayounrooz^2,3. ¹internal medicine, Stamford Hospital, Stamford, CT; ²Medicine, Stamford Health, Stamford, CT; ³Columbia University, New York, NY. (Control ID #4064608)

CASE: Clinical Presentation

A 64-year-old man with past medical history of NHL (follicular type) treated with Rituxan-Bendamustine, in remission, presented to the ED with one month of progressive ascending swelling involving bilateral lower extremities, scrotum and bilateral upper extremities and reported 20 kg weight gain. One week prior to presentation, he was started on hydrochlorothiazide but symptoms continued to worsen. His vitals were temperature 36.5, pulse of 68 bpm, blood pressure of 179/94 mmHg, respiratory rate of 16 bpm. His physical exams was significant for 3+ pitting edema on bilateral upper and lower extremities and swelling around abdominal wall and scrotum. His lungs were clear to auscultation bilaterally. Initial labs showed WBC of 4.1 L (4-10L), Hgb of 14.2g/dl (13.2-17.2), BUN 55mg/dl (9-23mg/dl), Cr 1.4mg/dl (0.5-1.3mg/dl), GFR 51ml/min, Albumin 1.9 L (3.5-5 g/dl), Urine protein >1000, Urine RBC 6-15/ hpf (0-5/ hpf). A renal biopsy was diagnostic of minimal change disease. He was treated with high dose steroids and diuretics with resolution of his symptoms and discharged with close outpatient follow-up. Due to prior history of follicular lymphoma, close follow up is imperative although his peripheral flow cytometry did not detect any immunophenotypic abnormalities and CT scan of the chest, abdomen, pelvis showed no evidence suggestive of recurrent lymphoma.

IMPACT/DISCUSSION: Nephrotic Syndrome (NS) is characterized by proteinuria of at least 3.5g/d, edema, hypoalbuminemia, and hyperlipidemia. NS in adults is rare, about 3 cases per 100, 000 of which Minimal Change Nephrotic Syndrome (MCNS) is approximately 10 -15 percent of those cases. The cause of minimal change disease is often idiopathic (primary) but may be triggered by infections, neoplasms like leukemias and lymphomas, drugs, and immunizations. Studies have reported a close relationship between the progression of Non-Hodgkin Lymphoma (NHL) and MCNS. Cases of MCNS diagnosed before or after the diagnosis of NHL has been described with a mean interval of about 15 months. Some suggest that MCNS may be considered as paraneoplastic syndrome.

CONCLUSION: In our patient with a prior history of NHL who presented with minimal change disease, close monitoring and follow-up is essential. This could be an early sign of possible recurrence of his NHL.

NEUROSYPHILIS AND BILATERAL FACIAL PALSY- RAISING THE INDEX OF SUSPICION.

Lyndsay Johnston³; Cameron Huddleston³; Sivateja Pati³; Bosky Modi¹; Barath Rangaswamy¹; Pablo Feuillet². ¹internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²Medical Center Hospital, Odessa, TX; ³Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX. (Control ID #4064884)

CASE: A 72-year-old male presented with bilateral facial weakness (right side more prominent than left), dysphagia, and slurred speech. Stroke protocol was initiated. Neuroimaging was negative for any acute intracranial abnormality or ischemia. Patient was discharged home with a diagnosis of acute Bell's Palsy on steroids. One-week later, the patient presented to the neurology clinic with no improvement, additionally had dizziness and head ache. Patient was admitted to inpatient care. Detailed history taking revealed that the patient was diagnosed and treated for syphilis at age of 16. She had low back pain and unsteady gait that started four months prior to this presentation, raising concern for tabes dorsalis. Neurological exam revealed an alert and anxious patient with bilateral facial palsy, no other cranial nerve abnormalities, 5/5 strength in bilateral upper extremity, 4/5 strength of bilateral lower extremities, 2+ biceps reflexes with 1 + patellar reflexes bilaterally. lumbar puncture was done. Spinal fluid analysis was positive for pleocytosis with elevated protein and RPR positive 1:16. Neurosyphilis was confirmed by VDRL 1:4 in CSF. Patient was started on IV Penicillin G for 10 days. Patient showed clinical improvement on day 3 of IV penicillin.

IMPACT/DISCUSSION: Bilateral facial nerve palsy is an exceedingly rare condition and presents a diagnostic challenge. It may result from cranial trauma, congenital abnormalities, inflammation, infiltration, or infection, but is rarely associated with syphilis. Syphilis is a re-emerging entity, awareness is crucial for early diagnosis. There has been a steady increase in syphilis incidence since 2000. Neurosyphilis is often called the "great imitator," that can occur at any time post-exposure with syphilis. It can be asymptomatic or it may result in a range of diseases which include meningeal, meningovascular, general paresis, and tabes dorsalis. Diagnosis of neurosyphilis is challenging due to no existing standardized testing, but it is rather made on a combination of history, clinical and CSF analysis findings. This case highlights the importance of history taking, including STIs, in patients presenting with neurological dysfunction to prevent misdiagnosis. Untreated neurosyphilis can result in permanent neurological sequelae, including paralysis, dementia, and death.

CONCLUSION: This case represents a misdiagnosis resulting in delayed treatment of neurosyphilis. Given increasing prevalence of syphilis and potential neurological consequences that can be easily prevented, early diagnosis and prompt treatment is imperative.

NEW ALTERED MENTAL STATUS AFTER HEMODIALYSIS IN A MALNOURISHED PATIENT

Kurestin Miller, Pankhuri Mohan, Tyler Chapman, Erica Bates. Internal Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA. (Control ID #4063960)

CASE: The patient is a 54-year-old male with a history of chronic osteomyelitis, T2DM, and longstanding malnutrition who presented for acute hypoxic respiratory failure due to aspiration pneumonia. His hospitalization was complicated by acute renal failure requiring dialysis. After two days of dialysis, he became obtunded without clear etiology. On further examination, he was found to have perifollicular hemorrhages on his abdomen with corkscrew hairs on his arms. A vitamin C level was obtained before starting HD and was < 5 millimole/L. Thus, he was initiated on IV Vitamin C therapy with marked improvement in his mental status.

IMPACT/DISCUSSION: Many hospitalized patients are at risk for malnutrition. We commonly test and prophylactically treat for many nutrients but neglect to test for Vitamin C. Clinical manifestations of scurvy can be seen in as little as 8-12 weeks of malnutrition. Symptoms of scurvy can include malaise, fatigue, and lethargy. As it progresses, it can lead to bone pain, poor wound healing, mood changes, perifollicular hemorrhages, and corkscrew hairs. In the later stages, symptoms can become life-threatening with generalized edema, convulsions, and death. Common risk factors for scurvy include alcoholism, low SES, and severe psychiatric illnesses, none of which our patient had. However, he did receive dialysis during his hospitalization which could have exacerbated his vitamin C deficiency leading to symptoms of late-stage scurvy. Once treatment begins, there can be improvement in the anorexia, fatigue, lethargy, and confusion within 24 hours. Supplementation should be gradually tapered due to the risk for rebound scurvy with sudden withdrawal of treatment.

CONCLUSION: Vitamin C deficiency is a relatively rare but life-threatening vitamin deficiency. It has several pathognomonic findings that practitioners need to be able to recognize as treatment for vitamin C deficiency is easy and curative. Practitioners should have a high index of suspicion in patients with malnutrition as signs and symptoms of scurvy can develop in as little as 8-12 weeks. Additionally, it is important to recognize that vitamin C is dialyzable so patients on hemodialysis are at higher risk for deficiency and should have supplementation.

NEW DIAGNOSIS OF MULTIPLE MYELOMA WITH SACRAL PLASMACYTOMA IN A 23-YEAR-OLD FEMALE

Jonathan Wong, Alexander Hammond, Antoni Wojtkowski, Farrah Malik. Internal Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4017791)

CASE: A 23-year-old female with a one-year history of intermittent back pain who presented to an outside hospital with acutely worsened low back pain, and new onset left leg weakness, constipation, and urinary retention. She did not have health insurance and was unable to seek proper medical care. She had been told her pain was possibly from inflammation of her sciatic nerve. MRI of the lumbar spine done at the outside hospital demonstrated an expansile sacral mass. She was then transferred to a tertiary care center for additional work-up and treatment.

Upon arrival, she reported severe lower back pain, constipation, and urinary retention. Physical exam revealed saddle anesthesia and numbness/weakness of the left lower extremity. She was placed on a hydromorphone patient-controlled analgesia pump. Pain control remained difficult during her admission, necessitating involvement of the pain management team. Other pain medications included tizanidine, oxycodone, ketorolac, acetaminophen, gabapentin, baclofen, methocarbamol, lidocaine patches, and diclofenac gel. Neurosurgery was consulted and recommended CT-guided biopsy of the sacral mass and conservative management. CT scan redemonstrated the sacral mass compressing the spinal canal and neural foramina. MRI brain, T-spine, and C-spine were negative for metastatic disease. Lab work was significant for pseudohyponatremia in the setting of hyperproteinemia with elevated free kappa, kappa: lambda ratio, and serum IgG. CT-guided biopsy of the sacral mass demonstrated sacral plasmacytoma. Bone marrow biopsy demonstrated multiple myeloma. She was taken for emergent external-beam radiation treatment by radiation oncology and initiated on IV steroids by hematology/oncology. She went on to complete a 12-day inpatient radiation therapy course prior to discharge, with planned outpatient follow-up for systemic therapy (DARA-VRd) followed by autologous stem cell transplantation.

IMPACT/DISCUSSION: The incidence of plasmacytoma in newly diagnosed multiple myeloma is relatively rare, with occurrence between 3.5-18%^1. Additionally, multiple myeloma is very rare in young patients, with diagnosis before 40 years of age representing <2% of all patients². Symptoms of MM and plasmacytoma include bone pain, fatigue, weight loss, constipation, and nausea. High dose chemotherapy plus autologous stem-cell transplantation (ASCT) is still considered the standard of care.

CONCLUSION: Although extremely rare in this age demographic, this case demonstrates the importance of keeping multiple myeloma on the differential in young patients with severe bone pain and neurologic symptoms without clear etiology. Delay in a thorough workup can lead to complications such as pathological fractures, renal failure, and cauda equina syndrome. Indications for imaging in adults with low back pain include severe or progressive neurologic deficits and signs of cauda equina syndrome (urinary retention/incontinence, fecal incontinence, saddle anesthesia, and significant motor deficits).

NEW HEART BLOCK DON'T GO INFILTRATING MY HEART

Fiona Splaine, Jonathan Cheah, Matthew McGuiness. Medicine, University of Massachusetts Chan Medical School TH Chan School of Medicine, Worcester, MA. (Control ID #4058670)

CASE: A 57-year-old male with BMI > 50, HTN, HLD, hypothyroidism, asthma, OSA on CPAP presented to his PCP with progressive SOB. Symptoms had started abruptly two months prior, at that time he presented to an outside hospital, and was treated for hypertensive emergency and bronchitis. His SOB worsened over time after discharge with the development of leg swelling, dizziness, and intermittent chest pressure. Two weeks prior to presentation, he had an unwitnessed syncopal event. At the office, ECG revealed third degree heart block without ST changes, and bradycardia to 30 bpm. He was transferred to the ED of an academic medical center in New England.

Medications included chlorthalidone, lisinopril, nifedipine, levothyroxine, albuterol, and fluticasone. He reported social alcohol use but no history of smoking or substance use.

In the ED, the patient was afebrile, HR 30s, BP 170/70, SpO2 >95% on RA. Exam demonstrated a well-appearing man, with sinus bradycardia no MRG, lungs CTAB, and +1 pitting edema. Initial work-up notable for unremarkable BMP and CBC, BNP 579 pg/mL, Troponin 0.04 ng/mL (repeat WNL), Lyme AB negative. CXR unremarkable and TTE LVEF >55%. Review of chest CTA from the prior admission demonstrated mediastinal lymphadenopathy.

Given concern for infiltrative disease a cardiac MRI was performed which showed late gadolinium enhancement in the basal septal region. An EBUS biopsy of the mediastinal lymph nodes demonstrated non-necrotizing granulomas, securing a diagnosis of cardiac sarcoidosis (CS). A PET-CT scan quantified baseline disease burden. The patient was initiated on high dose glucocorticoid therapy, and a dual chamber ICD was placed.

IMPACT/DISCUSSION: The differential of new onset complete heart block is broad and includes infections such as Lyme carditis, cardiac conduction system disease, medication effect and myocardial ischemia. Infiltrative conditions, such as sarcoidosis, are also an important cause but occur less commonly.

Sarcoidosis is a systemic inflammatory disease, caused by infiltrative non-caseating granulomas. Cardiac Sarcoidosis (CS) refers to the presence of granulomas in cardiac tissue, which can manifest as new-onset arrhythmias (commonly AV block), and heart failure. Only 5% of patients with sarcoidosis are diagnosed with CS, although silent cardiac involvement is estimated to affect 30% of sarcoid patients. Up to 50% of patients with CS will give no previous history of sarcoidosis.

CS is a rare disease, and a validated set of diagnostic criteria does not exist, making it a challenging diagnosis. Most guidelines use a combination of clinical features, imaging and biopsy results to categorize likelihood of disease.

CONCLUSION: A common presentation of CS is new onset 3^rd degree heart block

Many CS cases will not have a pre-existing history of sarcoidosis

Diagnostic criteria include clinical symptoms, imaging, and histopathology, but are not validated

NEWLY DIAGNOSED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS DISEASE IN AN ADULT PATIENT WITH MULTI-ORGAN FAILURE

Rayling Herrera, Priya Shah, Christine Lenchur, Ira Khanna. Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #4064431)

CASE: A 56-year-old male patient with HIV (CD4 24), mixed connective tissue disorder and Diffuse Large B Cell Lymphoma, presented with left-sided chest pain, cough and shortness of breath requiring oxygen. Physical exam was remarkable for bilateral axillary lymphadenopathy, confluent petechiae on trunk, diffuse edema and purpura on bilateral legs. Initial workup revealed pancytopenia, acute kidney injury, elevated CPK, INR, PTT, LDH, ferritin and transaminases (ALT 83, AST 550). CT chest showed bilateral subsegmental pulmonary embolism with possible superimposed pneumonia. He was admitted for anticoagulation, antibiotic therapy and further infectious workup. Hospital course was complicated by spiking fevers despite broad spectrum antimicrobials, melena secondary to anticoagulation for PE and altered mental status requiring ICU level of care. Had ongoing pancytopenia (hemoglobin 7.7g/dL, platelets 84K/uL; ANC 1.1k/uL), ferritin 33500ng/mL, CPK 1058 and hypertriglyceridemia of 357mg/dL. Blood cultures were without growth and PCR was positive for EBV. Given his fever >38.5, cytopenia with hemoglobin <9g/dL, platelets <100,000/microL; absolute neutrophil count <1000/microL, hypertriglyceridemia (fasting triglycerides >265 mg/dL) and ferritin >500 ng/mL, hemophagocytic lymphohistiocytosis (HLH) was suspected. To meet 5 out of 9 diagnostic criteria, bone marrow biopsy was performed, showing hemophagocytosis, confirming HLH. Treatment initiated with Dexamethasone, but given lack of clinical response, escalated to pulse dose steroids for 5 days. Anakinra was added to Dexamethasone. After an IVC filter was placed, IVIG was given for 3 days. However, the patient passed away from multi-organ failure leading to cardiac arrest.

IMPACT/DISCUSSION: HLH is a multisystemic condition characterized by widespread immune system activation. While it predominately manifests in children, there is an increasing recognition of HLH in adults. In this case, our patient had multifactorial etiologies, including autoimmune conditions, malignancy and viral infections such as EBV and HIV. A comprehensive physical examination is crucial, with a focus on identifying key indicators like fever, rashes, bleeding, and lymphadenopathy. In the absence of inflammatory markers (sCD25 or CXCL9), 5 out of 9 diagnostic criteria must be met to establish diagnosis of HLH. Data supports the combination of steroids, IVIG and Anakinra for patients with HLH. More evidence is needed to use plasmapheresis and Emapalumab for secondary HLH.

CONCLUSION: Due to the diverse nature of HLH in terms of organ involvement and laboratory findings, it is imperative to consider the combination of predisposing medical history, clinical features, and lab findings to prevent diagnostic delays and initiate treatment, since the mortality rate is 50-60%.

NEW ONSET DIABETIC AMYOTROPHY IN A 54 YEAR OLD FEMALE WITH A RECENT DIAGNOSIS OF TYPE TWO DIABETES MELLIETUS

Aliaa Mousa²; david kiviat¹. ¹Neurology, Capital Health, Trenton, NJ; ²Internal medicine, Capital Health, Trenton, NJ. (Control ID #4060534)

CASE: 54-year-old past medical history significant for recent diagnosis of type two Diabetes mellitus presents to the emergency department in July with chief complaint of nausea, vomiting and weakness that has been present since November of the preceding year. Patient mentioned that she has lost over 40 pounds since then. Patient had been seen by multiple specialists as outpatient and had upper endoscopy and colonoscopy, which were both normal. She also unable to walk and has been falling.Gastroenterology service was consulted and started the patient on 4 mg of Zofran every 6 hours for nausea and vomititng, also she was planned to have nuclar mediicne Gastric Emptying Study that showed gastroparesis and delayed gastric emptying. Later Neurology service was consulted for further assesment of the proxmal weakness of bilateral lower extremities. At that time ; the patient stated her symptoms started as severe pain in her glutes and thighs, then progressed distally. She subsequently also developed symptoms in her shoulders progressing downward. All of her new onset manifestations were accompanied by 40 pound weight loss and at that time she was diagnosed with the new onset diabetes. On physical exam she has diffuse weakness, proximal> distal, lower> upper extremties. She has significant muscle wasting, as well as a mixed sensory neuropathy. The whole clinical picture was highly suspecious of Diabetic amytrophy, however Magnteic reasoning imaging (MRI ) of cervical spine was ordered which showed No abnormal spinal cord signal and No abnormal enhancement. Also she was started on solumedrol 1 gram for 3 days and aslo intravenous immunoglobulin (IVIG) infusion 2 g/kg.

IMPACT/DISCUSSION: Diabetic lumbosacral radiculoplexus neuropathy (DLRPN) is an immune-mediated neuropathy linked to diabetes, characterized by acute onset, lasting months to two years. It differs from typical diabetic neuropathies in association with better glycemic control and lower BMI. The relationship between diabetes, DLRPN, and disease severity is unclear, suggesting diabetes may be a risk factor, not the primary cause. Shared pathophysiological features with idiopathic neuropathies warrant further studies for a comprehensive understanding. Nerve biopsy and neurophysiology studies reveal inflammation and ischemia as key mechanisms. Treatment involves immunosuppressants, though evidence is inconclusive. Symptomatic management includes pain relief, glycemic control, and mobility improvement. Counseling on the prolonged course, potential disability, and home safety is crucial, and managing diabetes may be recommended.

CONCLUSION: Diabetic amyotrophy is a rare disease cahractrized by proximal muscle weakness, numbness, tinglinig preceeded with pain mostly in the proximal lower extremities in patients with diabetes mellietus. Treatment involves immunosuppressants.

NEW SEVERE HEART FAILURE CLUES TO TRANSTHYRETIN AMYLOIDOSIS

Dalia Sriwi¹; Helena Ma¹; Parag Tipnis^2,1. ¹Internal Medicine, University of Wisconsin-Madison, Madison, WI; ²Cardiovascular medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4060251)

CASE: HG is an 81-year-old male with past medical history of diabetes, hypertension, and bilateral carpal tunnel release who presents with lower extremity weakness and swelling, a 30-pound weight gain, and dyspnea for 2 weeks. HG describes progressive weakness in his legs for years which had acutely worsened. Additionally, he has noted significant swelling in his lower extremities and scrotum accompanied by burning in his feet. He also reports dyspnea on exertion and palpitations. He denies paroxysmal nocturnal dyspnea, orthopnea, syncope, fever, or chills. Social history is significant for a 20 pack-year smoking history, and occasional glass of brandy, and no recreational drug use.

Pertinent physical exam findings include JVD, severe, bilateral pitting edema up to his thighs and scrotum, and bibasilar crackles in his lungs. Strength and sensation in his legs were normal.

Labs showed troponin elevation (0.17, 0.15), elevated total protein (6.4 g/dL), BNP of 981, and normal TSH. ECG showed sinus rhythm with 1st degree AV block and low voltage. Echocardiogram showed severely reduced LVEF of 28% and a severely reduced global longitudinal strain with preserved apical strain.

HG was treated with IV diuretics and guideline directed medical therapy was started. A coronary angiogram was performed which showed no significant coronary disease.

There were key features in his presentation that made infiltrative disease our prime suspect for new onset heart failure including a history of bilateral carpal tunnel, high protein levels, low voltage on ECG, and an “apical sparing” strain pattern on echo. Further testing included SPEP which showed no increased light chains. As our suspicion for amyloid remained high, we completed a nuclear pyrophosphate scan, which was strongly suggestive of cardiac transthyretin amyloidosis. He was referred to the advanced heart failure team for treatment options.

IMPACT/DISCUSSION: Cardiac amyloidosis is an underdiagnosed disease that requires a high index of suspicion. Two main forms of amyloidosis with cardiac involvement are amyloid light chain (AL) amyloidosis and amyloid transthyretin (ATTR) amyloidosis. When there is a strong suspicion, it is essential to employ non-invasive imaging modalities such as echocardiography, cardiac MRI, and PYP scans. Additional diagnostic measures may involve a cardiac biopsy or genetic testing. Distinguishing between subtypes is crucial due to varying treatment approaches: aiming to diminish the production of light chain proteins in AL and preventing protein misfolding in ATTR.

CONCLUSION: Cardiac amyloidosis should be suspected in new heart failure cases with progressive neuropathy and a protein gap. Echocardiogram findings may suggest the diagnosis, but a nuclear pyrophosphate scan or cardiac MRI is crucial for confirmation. Early differentiation between AL and ATTR amyloidosis is essential for tailored treatment.

NONALCOHOLIC FATTY LIVER DISEASE-INDUCED LIVER CIRRHOSIS: A COMMON PROBLEM BUT PREVENTABLE DISEASE WITH AGGRESSIVE SCREENING AND PREVENTION

Hillary K. Deveaux, Anjali Gundeti, Kristjana Mitrollari, Melanie Gordon. internal medicine, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #4016879)

CASE: 69-year-old Hispanic female teetotaller with class-II obesity, chronic kidney disease (CKD) stage IV, type II diabetes mellitus (T2DM), hypertension and paroxysmal atrial fibrillation, presented with exertional dyspnoea, abdominal pain, distention, bilateral lower extremity swelling for seven months and pruritis for six days. She presented from her native Mexico for a workup of portal-HTN and cirrhosis with ascites without varices concerning underlying ovarian malignancy after months of indeterminate investigations. She was haemodynamically stable, with creatinine 3.59, urea 90, platelets 129, nephrotic range proteinuria, MELD score 23, Child-Pugh class B, fibrosis-4 index 5.16 (indicating advanced fibrosis), aspartate aminotransferase platelet ratio 1.4 (indicating severe fibrosis). Infectious/autoimmune hepatitis, primary biliary cirrhosis, Wilson’s disease and alpha-1-antitrypsin deficiency tests returned negative. Liver biopsy revealed microvesicular steatosis, hepatocyte ballooning and fibrosis suspicious for steatohepatitis. Despite diuretic optimisation, she had three consecutive admissions, one week apart, for acute hypoxic respiratory failure from right hepatic hydrothorax and was transferred to a liver transplant centre for further evaluation.

IMPACT/DISCUSSION: Chronic liver disease (CLD) involves continuous destruction and regeneration of liver parenchyma from fat accumulation, causing fibrosis and cirrhosis. Annually, 4.5 million adults are diagnosed in the US, making it the ninth leading cause of death. Global incidence has increased by 106.12% from 1990-2017. Non-alcoholic fatty liver disease (NAFLD) has surpassed hepatitis C and alcoholic liver disease (ALD) as the major cause of CLD, with a spectrum of phenotypes; nonalcoholic steatohepatitis (NASH), advanced fibrosis, liver cirrhosis and hepatocellular carcinoma (HCC)

NASH is defined as indolent, progressive hepatic steatosis, inflammation and varied fibrosis. Primary risk factors include, obesity, metabolic syndrome, T2DM, CKD and female sex. A cohort study by Setiawan et al identified NAFLD as the commonest cause of CLD in various ethnic groups.

A postulated “multiple parallel hit” hypothesis describes NAFLD pathogenesis involving insulin resistance (the greatest correlate for disease severity), lipotoxicity, high-caloric diets influencing gut biome alterations, genetic susceptibility/epigenetics. Reactive oxygen species, lipid peroxidation and cytokines like tumour necrosis factor precipitate hepatocyte injury. Patients with NAFLD often remain asymptomatic, even in the presence of liver cirrhosis, until decompensation is triggered.

CONCLUSION: The rising prevalence of NAFLD necessitates heightened awareness among medical professionals. Screening and early treatment is paramount in patients with risk factors to reduce the disease’s impact, delay diagnosis and subject patient to invasive tests. This burdens healthcare institutions, patients and families from a financial, physical and psychological standpoint

NONBACTERIAL THROMBOTIC ENDOCARDITIS: GETTING TO THE HEART OF MENTAL STATUS CHANGE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Hania T. Mumtaz^2,1; Jane Abernethy¹. ¹General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; ²Internal Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4064933)

CASE: A 38-year-old woman with a history of antiphospholipid syndrome (APS) and hypertension complicated by episodes of hypertensive urgency presented to the hospital with three months of confusion. Her family noted fluctuating mental status, intermittent delusions and personality changes.

On arrival, she was also found to have a blood pressure 200/100. Neuropsychiatric evaluation was notable for inattentiveness and difficulty concentrating without other neurologic deficits. Work up showed 3+ proteinuria and microscopic hematuria and urine protein to creatinine ratio of 0.88 mg/dL. Erythrocyte sedimentation rate and C-reactive protein were elevated at 38 mm/hr and 0.40 mg/dL respectively. Antinuclear antibody titer was found to be elevated at 1:320. Three sets of repeat blood cultures were negative. Lumbar puncture was normal. MRI brain showed scattered punctate acute infarcts in the cortical and subcortical bilateral cerebral hemisphere as well as right basal ganglia likely secondary to an embolic process. Transesophageal echocardiogram revealed mobile echodensities on both the anterior and posterior leaflets of the mitral valve. Kidney biopsy showed glomerulomegaly and mild microangiopathic arteriolar changes suggestive of ischemic injury.

IMPACT/DISCUSSION: While a neuroinflammatory process secondary to systemic lupus erythematosus (SLE) was initially suspected, the patient’s mental status improved with initiation of blood pressure control and anticoagulation. She was diagnosed with hypertensive encephalopathy and Libman-Sacks endocarditis (LSE). LSE is a nonbacterial thrombotic endocarditis thought to be due to endothelial injury in the setting of a hypercoagulable state, most commonly seen in patients with malignancy, SLE, and APS. APS carries a high prevalence of LSE (15%), and early detection and initiation of treatment can prevent complications. No randomized trial has been performed to determine optimal treatment. Management centers on treating the underlying condition and initiation of warfarin for secondary prevention. In SLE and APS, use of hydroxychloroquine reduces thrombosis risk. Unfortunately, patients can develop thrombotic episodes despite anticoagulation, and serial echocardiograms are performed to assess valve function and disease progression. LSE can rarely contribute to the development of heart failure related to valve dysfunction.

The broad differential for mental status change in patients with concern for SLE includes neuropsychiatric lupus, stroke, seizure, infection, medication effects, hypertensive emergency, and sequelae of kidney dysfunction. Non-bacterial thrombotic causes of mental status change can be overlooked early on in work up but may carry significant implications for management.

CONCLUSION: Libman-Sacks endocarditis is a prevalent cause of stroke and mental status change in patients with SLE and APS.

Echocardiogram should be considered in the evaluation of the SLE and APS patient with mental status change.

NON-CARDIAC TROPONEMIA: A CASE OF IMMUNE-MEDIATED NECROTIZING MYOPATHY

Margaret Wang. Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4055276)

CASE: 70-year-old man with COPD, angina, glaucoma, HLD, HTN presents to the ED with cough and chest pain.

For the last week, he has had a productive cough with shortness of breath and associated left-sided chest pain. He denied any wheezing, fevers, headache, or myalgias.

Medications are albuterol, amlodipine, lisinopril, montelukast, omeprazole, and eye drops. He quit smoking in 2004.

He has a statin allergy due to “rhabdo." He was instructed to stop taking his statin per his PCP but was still taking it prior to admission.

In the ED his physical exam was notable for diffuse wheezing. He was treated with nebulizers and steroids. Labs notable for high-sensitivity troponin T (hsTnT) of 358 -> 347 -> 340. AST/ALT 175/175. CXR and CT abdomen/pelvis unrevealing. EKG non-ischemic without changes on serial EKGs. Cardiology was consulted and recommended invasive coronary angiography if troponins continued to increase, vs coronary CTA otherwise. Differential included myopericarditis given viral prodrome and troponemia. He was admitted to medicine for observation.

During admission, he received an echocardiogram, respiratory viral panel, and hepatitis panel which were negative. Liver ultrasound was normal. His hsTnT downtrended and his chest pain resolved. CT coronaries showed 60% stenosis of left distal circumflex artery. CK was 13,725, with CK-MB of 274.6 and index of 2.1. HMG-CoA autoantibody panel, aldolase, and myositis panel were sent.

He was discharged with close cardiology follow-up. He ws started on low-dose metoprolol for CAD, continued aspirin, and told to permanently hold his statin. 1 week later, his HMG-CoA antibody came back positive.

IMPACT/DISCUSSION: The patient’s presentation was initially highly concerning for ACS given his troponemia. However, EKG, TTE, and prior stress test in 2022 were normal, and the degree of CAD on CT was not severe enough to explain his symptoms. Indeed, although hsTnT is specific to cardiac muscle injury, studies show it to also be elevated in patients with skeletal myopathy. This patient's CK-MB index was notably 2.1. Indices < 3 tend to reflect skeletal muscle more than cardiac muscle injury. This, together with his normal cardiac studies and statin "allergy" showed that his troponemia was likely a red herring. His positive HMG-CoA antibody test later confirmed the diagnosis.

This case highlights the importance of revisiting diagnoses once initial workup comes back negative. After ruling out ACS and myopericarditis, we re-evaluated this patient by checking a CK-MB. As a result, we diagnosed immune-mediated necrotizing myopathy and started him on appropriate care.

CONCLUSION: While troponins are known markers of cardiac muscle injury, it also has cross-reactivity with skeletal muscle. CK and CK-MB index can be useful laboratory tests to help distinguish between skeletal and cardiac muscle injury in such cases.

Statin-induced myopathy is usually benign, but in cases of persistently high LFTs or CK, it is important to rule out autoimmune causes.

NON-CIRRHOTIC IDIOPATHIC PORTAL HYPERTENSION AND OBLITERATIVE PORTAL VENOPATHY SECONDARY TO SYSTEMIC LUPUS ERYTHEMATOSUS AND MIXED CONNECTIVE TISSUE DISEASE

Wei Tang, Vihanga Perera, Arushika Yedla, Pritika Sharma. Medicine, Westchester Medical Center, Valhalla, NY. (Control ID #4059631)

CASE: A 33-year-old female with a past medical history of systemic lupus erythematosus (SLE) on hydroxychloroquine, mixed connective disease (MCTD), Sjogren’s syndrome (SS), idiopathic thrombocytopenia purpura (ITP), and severe pulmonary hypertension (WHO groups 1 and 3) presented with nausea, vomiting, and diffuse abdominal discomfort for one week.

She denied recent travel, sick contacts, new foods/medications, bleeding, and any family history of gastrointestinal disease. Vital signs were within normal limits, and physical exam was notable for abdominal tenderness. Lab work revealed severe thrombocytopenia with intact synthetic liver function.

Abdominopelvic CT revealed normal hepatic parenchyma, a small caliber main portal vein, recanalized paraumbilical vein, and large abdominal and gastric varies with a gastro-renal shunt. EGD showed esophageal varices, portal hypertensive gastropathy, and large gastric varices. Abdominal ultrasound revealed normal portal veins.

Evaluation for autoimmune hepatitis, viral hepatitis, Wilson’s disease, hemochromatosis, and alpha-1 antitrypsin deficiency were negative. Her course was complicated by hepatic encephalopathy, prompting liver biopsy with histopathology indicating lymphocytic portal vein inflammation and destruction with few plasma cells, without interface hepatitis or lobular activity, and no evidence of cirrhosis.

The presence of portal hypertension in the absence of cirrhosis was consistent with a diagnosis of non-cirrhotic portal hypertension (NCPH). Histology, supported by vasculitis-associated disorders of SLE and MCTD, confirmed the diagnosis of obliterative portal venopathy (OPV).

Follow-up CT revealed interval development of extra-hepatic portal venous thrombosis (PVT) with cavernous transformation.

Symptom management was the mainstay of treatment, as she was not a candidate for liver transplantation due to severe pulmonary hypertension nor a candidate for anticoagulation due to severe thrombocytopenia.

IMPACT/DISCUSSION: - We present an extremely rare case of idiopathic portal hypertension secondary to OPV in a patient with SLE and MCTD.

- Our case demonstrated the importance of early differentiation between extra-hepatic portal vein obstruction (EHPVO) and idiopathic portal hypertension (IPH), as the latter is frequently complicated by the development of portal vein thrombosis.

- Follow-up abdominal imaging should be performed to monitor for common complications, including PVT and subsequent cirrhosis.

CONCLUSION: - NCPH describes unique diagnoses distinguished by their propensity to cause increased portal pressure in the absence of cirrhosis, the definite diagnosis of which is provided by histopathologic exclusion of cirrhosis and identification of portal vein destruction.

- Clinicians should maintain a high index of suspicion for IPH secondary to OPV in patients with predisposing vasculitis-associated rheumatologic disorders. Follow-up abdominal imaging should be performed to monitor the development of PVT.

NOT ALL THAT IS YELLOW IS LIVER FAILURE: AN OBSCURE CASE OF MIXED HYPERBILIRUBINEMIA CAUSED BY CONCOMITANT THROMBOTIC MICROANGIOPATHY AND HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

Benjamin Salwen¹; Rachel Park¹; Monique Fagan¹; Nathan Aleger¹; Sarah Cossich². ¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4064309)

CASE: A 38-year-old woman with a past medical history of hepatitis C (HCV) and polysubstance use presented with three days of fatigue, nausea/vomiting, and jaundice. She denied sick contacts, recent drinking, or new medications/supplements. She endorsed fentanyl use a week prior. Her initial vitals were unremarkable. She underwent an extensive lab workup which revealed numerous abnormalities. Hematologic: Leukocytosis (32.2), thrombocytopenia (21), normocytic anemia (hematocrit 25.1%), ferritin 10,312, LDH >3,600, D dimer 17,990, haptoglobin <30, and fibrinogen 238. Metabolic: Alkaline phosphatase 173, AST 238, ALT 63, PT/INR 16.6/1.4, Albumin 3.4, BUN 186, creatinine 8.17, Total bilirubin >90, direct bile >30 (>limits of our lab’s assays), C3/C4 80/12 and triglycerides 483. She had a negative infectious and autoimmune workup, normal lactate, negative drug screen, and negative HIV and hepatitis A/B/E screens. Ultrasound, CT, and MRCP revealed borderline hepatosplenomegaly with normal echogenicity and contour of the liver. Vasculature was patent with normal flow and no biliary obstruction.

She was treated supportively with hemodialysis (HD) while more studies were sent to elucidate her condition. These were notable for a normal ADAMTS-13 level, negative G6PD screen, IL-2 1962, HCV viral load 10,400,000, and CXCL9 4092. Renal biopsy revealed glomerular microangiopathic changes and severe acute tubular injury. She continued to require HD, however, her hyperbilirubinemia and overall condition improved and she was discharged home.

IMPACT/DISCUSSION: Hyperbilirubinemia is separated into conjugated (direct) and uncojugated (indirect). Conjugated hyperbilirubinemia is usually caused by increased production and unconjugated hyperbilirubinemia is usually caused by reduced excretion. Our patient had processes that contributed to both. Her renal biopsy was highly suggestive of thrombotic microangiopathy (TMA), which is supported by decreased C4 and evidence of hemolysis and thrombocytopenia. There appeared to be concomitant hemolysis caused by hemophagocytic lymphohistiocytosis (HLH). Her H score predicted a 96-98% probability of HLH as well as a significantly elevated CXCL9, a biomarker highly correlated to HLH. Her extremely elevated HCV viral load may have precipitated the above immunologic conditions as well as reducing her liver’s ability to conjugate the excess bilirubin produced by her hemolysis. This was exacerbated by her concomitant renal failure reducing her ability to excrete the water-soluble conjugated bilirubin, resulting in a massively elevated mixed hyperbilirubinemia.

CONCLUSION: Hyperbilirubinemia is usually a result of either hyperproduction or reduced clearance. Here we present a rare case of a patient with both TMA and HLA causing significant hyperproduction of bilirubin through massive hemolysis as well as reduced clearance secondary to both active HCV and renal failure.

NOT JUST PCP? AN UNEXPECTED CAUSE OF PNEUMONIA IN AN AIDS PATIENT

Michelle Zhao¹; Gabriela Ferreira². ¹RWJMS, Rutgers Robert Wood Johnson Medical School New Brunswick, New Brunswick, NJ; ²Department of Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ. (Control ID #4064905)

CASE: A 32-year-old male presented with two weeks of abdominal pain, diarrhea, hemoptysis, fever, and a 40-pound weight loss in the past year. He was diagnosed with HIV in 2018, started on antiretroviral therapy (ART), but was lost to follow-up in 2020. His last CD4+ count and viral load were unknown. Physical exam showed a temperature of 103.2 F, heart rate of 144, respiratory rate of 18, and oxygen saturation of 87% on room air. He in mild respiratory distress with coarse bibasilar breath sounds. Chest X-ray showed a diffuse micronodular miliary pattern and CT chest revealed small pulmonary nodules with ground glass opacities. CD4+ count was 12. In addition to airborne isolation for possible tuberculosis (TB), he was started on ceftriaxone and azithromycin for pneumonia. Due to high suspicion for Pneumocystis jirovecii pneumonia (PCP), he was also started on prednisone and trimethoprim/sulfamethoxazole (TMP-SMX). On hospital day 2, the patient desaturated to 90% on 6L oxygen and was upgraded to the intensive care unit. Sputum was negative for acid-fast bacillus stain, PCP PCR, and bacterial culture. Bronchoalveolar lavage (BAL) PCR was negative for AFB stain but urine was positive for Histoplasma capsulatum antigen. He began amphotericin for pulmonary histoplasmosis treatment and prophylactic dosing of TMP-SMX. On hospital day 9, his BAL was positive for PCP, prompting re-initiation of therapeutic-dose TMP-SMX and prednisone. He improved on this medication regimen and by hospital day 18, he was discharged with a prednisone taper, TMP-SMX, itraconazole, and ART with outpatient follow-up.

IMPACT/DISCUSSION: Although the incidence of opportunistic infections (OIs) in HIV patients has diminished with the development of ART, cases are prevalent among those not receiving treatment. Untreated HIV may progress to AIDS, defined as a CD4+ cell count <200 or the presence of an AIDS-defining OI. It is important to look for OIs in this population to not miss treatable causes. Lung OI organisms include Pneumocystis, Coccidioidomycosis, Aspergillosis, Mycobacterium avium complex, and miliary TB. Antigen and nucleic acid amplification tests (NAAT) should be first-line as they are the most sensitive for acute infection than culture or serologic testing. Patients may also be infected with more than one OI so comprehensive testing should be done. As highlighted in this case, BAL is more sensitive for infection detection than sputum, so bronchoscopy should be considered in severely ill, immunocompromised patients. In patients with newly diagnosed AIDS with social determinants of health barriers, close follow-up and monitoring are crucial.

CONCLUSION: It is important to recognize the different microbiology of infection in severely immunocompromised patients.

Antigen or NAAT are preferred over culture or serologies when diagnosing the cause of pneumonia in immunocompromised patients.

Bronchoalveolar lavage samples should be obtained in patients with AIDS and pneumonia who have negative sputum results.

NOT YOUR TYPICAL HEADACHE: A CASE OF CEREBRAL AMYLOID ANGIOPATHY-RELATED INFLAMMATION

Victoria Kalinoski-Dubose²; Deborah Setter¹; Darin Carabenciov¹. ¹Neurology, Mayo Clinic Minnesota, Rochester, MN; ²Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4064798)

CASE: A 57-year-old male comorbid with hypertension and benign prostatic hyperplasia presented to the emergency department with a 1-month history of worsening bifrontal headaches and progressive cognitive decline. The headaches were increasing in both frequency and severity, occurring throughout the day and night. He also endorsed nausea, light sensitivity, word-finding difficulty, and new memory impairments. Prior to this, he denied any history of headaches. Examination was significant for blood pressure of 195/130 and delayed speech initiation, but was otherwise normal, including high level cognitive functions. Serum chemistries, liver function tests, and complete blood count were within normal limits. CRP was mildly elevated at 5.5 (nl < 5) but erythrocyte sedimentation rate was normal. Lyme disease testing was negative. Cerebrospinal fluid analysis showed 2 total nucleated cells (54% lymphocytes), glucose 63 mg/dL, protein 38 mg/dL (normal <35). Brain MRI with and without contrast demonstrated extensive T2 hyperintensity in the right temporal parieto-occipital region and underlying cerebral microhemorrhages on SWAN with vascular and leptomeningeal enhancement. Vessel wall imaging did not demonstrate evidence of angiitis. A diagnosis of CAA-ri was made by clinical manifestations and MRI findings. The patient was prescribed IV methylprednisone 1000 mg daily for three days and was to complete a 6-week oral prednisone taper. Antihypertensives were titrated to a systolic blood pressure goal of < 140 mm Hg. A follow-up MRI 2 months later demonstrated markedly improved T2 hyperintensity in the right temporal parieto-occipital region. The patient’s clinical outcome at follow-up was improved.

IMPACT/DISCUSSION: Although still rare in clinical practice, it is encountered with increasing frequency and will be particularly important to recognize as the novel amyloid targeting therapies can result in a similar inflammatory response.

CONCLUSION: CAA-ri is a rare and aggressive small-vessel disease characterized by an inflammatory response to deposits of amyloid protein in the cortical or leptomeningeal vessel walls. Clinical presentation includes acute or subacute onset progressive headaches, memory impairment, multidomain cognitive decline, behavioral changes, and seizures. Although the gold standard for diagnosis is brain biopsy, this is often deferred given the invasive nature of this testing. The diagnosis is often made clinically based on symptoms and suggestive brain MRI findings, which classically reveal asymmetric, patchy white matter hyperintensities on T2-weighted sequences, leptomeningeal enhancement, and scattered microbleeds on gradient echo sequences. The mainstay of treatment is an initial burst of high-dose steroids followed by a taper over 6-12 weeks with interval MRI brain and clinical examination to evaluate recovery. Relapses occur relatively frequently and some patients are therefore transitioned to long term immunosuppressants.

OCULAR AND DERMATOLOGIC MANIFESTATION OF SYPHILIS IN ACUTE HIV INFECTION, AN UNUSUAL PRESENTATION

Erica L. Venable. Graduate Medical Education, AdventHealth Redmond, Rome, GA. (Control ID #4064362)

CASE: 29 y/o transgender woman AMAB with no medical history presents with diffuse body rash that had progressed over 2 months. She failed treatment with over-the-counter steroid cream. The rash continued to progress over the following months, ultimately covering her extremities, groin, back, abdomen, chest, and face, prompting her to present to our emergency room. The rash was pruritic and painful in nature, and consisted of a mix of violaceous nodules and annular plaques. Additionally, she reported bilateral eye pain with complete vision loss in the right eye and partial vision loss in the left eye two weeks prior to presentation. A hypopyon of the right eye was noted on exam. Skin biopsies were obtained and revealed caseating granulomas. Ophthalmologic evaluation revealed bilateral uveitis and nuclear sclerosis with right-sided hypopyon. Patient tested positive for HIV-1 antibody with positive RPR (1:128) and T. pallidum antibodies. CSF studies were negative for VDRL. Patient was diagnosed with HIV and secondary syphilis with ocular involvement and subsequently started on penicillin G. Over the following days, she had gradual improvement of the rash and visual impairments. Patient was discharged home on HAART with close follow up arranged.

IMPACT/DISCUSSION: Syphilis presents in the non-HIV population in distinct stages with characteristic features. However, for patients with HIV, syphilis can present in several ways. These include the concurrent presentation of primary and secondary syphilis, which can occur in up to 25% of patients, presentation of neurosyphilis at any stage of the disease, and ocular syphilis, which tends to have a high correlation with underlying neurosyphilis. These differences are important to recognize as coinfection of HIV and T. pallidum accounts for nearly 25% of all cases of primary and secondary syphilis in the United States. Treatment of ocular syphilis between HIV and non-HIV populations remain the same, with first line treatment being penicillin G.

CONCLUSION: Syphilis in the setting of HIV may present with an atypical or rapidly progressive course, and can be the initial presentation of previously undiagnosed HIV. Dermatologic findings of secondary syphilis in HIV-infected patients can vary widely, and are commonly misdiagnosed on initial presentation. Ocular syphilis is an uncommon finding among the non-HIV population and tends to occur more frequently in the HIV-infected population. Our case provides a prime example of an unusual presentation of syphilis and HIV in a previously healthy patient. Misdiagnosis early in the course may lead to treatment delay and further disease transmission.

ONE LUMEN, TWO ZEBRAS: NOCARDIA AND NON-TB MYCOBACTERIUM BACTEREMIA IN AN IMMUNOCOMPETENT PATIENT ON TPN

Navila Sharif, Steven Lewis, Annie Massart. Internal Medicine, Emory University, Atlanta, GA. (Control ID #4060275)

CASE: A 37-year-old female with short gut syndrome, severe malnutrition and total parenteral nutrition (TPN) dependence with indwelling Hickman catheter presented with fever, malaise and pleuritic chest pain for 1 week. On arrival, she was febrile to 39.6° C and tachycardic to 130 beats per minute with normal oxygen saturation. Her exam was notable for visible rigors and bibasilar crackles. Labs revealed pancytopenia: white blood cell count 2.9K/mcL, hemoglobin 5 gm/dL, and platelets 60,000. CT of her chest showed bilateral, multifocal ground glass opacities. She was started on empiric therapy with vancomycin, cefepime, azithromycin, metronidazole, and micafungin. Blood cultures grew branching gram-positive bacilli which later speciated to Nocardia africana/nova and Mycobacterium fortuitum. Her central line was removed, and the antibiotic regimen was narrowed to IV trimethoprim-sulfamethoxazole and linezolid. She underwent transthoracic and transesophageal echocardiogram and MRI brain, with no metastatic spread of infection identified. A bronchoscopy was performed and bronchoalveolar lavage (BAL) cultures were negative, though the sample was collected after several days of antibiotics. She improved clinically, and labs including pancytopenia normalized with resolution of sepsis. She was discharged with a prolonged course of IV imipenem and trimethoprim-sulfamethoxazole as well as infectious disease follow up.

IMPACT/DISCUSSION: Nocardia is a slow growing, partially acid-fast, gram-positive bacilli that often leads to pulmonary infection and other systemic symptoms in immunocompromised individuals. However, Nocardia bacteremia is particularly rare and associated with high mortality. Patients at higher risk for this opportunistic infection include those with malignancy, HIV, long-term steroid use, and transplant history. Indwelling catheters used for long term TPN are associated with increased risk, as they provide a direct portal of entry. Interestingly, our patient was pancytopenic, which may have been secondary to severe sepsis, or a result of chronic malnutrition that subsequently placed her at greater risk of infection. Concurrent Nocardia and non-tuberculous mycobacterium (NTM) bacteremia is not well studied, but both have been linked to central line–associated infections, with M. fortuitum having a high predisposition to form biofilms.

Early identification, initiation of proper therapy, and source control with removal of the line is crucial. Pulmonary infection is the most common presentation, while cardiac and neurologic manifestations can be seen with metastatic spread. Workup should include chest, cardiac, and brain imaging, sputum sample, and in most cases, bronchoscopy with BAL.

CONCLUSION: We describe a case of dual Nocardia and non-TB mycobacterium bacteremia in a young patient without overt immunodeficiency. In addition to traditional opportunistic infection risk factors, it is important to consider indwelling lines as a potential risk factor for these atypical organisms.

OPIOIDS AND OGILVIE’S SYNDROME: AN INTERESTING CASE OF OPIOID INDUCED ACUTE COLONIC PSEUDO-OBSTRUCTION!

Jake Goldstein¹; Meenu Singh². ¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²Internal medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4062819)

CASE: 50-year-old Female with a past medical history of stage IV poorly differentiated carcinoma who presented with pain in her left shoulder and chest. While her pain was well controlled with a fentanyl patch as well as a PCA pump, she was later was found to have abdominal pain and distention. A CT abdomen demonstrated a dilated colon of 11 cm as well as dilated small loops of bowel. Given the absence of other etiologies that would explain the acute change in her imaging, we determined that she likely suffered from opioid induced Ogilvie syndrome. Conservative measures including bowel rest and nasogastric tube decompression were trialed, however failed to improve the patient’s symptoms. Therefore, gastroenterology was consulted who recommended trialing Neostigmine administration and subsequent colonic decompression if necessary. In addition, she was maintained on an aggressive bowel regimen that included Senna-Docusate and MiraLAX 17 grams three times daily. Finally, she was prophylactically treated with piperacillin-tazobactam 3.375 grams Q6H given her risk of gut bacterial translocation. Ultimately, the patient’s colonic dilation failed to improve with neostigmine administration, and she underwent colonic decompression that was successful. She was soon after discharged with a modified pain regimen that reduced opioid administration and maximized ketamine treatment.

IMPACT/DISCUSSION: Large-bowel obstruction accounts for approximately 25% of all intestinal obstructions. Acute colonic pseudo-obstruction (ACPO), otherwise known as Olgivie syndrome, is one of the causes of benign large-bowel obstruction. This case highlights key points in the diagnosis and management of Ogilvie syndrome, especially in the setting of significant opioid administration. Firstly, a diagnosis was made upon objective evidence of proximal colonic dilatations without a visualized transition point. The etiology is thought to involve dysfunction of the autonomic nervous system. Secondly, a discussion took place over using a peripherally acting opioid antagonists such as methylnaltrexone, however given the risk of bowel perforation reported in the past¹, we decided to pursue treatment with Neostigmine and colonic decompression. In addition, given her degree of colonic dilation we felt it judicious to start broad-spectrum coverage with antibiotic. Gut translocation of bacteria has been reported in the past as a possible source of sepsis²; thus, we felt it appropriate to ensure adequate prevention of bacterial sepsis given our patient’s likely inability to recover from a systemic infection.

CONCLUSION: Opioid-induced Ogilvie syndrome is a life-threatening condition that can occur in patients taking high dose opioids. Treatment consists of nasogastric tube decompression and bowel rest, as well as neostigmine administration and colonic decompression. Antimicrobial therapy is reasonable to begin given the high risk of bacterial translocation and subsequent systemic infection.

ORTHOPNEA: ANCHCORING TO THE HEART

humayra mayat. internal medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4065062)

CASE: An 85-year-old male with a history of prostate cancer presents to the ED for orthopnea. His symptoms began suddenly 3 days prior and occurred predominantly at night. He has no history of heart failure, COPD, recent viral illness, dyspnea on exertion (DOE), or paroxysmal nocturnal dyspnea (PND). At baseline, the patient uses a cane but recently has required a walker to ambulate due to a fall that required a hip replacement 2 months prior. The patient endorsed some generalized weakness for which he was working with physical therapy.

The patient was admitted to the hospital due to his orthopnea. CT-angiography of the chest revealed no signs of pulmonary embolism. Echocardiography demonstrated normal left ventricular ejection fraction. On admission to the floor, the patient was initially comfortable on room air when sitting up, however upon lying down he was immediately notably distressed. His oxygen saturation drops to 85%, and he becomes tachycardic to the 110s.

On physical examination, the patient was noted to have a weakness with holding his neck erect. An EMG was ordered for a neuromuscular etiology which was consistent with Myasthenia Gravis. He was ultimately started on pyridostigmine with relief of his presenting symptoms.

IMPACT/DISCUSSION: Orthopnea can be easily mistaken as a pathognomonic sign of heart failure. This may in part be due to its very high specificity (~89% by some studies) and thus it can lead to anchoring quickly. However, hypervolemia due to other causes like ascites or effusions, neuromuscular disease, and diaphragm paralysis can all lead to similar presentations. Several features of our patient's presentation pointed towards a neuromuscular diagnosis. The most striking feature was how quickly the patient's dyspnea began after lying down. This was the first tip-off that this was not a mere case of hypervolemia as orthopnea from volume overload generally develops over a more prolonged period.

In particular, our patient's neck weakness was a key association that led us to believe this may be a problem of muscle fatigue and thus diaphragm failure became the leading differential. The unusual part of this case is that Myasthenia Gravis usually does not have isolated respiratory or neck weakness as a presenting symptom. Ocular manifestations like ptosis or diplopia are the presenting features of more than 50% of people. This is closely followed by bulbar symptoms such as dysphagia or dysarthria. His hip replacement 2 months before admission was also a key feature as that was thought to have precipitated his Myasthenia.

CONCLUSION: In patients presenting with orthopnea, it can be very helpful to determine the timeframe between recumbency and the onset of dyspnea. This can help broaden the differential beyond normal hypervolemia, cardiac, or lung pathology.

OSMOTIC DEMYELINATION SYNDROME WITH RAPID CORRECTION OF HYPEROSMOLAR HYPERGLYCEMIC STATE: ARE WE DOING IT WRONG?

Dhairya Salvi^1,2; Wadid Sirry^1,2; Jai Kumar^1,2; Pedro Pineiro^1,2; Zain Kulairi². ¹Internal Medicine, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Ascension Providence Rochester Hospital, Rochester, MI. (Control ID #4064545)

CASE: We present a case of a 59-year-old male with polyuria, polydipsia and generalized weakness for 2 weeks. He had not seen any physician in the last 20 years. On arrival at the hospital, patient was slightly tachycardic with dry mucous membranes. Neurological exam was completely unremarkable. Labs showed blood glucose 844 mg/dL, sodium 129 mmol/L (corrected sodium 141 mmol/L), potassium 5.1mmol/L, bicarbonate 24 mmol/L, anion gap 14 and blood urea nitrogen 29 mg/dL. HbA1c was >14%. Beta-hydroxybutyrate was 0.50 mmol/L. Patient was in Hyperosmolar Hyperglycemic state (HHS). He received 2 liters of normal saline bolus and 15 units of regular insulin. Four hours later his blood glucose improved to 464 mg/dL with a sodium level of 137 mmol/L (corrected sodium 143 mmol/L). He was further started on a basal-bolus insulin regimen. Approximately 16 hours from arrival, the patient had a transient episode of dysarthria and right hemiplegia. Labs then showed glucose 178 mg/dL and sodium 139 mmol/L (corrected sodium 140 mmol/L). Code stroke workup did not show any acute intracranial hemorrhage or large vessel occlusion. MRI brain showed abnormal restricted diffusion and abnormal increased T2 signal intensity in the pons concerning for osmotic demyelination syndrome (ODS). It also showed a small acute infarct adjacent to an old lacunar infarct in the splenium of the left corpus callosum. Patient did not have any residual neurological deficit during the hospital course. At his 3 months follow-up, his neurological function remained completely intact.

IMPACT/DISCUSSION: Hyperosmolar hyperglycemic state is a complication of type 2 diabetes mellitus which develops gradually over weeks. Severe hyperglycemia causes hyponatremia and therefore we commonly refer to the sodium level corrected for hyperglycemia in our clinical practice. In this case, rapid correction of blood glucose led to an increase in “measured” sodium levels by 8 mmol/L over 4 hours, which likely precipitated the event of osmotic demyelination. It is important to note that the increase in sodium level when corrected for hyperglycemia was only 2mmol/L. This raises the question if measured sodium levels are a better predictor than corrected sodium levels for clinical outcomes among such patients. Further studies need to be conducted to delineate the exact pathophysiological mechanism of ODS in HHS and whether a slower reduction in blood glucose is a feasible option in such patients.

CONCLUSION: A rapid rise in sodium levels occurs indirectly from the rapid lowering of blood glucose, which is often overlooked, and may result in a fatal outcome.

OVERDIAGNOSIS OF VZV MENINGITIS AND ACYCLOVIR NEUROTOXICITY: A FATAL CASE HIGHLIGHTING THE POTENTIAL PITFALLS OF PCR TESTING

Masakazu Toda¹; Masaji Saijo¹; Shadia Constantine². ¹Primary Center, Sapporo Tokushukai Byoin, Sapporo, Hokkaido, Japan; ²Primary Center, Sapporo Tokushukai Hospital, Sapporo, Hokkaido, Japan. (Control ID #4063915)

CASE: An 89-year-old man with a history of CKD 3 and mild dementia presented to our emergency department due to a progressive altered mental status, which started three days prior. Symptoms coincided with the development of herpes zoster.

He had normal vital signs. He had a vesicular eruption localized to the L4 dermatome. His Glasgow Coma Scale was 11, E4 V1 M6. Apart from the altered mental status, the rest of his neurological exam was unremarkable. A brain CT scan showed no acute abnormalities. A lumbar puncture revealed CSF with a WBC count of 3 cells/mL, protein 55 mg/dl, and glucose 49 mg/dl, all within our institutional normal limits. However, the CSF PCR tested positive for Varicella-Zoster Virus (VZV.) The patient began treatment with acyclovir IV 500 mg daily (adjusted dose). During admission, his renal function declined from his baseline. In addition, the mental status also declined significantly. Repeated imaging was negative for meningitis/encephalitis. By day ten, he was comatose. Given the possibility of acyclovir neurotoxicity, we stopped the medication. Shortly after, the patient's renal and mental status improved, and by Day 15, he was able to follow commands and communicate his needs. Unfortunately, during this period, he lost his ability to swallow safely and developed severe aspiration pneumonia, which finally was the cause of his death.

IMPACT/DISCUSSION: VZV meningitis/encephalitis is often unrecognized. It has a mortality rate of 9-20% and frequently causes neurological sequelae. Older adults, especially those with comorbidities, are more susceptible to severe outcomes due to weakened immunity.

PCR for CSF, now more accessible post-COVID-19, is crucial for diagnosis but poses a risk of overdiagnosis. Positive results can lead to unnecessary treatment and increased healthcare costs. Wilen et al. found that only 1.7% of 1588 VZV studies were positive, with one false-positive. They proposed criteria (>10 nucleated cells/l) for ordering viral CSF NAAT assays, reducing testing by 46% and achieving cost savings.

There are effective therapies for Herpesviridae CNS infections; therefore, prompt antiviral therapy initiation is crucial. Acyclovir is preferred due to its CSF penetration. However, in older patients with renal dysfunction, high-dose antivirals can lead to adverse events like acute renal failure and neurotoxicity, as seen in our patient. Robertson et al. also reported a similar case of acyclovir neurotoxicity due to a false-positive PCR.

CONCLUSION: Consider a careful evaluation in older patients with VZV-positive CSF PCR.

Need to corroborate PCR results with clinical presentation and other lab data before diagnosing CNS infection and initiating acyclovir treatment.

Be aware of potential serious side effects of acyclovir, including renal failure and neurotoxicity.

PAIN IN THE NECK: A CASE OF DIABETIC KETOACIDOSIS AND BACTEREMIA CAUSED BY SPONTANEOUS EPIDURAL ABSCESS

Arina Alexeeva¹; Gilbert A. Hernandez¹; Kevin S. Tang². ¹Internal Medicine, University of California Irvine, Irvine, CA; ²Internal Medicine, UC Irvine Douglas Hospital, Orange, CA. (Control ID #4062264)

CASE: Mr. B was a 59 year old male with insulin dependent diabetes mellitus and peripheral vascular disease who presented to the Emergency Department with two days of neck and shoulder pain. The pain was intensified with movement. He denied any inciting events, trauma, recent illness, fevers, chest pain, shortness of breath, bladder/bowel incontinence or dysuria. Physical exam was significant for tachycardia without fever and severe pain to palpation in cervical and shoulder regions. Kernig and Brudzinski signs were negative, but he endorsed severe pain with passive neck flexion. Mr. B was found to be in diabetic ketoacidosis (DKA) with glucose of 433, beta-hydroxybutyrate 4.42, and an anion gap of 19. Labs were also notable for white blood cell count 20.2. Initial CT cervical spine was unremarkable. Mr. B was admitted, placed on an insulin drip for DKA, and started on ceftriaxone and vancomycin for presumed central nervous system (CNS) infection. His DKA resolved by hospital day 2, however his neck pain persisted and leukocytosis worsened. Subsequent infectious workup revealed negative urinalysis, chest X-ray, and echocardiogram, however blood cultures grew Streptococcus. MRI revealed a large cervical and thoracic spine epidural abscess with cervical cord compression. Neurosurgery subsequently brought the patient for a posterior cervical laminectomy C3 – T1 with drain placement. Mr. B had good recovery following the operation with near resolution of neck pain. He was ultimately discharged home on a 6-week course of ceftriaxone for Streptococcus agalactiae bacteremia.

IMPACT/DISCUSSION: DKA is an increasing cause of hospitalizations with well documented etiologies; infections making up 30-40% of total cases. However, spinal epidural abscesses (SEA) in DKA patients are not well described. SEA are a rare cause of back pain, with only 20% occurring in the cervical region, associated with alcoholism, diabetes, IV drug use, immunocompromise, and spinal surgery. Patients classically present with back pain (most common), fever and neurological deficits, although rarely are all three initially present. Despite its rarity, clinicians should have low threshold to consider SEA in patients with new onset back pain, especially in setting of DKA where infectious etiology is suspected. Prompt imaging and surgical consultation can shorten time to surgical intervention and thus reduce long-term neurologic complications. Although CT is typically an acceptable alternative to MRI in SEA detection, we would encourage clinicians to pursue MRI if clinical suspicion of SEA remains high despite negative CT. Furthermore, as in our case of Mr. B, clinicians should exercise caution when considering lumbar puncture in these patients given risk of CNS infectious seeding.

CONCLUSION: Presentations for DKA are ubiquitous and often due to inadequate glucose control, however infectious causes must also be investigated. CNS infections including SEA and subsequent bacteremia are rare but important etiologies for DKA.

PANCREATIC INVASION BY AN AGGRESSIVE BURKITT’S LYMPHOMA (BL) PRESENTING AS ACUTE PANCREATITIS IN A YOUNG MALE

Rachael Hagen¹; Matthew L. Widlus²; Cunegundo Vergara¹. ¹Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; ²Internal Medicine, UConn Health, Farmington, CT. (Control ID #4062273)

CASE: A 23-year-old with a history of lumbar disc herniations presented with 1 week of nausea, vomiting, and abdominal pain. He reported excessive weight loss and 6 months of night sweats. Exam revealed a diffusely tender, non-distended abdomen. Lab workup was remarkable for WBC 13.3 with left shift, lipase 402, LDH 1733. CTAP showed large retroperitoneal and intraperitoneal masses, measuring up to 9 cm, encasing the pancreas, left kidney, renal vasculature, and a pancreatic mass. MRI brain showed a mass within right cranial nerve 5. EUS revealed peripancreatic lymphadenopathy (LAD) and ulcerated masses in the stomach and duodenum. Lymph node and bone marrow biopsies confirmed BL. Testicular ultrasound showed hypoechoic foci in the bilateral testes, suggestive of testicular lymphoma.

His course was complicated by SBO from BL infiltrating the cecum and causing cecal perforation, necessitating exploratory laparotomy and right hemicolectomy with end ileostomy. An intraventricular catheter was implanted for intrathecal chemotherapy. Subsequently, he began treatment with rituximab and CODOX-M.

IMPACT/DISCUSSION: BL is an aggressive non-Hodgkin B-cell lymphoma. Sporadic BL commonly involves the lymph nodes and abdomen, particularly in the lymphatic-rich ileocecal area. This may induce SBO from intussusception. While pancreatic involvement is rare, acute pancreatitis is often the initial presentation of BL. Imaging may demonstrate significant inflammatory changes, potentially obscuring the underlying tumor. Abdominal CT is essential for diagnosing and evaluating disease severity.

CT often shows peritoneal thickening, discrete or conglomerated masses, widespread LAD, and tumors affecting abdominal organs. Infiltrative growth with involvement of retroperitoneal lymph nodes and encasement of mesenteric vessels is frequently seen. Our patient presented with diffuse LAD and contiguous tumors invading the pancreas, kidney, and vasculature, aligning with the classic presentation of BL. It is important to assess for testicular or ovarian involvement, as seen in this case.

BL has the shortest doubling time among neoplasms. Prognosis is favorable when treated with chemotherapy, emphasizing the importance of early recognition to expedite treatment. This case highlights the importance of remaining vigilant when assessing patients for acute pancreatitis, especially if the patient has persistent symptoms despite treatment. The internist should consider BL when abdominal and lymph node masses are visualized.

CONCLUSION: BL should be suspected in patients with abdominal and lymph node masses, elevated LDH, and rarely, pancreatitis from pancreatic involvement. Work up involves oncology referral, abdominal CT with contrast, and ovarian/testicular imaging.

BL and its complications are life-threatening. Prompt diagnosis with follow up cross-sectional imaging is crucial for a favorable prognosis given the rapid proliferation of this aggressive yet curable cancer.

PANCREATIC NEUROENDOCRINE TUMOR PRESENTING AS AN ABDOMINAL PAIN FOLLOWING SUCCESSFUL H. PYLORI ERADICATION

Omar Belfaqeeh, Frederick Rozenshteyn, Bruce Gelman. Internal Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #4053696)

CASE: A 67-year-old male with a history of partial liver resection, peptic ulcer disease, and H. Pylori gastritis s/p quadruple therapy presented with acute on chronic abdominal pain despite being on a PPI. He had abdominal pain for the past 5 years associated with nausea, vomiting, diarrhea, and a 50-pound unintentional weight loss. An EGD six months ago demonstrated PUD and H. pylori which was successfully eradicated.

He underwent a CT AP with IV contrast in the ED which revealed an enhancing 3.4 cm mass in the head of the pancreas with retroperitoneal lymphadenopathy. MRI of the abdomen confirmed the presence of a 3.2 cm enhancing pancreatic head mass with direct extension into the second portion of the duodenum and multiple enlarged retroperitoneal lymph nodes. EGD was remarkable for edema and granularity in the first portion of the duodenum. EUS was notable for a hypoechoic and heterogeneous irregular mass in the pancreatic head measuring 25 mm by 23 mm in maximal cross-sectional diameter with invasion into the serosa and muscularis mucosa of the duodenum. FNA of the pancreatic mass for cytology revealed a well-differentiated pancreatic neuroendocrine tumor (Ki-67 index <1%). Gastrin levels were ordered. He presented again to the hospital in 3 weeks with worsening epigastric abdominal pain and nausea despite adhering to PPI therapy. CT abdomen revealed new proximal duodenal ulcerations. Gastrin level from the prior admission was noted to be 1988 pg/mL. He subsequently underwent a Whipple's procedure with no complications and was discharged home with a planned EGD surveillance in 6 months.

IMPACT/DISCUSSION: Zollinger-Ellison syndrome (ZES) is caused by functional duodenal or pancreatic neuroendocrine tumors (NET) that secrete gastrin resulting in excess acid production causing peptic ulceration, reflux esophagitis and diarrhea. It is estimated that the annual incidence is one per million population, of which 20 to 30 percent are associated with multiple endocrine neoplasia type 1 (MEN1). Recent studies have demonstrated that 70-80% of gastrinomas arise in the duodenum. Establishing a diagnosis of ZE can be difficult due to the lack of consistent diagnostic criteria, the widespread use of PPIs that masks mask the symptoms and limited access to gastric pH testing.

CONCLUSION: In our case, the diagnosis was based on a fasting serum gastrin level, FNA results, and imaging findings. Owing to its variable clinical presentation, high mortality, and challenging primary lesion identification, clinicians should consider ZE in the differential diagnosis of patients who are symptomatic despite taking PPI, having H. Pylori successfully eradicated or having multiple duodenal and gastric ulcers that fail to respond to therapy.

PANCREATICOBRONCHIAL FISTULA FOLLOWING CHRONIC PANCREATITIS

Farha N. Ebadi^1,2; Christelle Nzugang³. ¹Internal Medicine, Kent Hospital, West Warwick, RI; ²Internal Medicine, On Lok SeniorHealth Inc, San Francisco, CA; ³Beth Israel Lahey Health, Cambridge, MA. (Control ID #4016040)

CASE: 30-year-old gentleman with a history of alcohol use disorder (drinking 3-4 nips of vodka daily for 10 years) complicated by delirium tremens and withdrawal seizures, chronic pancreatitis complicated by pancreatic insufficiency, splenic vein thrombosis, and diabetes mellitus type 2, who presented to the hospital for hemoptysis and left-sided chest pain ongoing for 1 to 2 weeks. Patient had these symptoms intermittently for the past several months. Upon ED arrival, vital signs were stable and labs demonstrated lipase of 139 IU/L, and unremarkable liver studies. CT of chest with contrast showed a new 7.5 cm x 7.3 cm collection in the left anterior perihilar region, appearing to be a cystic collection contiguous with small collection in the distal esophagus, stomach, and tail of the pancreas. Thoracentesis was completed and approximately 1.25 L of dark red-wine colored fluid was drained from the left side which showed LDH 723 IU/L, pH 7.27, and amylase 2822 IU/L. Post-thoracentesis chest x-ray showed an increase in pleural effusion; thus, chest tube and thrombolytics were placed. Findings were concerning for pleural pancreatic fistula. Patient was treated with vancomycin, Zosyn, and azithromycin for initial concern of community acquired pneumonia. The patient was started on octreotide with little improvement. Patient underwent endoscopic retrograde cholangiopancreatography with pancreatic tocography that revealed a stricture of the proximal pancreatic duct for which stent was placed. He was transferred for pancreatico-pleural fistula diversion and thoracoscopy.

IMPACT/DISCUSSION: Internal pancreatic fistulas are a well-known complication of acute on chronic pancreatitis as well as pancreatic trauma. The etiology of this complication arises from a disruption in the pancreatic duct and spillage of secretions in the surrounding compartments. The exocrine secretions of the pancreas can erode the diaphragm itself and lead to mediastinal involvement, which is undoubtedly rare. Octreotide has been proven to effectively inhibit various gastrointestinal functions including exocrine and neuroendocrine secretion, motility, and splanchnic blood flow. Our patient unfortunately failed octreotide as well as other noninvasive measures and was thus referred for pseudocyst drainage and surgical intervention.

CONCLUSION: Pancreaticobronchial fistula is formed because of lung’s pleura adhesion to the diaphragm, however such manifestation are rare. We chose to present this patient due to the rarity of pancreaticobronchial fistula and the challenge and difficulty associate with diagnosing and treating it efficiently. The most common cause of pancreatic pseudocyst in adults is alcoholic pancreatitis. There are less than 60 cases reported in literature, for which most frequently present symptoms include dyspnea, chest pain, abdominal pain, and weight loss.

PARALYZED BY UNCERTAINTY: UNWINDING A CASE OF SEVERE HYPOKALEMIA

Yuming Shi²; Kathryn Leyens¹. ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4063128)

CASE: A 42-year-old female with a history of fibromyalgia, hypertension, depression, peripheral neuropathy, and prior hypokalemia presented with generalized weakness, found to have K 1.6mEq/L and QTc prolongation to 545ms. While at home, the patient had ascending lower extremity weakness with nausea and vomiting. She collapsed to the floor where she was unable to move for multiple hours before being found by her partner. The patient had prior hypokalemia to potassium 2.9mEq/L measured 22 months prior to presentation, though had multiple normal potassium levels more recently. She consumed a vegetarian diet limited to one daily meal of pasta, cheese, and soy-based meat alternative. On admission, lab values were Na 142mEq/L, Cl 114mEq/L, K 1.6mEq/L, Mg 2.4mEq/L, HCO2 14mEq/L. There was an anion gap of 14mEq/L and delta gap of 2mEq/L suggestive of hyperchloremic normal anion gap acidosis. On hospital day 1, VBG demonstrated a pH 7.38. A 24hr urine collection was notable for pH 7.0, normal urine Ca (256mg), and low urine K (17mEq). Other urine electrolytes, serum aldosterone, and serum TSH were within normal range. The patient had rapid normalization of serum potassium levels with repletion. Weakness fully resolved by hospital day 3. On hospital day 4, patient had K 4mEq/L and was discharged with oral potassium supplementation. Working diagnose at the time of discharge was renal tubular acidosis (RTA) vs. hypokalemic periodic paralysis (HypoKPP). Genetic testing for both conditions is ongoing.

IMPACT/DISCUSSION: We present a case of sudden severe hypokalemia with muscle paralysis and QTc prolongation occurring in the setting of intermittent hypokalemia of unclear cause. Approximately 49% of patients with severe hypokalemia (K<2.5mEq/L) are symptomatic, predominantly with muscle weakness/paralysis. Etiologies considered in this case include hyperaldosteronism, thyroid disease, RTA (types 1 and 2), HypoKPP, and dietary. Normal aldosterone and TSH in this case made these diagnoses less likely. Poor potassium intake secondary to limited diet may have contributed but is unlikely to be the sole cause of her presentation. We initially suspected RTA given hypokalemia in setting of normal anion gap metabolic acidosis. While inappropriately elevated urine pH does support Type 1 RTA, both RTA types are less likely with a normal urine potassium level. We also had concern for HypoKPP, a rare skeletal muscle channelopathy (incidence 1:100000) characterized by severe muscle weakness with sudden profound hypokalemia, typically triggered by strenuous exercise or high carbohydrate diet.

CONCLUSION: - Muscle weakness is a presenting symptom in approximately half of cases of severe hypokalemia (<2.5mEq/L). Other symptoms that can been seen in these cases include nausea/vomiting and QTc prolongation.

- Type 1 and 2 RTA is associated with hypokalemia with increased urine potassium level.

- HypoKPP is a rare condition (incidence 1:100000) associated with severe muscle weakness and sudden profound hypokalemia.

PARANEOPLASTIC CEREBELLAR DEGENERATION IN METASTATIC PROSTATE CANCER: A CASE REPORT

Janani Arunachalam¹; Christine Li¹; Natalie Zolotareva¹; Madura Saravanan². ¹Internal medicine, UConn Health, Farmington, CT; ²Medicine, UConn Health, Farmington, CT. (Control ID #4064946)

CASE: A 60-year-old male with a history of metastatic prostate adenocarcinoma, status post 2 cycles of docetaxel and 6 months of androgen deprivation therapy (ADT) with abiraterone and leuprorelin, alcohol and tobacco use disorder presented with worsening lower and upper extremity weakness and paresthesia with frequent falls and associated slurred speech for 2 months. Neurologic examination revealed positive finger-to-nose and heel-to-knee tests, mild truncal ataxia with a wide-based gait with dysdiadokinesia and positive Romberg sign. Muscle strength was 5/5 in all four extremities with absent deep tendon reflexes, except 1+ in the right bicep. Motor speech dysarthria was observed with 100% intelligibility, but reduced artic precision. He had intact extraocular movements with coarse end-gaze nystagmus bilaterally. Pertinent lab findings include no leukocytosis, negative urine toxicology, normal TSH and B12 levels. Serum paraneoplastic Ab panel was positive for anti-VGCC (>30 pmol/l) and negative anti-Hu antibodies. Brain MRI was unremarkable for any acute intracranial abnormalities including stroke. The patient was initially administered high-dose thiamine as part of the diagnostic workup for the possibility of nutritional deficiency-related neurological symptoms; however, there was no improvement in the neurological symptoms. Further investigation was pursued. Lumbar puncture was negative for malignant cells and paraneoplastic antibodies. Multiple myeloma and neurosyphilis workup was negative. Repeat PSA testing showed increased levels. CT chest, abdomen and pelvis showed known diffuse skeletal sclerotic metastases, however no abnormal masses or pathologic lymphadenopathy. Patient was diagnosed with paraneoplastic cerebellar degeneration secondary to progressive prostate malignancy. He was treated with intravenous Solu-Medrol 1 gram daily for 3 days and later transitioned to oral prednisone with significant improvement in his neurological symptoms.

IMPACT/DISCUSSION: Neurologic paraneoplastic syndromes, a rare sequela of cancer are most commonly seen in small-cell lung cancer and thymomas. Anti-Hu antibodies are typically associated with rapidly progressive cerebellar degeneration, while anti-Voltage Gated Calcium Channel (VGCC) antibodies are associated with Lambert-Eaton syndrome (LES). However, we present a case of cerebellar degeneration in the setting of metastatic prostate adenocarcinoma with positive anti-VGCC antibodies. It shows an overlap of serum lab findings between LES and rapidly progressive cerebellar degeneration, in addition to an uncommon association between metastatic prostate cancer and paraneoplastic syndrome.

CONCLUSION: Paraneoplastic cerebellar degeneration was found to be related to increased severity of associated malignancy and is often diagnosed in later stages as seen in our patient with metastatic prostate cancer. Further investigation may be needed to determine further implications of specific antibodies and its mechanism of disease.

PARANEOPLASTIC CUSHING’S SYNDROME IN METASTATIC SMALL CELL CARCINOMA

Elizabeth McDonald¹; Victoria Vardell²; Mita S. Hoppenfeld²; Heather Balch³. ¹internal medicine, University of Utah Health, Salt Lake City, UT; ²Internal Medicine, University of Utah Health, Salt Lake City, UT; ³Department of General Internal Medicine, University of Utah, Woods Cross, UT. (Control ID #4060410)

CASE: A 57-year-old male with a history of class 3 obesity and recently diagnosed hypertension presented to an oncology clinic with right upper quadrant pain and imaging findings of multiple pulmonary nodules, hepatic lesions, a gallbladder fossa mass, and osseous lesions concerning for metastatic malignancy of unknown primary. Initial work up revealed a CA 19-9 of 4888 U/mL and a CT-guided liver biopsy was performed. A few days later he was admitted for worsening dyspnea, edema, blurry vision, polyuria, and polydipsia. He reported a 70lb weight gain over 6 months, reaching 460lbs. His blood pressure, previously well controlled, was now 176/92. Exam noted abdominal striae, obesity, and 3+ pitting edema to the hip. Labs were significant for potassium of 2.9 mEq/L, glucose of 411 mg/dL, A1c of 9.6% from less than 6% one year prior. Cortisol was elevated to 49.7 mcg/dL with an ACTH of 105 pg/mL, which increased to 148 following 1mg dexamethasone suppression testing. 24-hour urine cortisol was 5060 mcg/day concerning for paraneoplastic Cushing Syndrome. Liver biopsy returned with small cell carcinoma positive for CK7, Synaptophysin, and TTF-1. While TTF-1 may indicate a lung primary, imaging was more consistent with a primary gallbladder malignancy.

He was treated with spironolactone and insulin, and started ketoconazole followed by metyrapone for his hypercortisolism. His symptoms rapidly responded, with normalization of lab values, blood pressure, resolution of diabetes, and a 40lb weight loss. His malignancy was managed with carboplatin, etoposide, and atezolizumab, and remains stable.

IMPACT/DISCUSSION: Cushing’s syndrome presents with many nonspecific signs that can easily be confused for progression to metabolic syndrome in a patient with obesity, and contribute to delay in diagnosis and treatment. This can highlight the need for physician self-reflection on obesity and overweight bias and how it can impact clinical care. Rapid development of diabetes, weight gain, lower extremity edema, and new onset hypertension should prompt additional workup of etiologies beyond obesity-associated metabolic syndrome. Paraneoplastic cushing syndrome is exceedingly rare and its management is unique, with treatment of the underlying malignancy required for long term control. While small cell carcinoma is generally associated with Cushing Syndrome, here the primary malignancy is thought to be of gallbladder primary, adding to the exceptionality of this case.

CONCLUSION: -Cushing’s syndrome has nonspecific features that can easily be attributed to progression to metabolic syndrome in a patient with obesity, delaying diagnosis and treatment

-Though just 10-15% of Cushing’s cases, paraneoplastic ectopic ACTH production requires unique management with treatment of the underlying malignancy for long term control.

PARANEOPLASTIC SYNOVITIS AS A RHEUMATOLOGICAL PRESENTATION OF LUNG CANCER

Emmanuel Oundo. Internal Medicine, University of Kansas - Wichita, Wichita, KS. (Control ID #4064066)

CASE: A 71-year-old male presented with a three-week history of fatigue and waxing and waning bilateral midfoot, ankle, knee, hip, middle finger, and shoulder pain. His past medical history included chronic obstructive pulmonary disease, and a 50-pack year smoking history.

Insidious in onset, his pain worsened over the preceding 3 weeks. It made standing for extended periods of time difficult, was worse in the mornings, and improved by evening. He endorsed warmth and swelling of the middle fingers, without swelling of his other fingers. In the year preceding his current presentation, he experienced unintentional weight loss of 20 pounds.

On examination, both third fingers were swollen from the distal end of the middle phalanx to the proximal end of the proximal phalanx (see image). The swelling was fluctuant, and non-pitting. The overlying skin was erythematous and warm. Both third fingers were tender to touch, and the pain was aggravated by flexion of the fingers.

His serum sodium was 117 mmol/L; urine sodium 25 mmol/L and urine osmolality 488 mOsm/kg. Rheumatoid factor and anti-CCP antibodies were positive. X-ray of the hands showed that the finger joint spaces were well maintained.

Favoring syndrome of inappropriate anti-diuretic hormone (SIADH), a chest X-ray was obtained. It showed an irregular nodule in the right upper lobe with multiple enlarged mediastinal lymph nodes. The biopsy of the nodule was positive for small cell carcinoma (SCLC) with positivity for TTF-1, synaptophysin, CD 56, pancytokeratin, CK-7, EMA, NSE, and Ki-67.

The hyponatremia had good response to hypertonic saline, and the patient was discharged from the hospital with follow up appointments for primary care and oncology. Upon 2-month follow up as outpatient, he was started on carboplatin, etoposide, and dexamethasone for chemotherapy, and duravalumab for immunotherapy. His finger swelling and finger joint pain, erythema, and swelling had resolved.

IMPACT/DISCUSSION: Classically, paraneoplastic rheumatic syndrome will appear either simultaneously, or up to 2 years preceding the diagnosis of malignancy<span style="font-size:10.8333px">.</span> Additionally, treating the malignancy will lead to complete resolution of the paraneoplastic rheumatoid disease, confirming the causality. Suhel G et al summarized case series in which out of 44 lung cancer cases that had paraneoplastic inflammatory arthritis, 26 were non-small cell and 3 were small cell lung cancer.

This patient’s synovitis was thought to be paraneoplastic due to lack of joint destruction on imaging and the atypical RA clinical presentation of affecting the hands bilaterally but only in the 3^rd finger. The causality has been established in follow-up as the patient’s inflammatory arthritis has resolved with treatment of his SCLC.

CONCLUSION: This case shows that careful consideration and recognition of rheumatological diseases as atypical paraneoplastic presentation may help to diagnose lung cancer and other malignancies.

PEMBROLIZUMAB-INDUCED HYPOTENSION, HYPERFERRITINEMIA, AND DISSEMINATED INTRAVASCULAR COAGULATION SUCCESSFULLY TREATED WITH GLUCOCORTICOIDS

Alex Eishingdrelo^1,2; Chang Yoon Doh^2,1; Ho Jun Lee¹; Marcus Trybula¹; Ankit Mangla¹; Sherwin DeSouza¹; Benjamin Tomlinson¹; Koen van Besien¹; Albert Jang¹. ¹Hematology/Oncology, University Hospitals, Cleveland, OH; ²Case Western Reserve University School of Medicine, Cleveland, OH. (Control ID #4060274)

CASE: A 48-year-old woman with triple-negative stage IIIB breast cancer receiving neoadjuvant therapy presented with high fever, tachycardia, and painless blanching rash. The patient had previously completed four cycles of pembrolizumab/carboplatin/paclitaxel, with most recent infusion three weeks prior to her presentation. The patient met criteria for severe inflammatory response syndrome (SIRS) and was admitted to the ICU, where norepinephrine infusion was given after her hypotension was refractory to intravenous fluids. She was initially treated with antibiotics for suspected sepsis, but blood cultures and urinalysis were negative. Renal function panel was unremarkable, and CT scan of the chest, abdomen, and pelvis showed no acute abnormalities. Additional studies revealed ferritin of >9,000 ng/mL, C-reactive protein of 20.89 mg/dL, and soluble IL-2 Receptor to 9418 pg/mL. From her admission to hospital day four, the patient had worsening anemia (from 10.8 g/dL to 8.2 g/dL) and thrombocytopenia (from 144,000/uL to 36,000/uL), prompting further tests. These revealed a decrease in fibrinogen (from 312 mg/dL on admission to 130 mg/dL on hospital day 4), along with elevated D-Dimer (62,272 ng/mL) and a protime (PT) of 18.0 seconds. Bilateral upper extremity venous thromboses were also identified on ultrasound. The patient thus met clinical diagnostic criteria for both disseminated intravascular coagulation (DIC) and hemophagocytic lymphohistiocytosis (HLH), although cytokine-release syndrome (CRS) could not be excluded. The patient was given 2 mg/kg/day of prednisone and received a non-titrated heparin drip. The heparin dose was gradually increased as tolerated and supportive blood products were also administered as needed for DIC. The patient showed clinical improvement marked by a steady rise in platelet counts and a reduction in ferritin and D-dimer levels. Consequently, the patient was discharged with long-term prednisone taper and anticoagulation.

IMPACT/DISCUSSION: Immune checkpoint inhibitors (ICIs), such as pembrolizumab, show therapeutic promise across various malignancies and improve event-free survival in early triple-negative breast cancer. However, ICIs, by activating T-cells, may cause severe inflammatory responses, including HLH, CRS, and DIC. At present, these complications have limited documented cases, which may prevent their timely recognition. In our case of severe ICI-induced inflammation, a collaborative approach involving internists, intensivists, oncologists, allergists, and dermatologists proved essential. Furthermore, our case underscores that the timely administration of high-dose steroids can swiftly alleviate inflammation-related complications associated with ICIs.

CONCLUSION: ICIs are a promising asset in cancer treatment but can result in severe immune-related complications. Our case underscores the importance of interdisciplinary care and treatment with high-dose steroids in the management of ICI-induced inflammatory-mediated complications and DIC.

PERFORATED SIGMOID DIVERTICULITIS PRESENTING AS PNEUMOMEDIASTINUM

Nancy Mayer, Vijay Kata, Trisha Andrews, Nishita Vattem. Internal Medicine, Riverside HealthCare, Kankakee, IL. (Control ID #4064342)

CASE: A previously healthy 63-year-old with past medical history including rheumatoid arthritis, prostate cancer, and GERD presented with a complaint of shortness of breath and neck swelling. The patient noted a vague abdominal pain but had no signs of peritoneal irritation or abdominal tenderness. Physical exam demonstrated predominant crepitus and bloating of the neck. Urgent chest imaging revealed extensive pneumomediastinum that tracked inferiorly with subcutaneous emphysema in the abdominal wall. Given the risk of respiratory compromise, the patient was placed in the intensive care unit for close observation and further work-up of primary versus secondary pneumomediastinum. The work-up including CT esophagram was unrevealing, his respiratory status remained stable, and he was ultimately discharged home with a CT scan ordered for two weeks post-discharge. However, the patient returned to the hospital one week later with infectious symptoms and was empirically covered for mediastinitis with broad-spectrum antibiotics. During this admission, the patient’s recurrent, progressive symptoms were investigated with a CT scan of the chest, abdomen, and pelvis that demonstrated a 3.1 cm loculated fluid collection adjacent to the sigmoid colon with extravasation of gas into the adjacent subcutaneous space. A diagnosis of perforated diverticulitis with abscess and subcutaneous fistula was made. The patient's initial presentation of pneumomediastinum and subcutaneous emphysema of the abdominal wall was due to the rostral tracking of air from the sigmoid fistula through the subcutaneous space. The patient had a sigmoid colectomy and was discharged 3 days postoperatively.

IMPACT/DISCUSSION: Pneumomediastinum is typically seen from alveolar rupture. Subcutaneous emphysema of gastrointestinal origin is extremely rare. Existing literature suggests it is most frequently seen in surgical complications such as the breakdown of anastomoses, fistula formation, or infections. Fewer than 20 cases of pneumomediastinum due to colonic perforation, excluding iatrogenic and traumatic injury, exist in the literature. Although rarely caused by nontraumatic perforations, abdominal etiologies should be considered in the setting of idiopathic pneumomediastinum as subcutaneous air prefers to track superiorly.

CONCLUSION: In closing, diverticular perforation may be complicated by a subcutaneous fistula that presents with subcutaneous air in compartments outside of the abdomen. Although this condition is rare, it is a stark reminder that the patient’s chief complaint, which in this case was abdominal pain, should be respected in the initial evaluation of disease. Further emphasis on patient-centric complaints will improve outcomes and prevent delayed diagnoses.

PERSISTENT, SUBACUTE HIGH GRADE FEVER SECONDARY TO MULTIPLE LOCULATED LIVER ABSCESSES: AN UNCOMMON CASE OF NEWLY DIAGNOSED CHRONIC GRANULOMATOUS DISEASE (CGD) IN AN ADULT PATIENT.

Matthew Gott¹; Rachael Hagen²; Thomas Erwes³; Jennifer D. Baldwin¹. ¹Internal Medicine, UConn Health, Farmington, CT; ²Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; ³Infectious Diseases, UConn Health, Farmington, CT. (Control ID #4065009)

CASE: A 29-year-old male with a history of Crohn’s disease on adalimumab, skin infections, and respiratory infections over the past year presented with fevers to 104F x4 weeks. Fevers were associated with night sweats, a 20lb weight loss, cough, abdominal pain, and diarrhea. Social history was significant only for tobacco use. Exam found diffuse abdominal tenderness and an enlarged, painful liver. Lab workup found a WBC of 21K, normal immunoglobulin levels, and a negative HIV test. CT imaging found a spiculated lesion in the right upper lobe and emphysematous changes of the right lung. Right upper quadrant ultrasound found cystic and solid masses concerning for liver abscesses. Drains placed produced minimal output and cultures grew MSSA. Drainage and IV antibiotics failed to improve the patient’s condition. After learning from the patient’s mother the patient had recurrent skin and respiratory infections starting in childhood, a DHR 123 oxidation assay was obtained. Results supported a diagnosis of chronic granulomatous disease (CGD). Corticosteroids were started and symptoms abated. The patient was discharged with IV cefazolin, prophylaxis for infection, serial imaging, a referral to genetics, and a referral to hematology for bone marrow transplant consideration.

IMPACT/DISCUSSION: CGD is a rare genetic disease with variability in phenotype. Granuloma formation and impaired destruction of pathogens due to impaired function of NADPH oxidase results typically in skin, GI, and respiratory infections, although any organ system can be affected. Milder forms can be diagnosed late in life. DHR 123 oxidation assay is the initial test. Genetic testing is used to confirm and to determine carrier status of relatives. INF-gamma is strongly recommended along with infection prophylaxis. Hepatic abscesses can occur in up to 25% of patients with CGD and unlike immunocompetent persons, patients with CGD will usually not improve on antimicrobial therapy and drainage alone. Corticosteroids are strongly recommended for the resolution of abscesses and surgery is sometimes required. Often, CGD patients are mistakenly diagnosed with Crohn’s disease given the similar presentation of colitis, diarrhea, and fistula formation. Both show inflammation and granulomas on colonic biopsies. CGD colitis patients may be treated with TNF inhibitors and immunosuppressants for presumed Chron’s disease. These can cause severe infections or death. This case demonstrates the importance of questioning previous diagnoses and paying careful attention to the patient’s past medical history. It is important to remember that while congenital conditions are classically diagnosed during childhood, the internist should not discount the possibility of an undiagnosed congenital pathology.

CONCLUSION: Symptoms of CGD can be missed when the patient is a child depending on the phenotype. Management of hepatic abscesses differs in patients with CGD patients and requires use of corticosteroids in adjunction to IV antibiotics.

PFOCUS ON THE UNUSUAL: A STROKE OF PARADOX

Michael Sabina¹; Aqeel A. Khanani²; Joshua Tsai³; Amanda Rigdon². ¹Internal Medicine - GME, Lakeland Regional Medical Center Inc, Lakeland, FL; ²Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; ³Graduate Medical Education, Lakeland Regional Health, Chino Hills, CA. (Control ID #4064962)

CASE: An 83-year-old male with a complex medical history, including atrial fibrillation, prior transient ischemic attacks, myocardial infarction, and diabetes, presented with stroke-like symptoms. Initial evaluation revealed a left middle cerebral artery occlusion and a left leg deep vein thrombosis (DVT). Subsequently, he developed a hemorrhagic conversion of the stroke. An echocardiogram raised the possibility of a PFO, suggesting a paradoxical embolus as the stroke's etiology. Due to hemorrhagic conversion, anticoagulation was contraindicated, and an inferior vena cava (IVC) filter was placed.

IMPACT/DISCUSSION: Paradoxical embolism represents a phenomenon where an embolic thrombus aberrantly traverses from the venous to the arterial system, frequently through a patent foramen ovale (PFO). The therapeutic approach to paradoxical emboli primarily encompasses systemic anticoagulation therapy, and in select scenarios, surgical or transcatheter closure of the PFO. Clinical decision-making in PFO management incorporates an evaluation of the Risk of Paradoxical Embolism (RoPE) score, in conjunction with the PFO's anatomical characterstics as per the PASCAL classification system. These assessments facilitate stratification of the recurrence risk for paradoxical embolic events, spanning a spectrum from low to high, which consequently guides clinical strategies. In individuals over 60 years of age, PFO closure is generally reserved for cases exhibiting probable to high classification. Guidelines are less definitive for patients exceeding 80 years of age with a high risk PASCAL classification. A clinical dilemma emerges in cases where a patient experiences an ischemic stroke, secondary to a lower extremity deep vein thrombosis (DVT), followed by hemorrhagic transformation. The decision to implant an IVC filter, in lieu of anticoagulation or PFO closure, was predicated on the patient's overall clinical picture and the immediate risk of further hemorrhagic events. Despite the high risk as per the PASCAL classification, the hazards of surgical intervention in the context of hemorrhagic stroke, coupled with the contraindication for anticoagulation, necessitated the IVC filter placement as the most beneficial intervention with minimal risk.

CONCLUSION: In patients with paradoxical embolism and contraindications to anticoagulation or invasive procedures, an individualized approach is crucial. The use of an IVC filter in this context was a strategic decision to reduce the risk of further embolic events while minimizing the risk of exacerbating the current intracranial hemorrhage. This case underscores the importance of tailoring management strategies to the unique clinical scenarios of each patient, especially in the context of multiple, complex comorbid conditions.

PHEOCHROMOCYTOMA CRISIS

Mariel Duchow, Gordon White, Virginia Velez Quinones, Muhammed Rehan, Shaun Isaac. Internal Medicine, University of Miami School of Medicine, Miami, FL. (Control ID #4019469)

CASE: This is a male in his sixties with newly diagnosed stage III colorectal cancer who was referred to the emergency department from his oncologist office for evaluation of tachycardia and dyspnea. The day prior, the patient underwent his first cycle of chemotherapy and also received a dose of dexamethasone for chemotherapy-induced nausea and vomiting prophylaxis. After receiving the infusion, he went home with chills, nausea, and vomiting. After following up with his oncologist the following morning, he was found to be dyspneic. The patient’s past medical history is significant for cerebrovascular accident and pheochromocytoma (PC) of right adrenal gland. A year prior, the patient was hospitalized for a cerebrovascular accident and found to have a complex adrenal mass on imaging. Due to concerns for malignancy, the patient underwent needle biopsy of right adrenal mass consistent with PC. Initial vital signs revealed blood pressure of 125/92 mmHg, tachycardic to 153 beats per minute, tachypneic with a respiratory rate of 28, oxygen saturation of 88-94% on nonrebreather. The remainder of his physical exam was unremarkable. At initial assessment, medical records including the histology report were unavailable to the medical team. His initial labs were concerning for end-organ dysfunction.

Given the severe laboratory derangements, the patient was admitted for presumed severe sepsis. The patient was fluid resuscitated, received dose of ondansetron for nausea, and started on broad-spectrum antibiotics. During the initial workup, the patient’s condition deteriorated dramatically over a few hours with symptoms of weakness, pallor, sweating, and wide fluctuations of blood pressure. Surgical adrenalectomy was considered, though not executed in view of new information. After discussion with hematology-oncology, tissue biopsy of rectal mass and inguinal node were thought to be small cell cancer, but consistent on rereview with PC metastasis. Five days later, despite attempts of intermittent initiation of alpha-blockade, hemodynamic instability persisted. Multi-organ dysfunction progressively worsened. After discussion with family about goals of care and prognosis, they transitioned the patient to hospice care.

IMPACT/DISCUSSION: We present a case of catecholaminergic crisis precipitated by steroids in the presence of pheochromocytoma. There are numerous case reports describing the presentation of pheochromocytoma crisis, but data on the perioperative management of these patients are lacking.

CONCLUSION: Although rare, clinicians should consider pheochromocytoma crisis if a patient presents with elevated lactic acidosis and end-organ dysfunction after recent steroid administration, with or without hypertension, in the setting of a known adrenal mass.

PLEASE REMAIN SEATED IN YOUR VENTRICLE: MANAGING A CLOT-IN-TRANSIT IN A PATIENT PRESENTING WITH PULMONARY EMBOLI

Brett Chen¹; Alban Cela¹; Aron Soleiman²; Maneesha Bangar³. ¹Medicine, Montefiore Medical Center, Bronx, NY; ²Pulmonary & Critical Care Medicine, Northwell Health, New Hyde Park, NY; ³Critical Care Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4063928)

CASE: A 39-year-old female with a history of human immunodeficiency virus and pulmonary embolism, non-adherent to chronic anticoagulation, presented to a tertiary medical center reporting shortness of breath. Point-of-care echocardiography revealed a 2.8-centimeter right ventricular mass, concerning for thrombus, with right heart strain. Computed tomography imaging additionally showed pulmonary emboli in all right pulmonary lobes and the left upper lobe. Blood pressure remained normal. The patient was heparinized and transferred to an intensive care unit where systemic tissue plasminogen activator was administered. Despite thrombolysis, repeat echocardiography showed no change in mass size. Prophylactic femoral artery and vein cannulation for potential extracorporeal membrane oxygenation (ECMO) was performed in case of deterioration.

After an inter-specialty discussion on optimal management, surgical thrombectomy was planned. Right ventricular thrombectomy and pulmonary artery embolectomy were performed under cardiopulmonary bypass. A sample of the right ventricular mass was confirmed to be thrombus. Post-procedurally, the patient experienced a brief period of cardiogenic shock requiring inotrope support but otherwise recovered well. They were started on apixaban before being discharged with outpatient Hematology follow-up for coagulopathy evaluation.

IMPACT/DISCUSSION: Pulmonary embolism is relatively common, occurring one to two times per 1000 patients annually. About 4% of these patients have a free-floating thrombus in the right heart, commonly referred to as "clot-in-transit", which conveys an overall in-hospital mortality rate of 45%. However, mortality varies based on treatment modality - 100% with no intervention, 28.6% with anticoagulation, 23.8% with surgical embolectomy, and 11.3% with thrombolysis. Catheter-directed thrombectomy and thrombolysis are additional treatment options. There are no widely accepted guidelines to direct management.

Determining when a clot-in-transit might migrate into the pulmonary vasculature is difficult, and patients are at a high risk for obstructive shock and death. Monitoring should be conducted in a critical care setting. Multidisciplinary management with a Pulmonary Embolism Response Team is recommended. If systemic thrombolysis is contraindicated or fails, catheter-directed or surgical thrombectomy are often indicated. Early Cardiothoracic Surgery consult for ECMO is suggested in such patients due to high risk of cardiopulmonary collapse.

In this case, anticoagulation and systemic thrombolysis were chosen for initial management. However, treatment choice may be affected by patient comorbidities, degree of hemodynamic instability, and the resources available at the treating facility.

CONCLUSION: A clot-in-transit is a life-threatening condition with a high risk for rapid clinical deterioration. Prompt and individualized treatments with close monitoring in an intensive care setting are vital for ensuring the best possible clinical outcome.

PLEURAL BIOPSY POSITIVE FOR INTERNIST'S TUMOR

Harpreet Gosal, Sarbjit Masson. Internal Medicine, Hamilton Medical Center, Dalton, GA. (Control ID #4063000)

CASE: Our patient is a 69-year-old male with a past medical history of renal cell carcinoma (RCC) in remission, left radical nephrectomy, and a history of repeated thoracentesis in the last six months. Results of multiple pleural fluid analyses were indicative of exudative fluid and negative for malignancy. The patient eventually underwent placement of a Pleurx catheter with slight improvement of his symptoms. The Pleurx catheter was removed due to difficulty with adequate fluid drainage. Shortly afterward, the patient presented to our inpatient facility for progressively worsening shortness of breath, requiring 4L nasal cannula. Labs revealed a leukocytosis of 12.4 x 0^3/mcL and hemoglobin of 9.2 g/dL. A large effusion of the left hemithorax was prevalent on chest x-ray. CT chest showed emphysema with a large loculated left pleural effusion and rim enhancement. The patient underwent CT-guided drainage with aspiration of 100 mL of exudative pleural fluid. There was no growth on cultures and cytology was negative. Despite multiple courses of antibiotics, the patient continued to have a loculated pleural effusion with trapped lung. He then underwent video-assisted thoracoscopic surgery (VATS) that was converted to a standard thoracotomy with intrapleural pneumonolysis, total pulmonary decortication, and mechanical pleurodesis. The pleural biopsy returned positive for clear cell carcinoma consistent with a renal primary.

IMPACT/DISCUSSION: Pleural effusion is a known complication of advanced malignancy, and is a poor prognostic marker¹. The pathophysiology of malignant pleural effusion associated with RCC is secondary to lymphatic drainage of lung metastasis or hematogenous spread through renal veins². On average, the amount of malignant effusion ranges between 500-2000 mL³. Pleural fluid cytology is the first step in diagnosing malignant effusions. The diagnostic rate with initial thoracentesis is 65%, adding 27% to the success rate with a second thoracentesis, and an additional 5% with a third thoracentesis³. In our patient, malignant cells were not identified on fluid analysis. In a retrospective study consisting of 152 patients with malignant pleural effusions, 48% were diagnosed by cytology⁴. In another study, 75% of patients had positive cytology from the first pleural fluid⁵. However, in this study, the sensitivity of pleural fluid was highest in lung and breast cancer, with no direct data on RCC⁵. Overall, RCC accounts for only 1-2% of all malignancy-related pleural effusions². Provided the low sensitivity in cytological testing, further investigations with pleural biopsy, VATS, or thoracotomy are warranted⁶. Due to it's elusive diagnosis, RCC is labeled the internist's tumor. Treatment remains palliative in all cases of malignant pleural effusions¹.

CONCLUSION: Despite multiple pleural fluid analyses, the results were inconclusive for malignancy. Our patient was in remission with no other clinical signs of active cancer. Hence, the role of cytology is limited in cases of RCC.

PLEURAL EFFUSION IN A PATIENT WITH NO KNOWN MEDICAL HISTORY

Erik X. Tan, Anita Lee. Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4056020)

CASE: A 36-year-old male with no known past medical history presented with two weeks of nausea, vomiting, abdominal pain, and chest pain along with new-onset fevers. Initial imaging showed a moderate-sized right pleural effusion and bilateral groundglass opacities and tree-in-bud nodules. He was initially started on community-acquired pneumonia coverage, but after admission, he was recommended chest tube placement after bedside ultrasound showed clear loculations, though likely simple fluid. History gathered included recent arrival from Africa, prior incarceration, taking care of a patient with active tuberculosis 6 years prior, and active tobacco use. He did not have any prior tuberculosis testing but did report prior chest x-rays without concern for active pulmonary tuberculosis. Fluid studies from the chest tube were consistent with lymphocytic exudative effusion, without empyema, and noted a mildly elevated ADA. Infectious workup, including three consecutive induced sputum AFB stains, remained negative other than a positive rhinovirus/enterovirus, and his symptoms persisted on antibiotics. He eventually underwent a pleural biopsy which showed necrotizing granulomas without evidence of malignancy. He was started on RIPE even with negative AFB stains from the pleural biopsies and quickly defervesced. Over two weeks later, mycobacterium tuberculosis grew in multiple pleural biopsy samples.

IMPACT/DISCUSSION: Pleural tuberculosis is a common cause of pleural effusions in endemic regions but is rarely seen in the US. In most cases, thoracentesis is sufficient to obtain fluid studies and provide symptomatic relief for these effusions. Though most often a cause of exudative, lymphocytic effusions, chronic cases can lead to empyema formation. Pleural fluid pH is normally low, but high levels cannot be used to rule it out. Sputum AFB stains and culture along with pleural AFB stains may be negative, but treatment should not be deferred for a positive culture result if there is high pretest probability and other possible causes, including infection and malignancy, are ruled out.

Another notable learning point from this case is a reminder to take focused but thorough histories on initial patient presentation. This patient had many risk factors for tuberculosis that allowed for quick pivoting in his care and should have warranted earlier airborne precautions to limit potential exposure of other healthcare providers. Notably, however, pleural tuberculosis is not contagious in the same way as pulmonary tuberculosis, and airborne precautions were stopped 72 hours after RIPE therapy was initiated.

CONCLUSION: - Pleural tuberculosis is not often seen in the US but is a common cause of pleural effusions worldwide, so it must be considered in patients from endemic regions.

- Obtaining a focused but detailed history on initial presentation can change the course for patients and protect other healthcare providers from unnecessary exposures.

PNEUMOCYSTIS JIROVECII PNEUMONIA AND HIV: AN UNCOMMON PRESENTATION WITH DERMATOLOGIC MANIFESTATIONS

Brian Hall²; Ruth Dunn¹; Christopher O'Donnell³. ¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Emory University School of Medicine, Atlanta, GA; ³Medicine, Emory University, Atlanta, GA. (Control ID #4064489)

CASE: A previously healthy 30-year-old male presented to the emergency department with a one-month history of dyspnea and productive cough. He reports being unable to walk more than a block without severe dyspnea. He denied fever, chills, chest pain, weight loss, and nausea. Home Covid-19 test was negative. He reported occasional marijuana use, which exacerbated his symptoms, and three sexual partners in the past year. He reports inconsistent use of condoms. He endorsed cat and flea exposure.

Exam findings revealed diffuse lung crackles, cachexia, and diffuse round, purple excoriated papules on his extremities sparing his palms and soles. A painless, clean-based lesion was found on his scrotum. Labs were significant for hyponatremia (sodium 129) and leukocytosis (leukocyte count 17.1). A computed tomography scan of the chest revealed ground-glass opacities concerning for multifocal pneumonia.

Empiric treatment with ceftriaxone and doxycycline was started for community-acquired pneumonia and atypical pneumonia. Sexually transmitted infection (STI) screening was also performed. Subsequent discovery of human immunodeficiency virus (HIV) positivity with a CD4 count of 30 led to empiric Pneumocystis jirovecii pneumonia (PJP) treatment using Bactrim DS. Treatment was continued when PJP polymerase chain reaction (PCR) testing returned positive.

The hospitalization course was complicated by severe dyspnea requiring steroids. The patient also developed a Type IV Renal Tubular Acidosis (RTA) secondary to Bactrim use. PJP treatment was transitioned to clindamycin and primaquine with good effect. Dermatology consultation suggested a diagnosis most consistent with a papular, pruritic eruption of HIV, likely triggered by a hypersensitivity reaction to arthropod bites. Antiviral therapy was initiated, and upon discharge, the patient received a reduced dose of Bactrim for prophylaxis, which he tolerated well during subsequent follow-ups.

IMPACT/DISCUSSION: This case highlights the rarity of PJP as a presenting sign for patients with undiagnosed HIV and draws attention to dermatological manifestations in those with immunosuppressed states. Specifically, the patient’s skin reaction following arthropod exposure advocates for greater exploration into the correlation between unusual dermatologic findings and infectious diseases. Additionally, the development of a Type IV RTA emphasizes the importance of recognizing adverse medication reactions and remaining adaptable in treatment approaches.

CONCLUSION: 1. Remain vigilant for uncommon disease presentations. Unusual symptoms like dermatological manifestations might offer diagnostic clues and prompt a broader investigation.

2. Stay flexible in addressing patient intolerance to initial treatment protocols.

PNEUMOCYSTIS PNEUMONIA FOLLOWING RITUXIMAB AND CORTICOSTEROID THERAPY - A CHALLENGING CASE OF FULMINANT OPPORTUNISTIC INFECTION

Eric S. Norrell²; Emily Nehl¹; Wanna Zhang¹; Sabrina Schundler². ¹Rush University Medical Center, Chicago, IL; ²Rush University Rush Medical College, Chicago, IL. (Control ID #4046859)

CASE: An 85-year-old female with a history of insulin-dependent diabetes and pemphigus vulgaris treated with rituximab infusions and chronic prednisone therapy presented with four days of dyspnea and non-productive cough. The patient was hypoxic to 84% on room air requiring 6L of O₂ via nasal cannula. Inspiratory crackles were heard in the bilateral lower lung fields. Chest x-ray revealed ill-defined ground-glass opacities in the perihilar and basilar lungs.

Persistent hypoxic respiratory failure despite community acquired pneumonia (CAP) treatment and social history of prior bird ownership raised suspicion for interstitial lung disease. High-resolution CT of the chest demonstrated indistinct ground-glass opacities with upper lobe predominance and areas of mosaic attenuation, raising concern for pneumocystis pneumonia (PJP). Empiric trimethoprim-sulfamethoxazole and high-dose prednisone were initiated while awaiting confirmatory testing. Bronchoalveolar lavage (BAL) fungal panel initially returned positive for galactomannan antigen concerning for aspergillosis or histoplasmosis. Two days later, BAL PCR analysis returned positive for Pneumocystis jirovecii, confirming diagnosis of PJP. Subsequent serum studies ruled out aspergillosis and histoplasmosis, and the BAL galactomannan result was deemed to be a false-positive. The patient was discharged upon resolution of hypoxia and cough on day 22 of admission to finish a 21-day course of PJP treatment.

IMPACT/DISCUSSION: PJP has historically been associated with underlying HIV infection and CD4 counts <200 cells/μL. However, improvements in antiretroviral therapy and routine prophylaxis have decreased prevalence among HIV-positive individuals. Conversely, PJP incidence has risen among HIV-negative populations due to increased use of immunosuppressive agents for various conditions. Additionally, HIV-negative patients with PJP have a greater estimated mortality compared to HIV-positive patients.

The reason for this discrepancy in illness severity is multifactorial. First, the higher burden of organisms found in HIV-positive patients allows for easier identification of P. jirovecii via microscopy. This, along with a higher degree of clinical suspicion in HIV-positive patients, may prompt earlier diagnosis. Second, HIV-negative patients have significantly higher levels of intra-alveolar neutrophilic infiltrates which correlate with more severe lung disease and lower arterial oxygen tension.

CONCLUSION: This case highlights the importance of maintaining a high suspicion for PJP in HIV-negative patients that may be immunocompromised from another condition or treatment. Prior exposure to prednisone and rituximab were important clinical clues as these immunosuppressants increase susceptibility to PJP. Given the presence of symptomatic hypoxia on presentation and propensity for fulminant PJP in HIV-negative patients, empiric treatment prior to diagnostic confirmation was instrumental in averting a poor outcome in this case.

POLYSUBSTANCE ABUSE OF THE BRAIN: A CASE OF SUBSTANCE-INDUCED ACUTE DISSEMINATED ENCEPHALOMYELITIS (ADEM)

Asma Mohammadi, Marc Roberge. Internal Medicine, UPMC Mercy, Pittsburgh, PA. (Control ID #4039482)

CASE: A 66-year-old male with a medical history of polysubstance use (Kratom and synthetic Marijuana) presented with progressively declining mental status over the past six months. Initial Magnetic Resonance Imaging (MRI) of the brain was negative for any acute process. He was initiated on doxycycline for empiric treatment of presumptive tickborne encephalitis. Initial infectious and metabolic workup was unremarkable. The electroencephalogram was negative for epileptic activity. Cerebrospinal fluid study came back positive for elevated protein (14-3-3 protein) levels concerning for possible autoimmune encephalitis. Repeat Brain MRI showed new generalized white matter changes in the supratentorial region concerning for toxic encephalopathy. He underwent a right frontal brain biopsy which showed the histologic picture of a macrophage-rich and lymphocyte-poor demyelinating process suggestive of ADEM. He was treated with five days of methylprednisolone and two doses of Intravenous Immunoglobulin but did not demonstrate improvement in mentation. Subsequently, he was started on plasmapheresis for five days, which resulted in improvement in mentation.

IMPACT/DISCUSSION: Kratom is an herbal supplement derived from the Asian plant Mitragyna speciosa and is predominantly used for self-treating pain or mood disorders in the United States. However, recent evidence suggests it is being increasing used as an alternative to buprenorphine or methadone for opioid use disorder. Adverse effects of kratom use include agitation, confusion, and seizures. Cannabis, derived from the plant Cannabis sativa, remains the most commonly used federally-illegal illicit drug within the United States. Common adverse effects include impaired decision-making and impaired memory, but there is increasing association with psychosis and schizophrenia-spectrum disorders. Cannabis use has also been associated with development of acute encephalitis in chronic users who smoke greater than ten joints per day. We report a case of an elderly male with Acute Disseminated Encephalomyelitis (ADEM) secondary to polysubstance use.

CONCLUSION: ADEM is a rare disorder, characterized by widespread demyelination in the brain and spinal cord white matter. It remains difficult to diagnose, as it can present with either focal or multifocal neurologic symptoms, and the underlying disease pathophysiology remains unclear. Although previously associated with recent febrile illnesses and vaccinations, there have been a number of cases within the last decade attributed to external/ingested substances, including natural and synthetic cannabinoids, cocaine, heroin, and amphetamines. With the increasing use of legal and illegal substances, greater attention is needed to attempt to identify other potential triggers for ADEM. As there is currently limited data associated with ADEM associated with substance abuse, this case serves to further expand available literature and to raise awareness of substance-induced ADEM.

POST-INFECTIOUS PR3-ANCA POSITIVE GLOMERULONEPHRITIS AS A COMPLICATION OF BARTONELLA HENSELAE ENDOCARDITIS

Christopher Jowdy¹; Jess Dreicer². ¹School of Medicine, University of Virginia, Charlottesville, VA; ²Medicine, University of Virginia, Charlottesville, VA. (Control ID #4063811)

CASE: A 24-year-old man with a history of tetralogy-of-fallot was transferred to an academic medical center for evaluation of months of unexplained fever, chills, night sweats, weight loss, myalgias, arthralgias, and transient petechial rash. Initial work-up at the outside hospital included an unremarkable lumbar puncture and transthoracic echocardiogram (TTE). The patient was treated with three, two-week courses of doxycycline for presumed tick-borne illness. Fevers resolved with treatment but recurred with discontinuation and the patient re-presented in renal failure. Serologies revealed elevated Proteinase 3 - Anti-Neutrophil Cytoplasmic Antibody (PR3-ANCA) and low Complement 3. He was started on high dose steroids for suspected autoimmune disease. Renal biopsy was consistent with post-infectious glomerulonephritis and the patient was transferred to our hospital. Additional history was notable for epistaxis, cat ownership, and an aunt with systemic lupus erythematosus (SLE). Physical exam was unremarkable. Initial labs were notable for creatinine (Cr) of 10.0. Blood cultures were negative, a transesophageal echocardiogram (TEE) and tagged white blood cell scan gave no evidence for endocarditis. We continued steroids for possible ANCA vasculitis with resulting improvement in his Cr. B. henselae immunoglobulin G titers resulted and were elevated to 1:32768, yet immunoglobulin M titers were <1:20 and serum polymerase chain reaction was negative. The patient’s prodromal symptoms, epistaxis, family history of SLE, positive PR3-ANCA, and improvement with steroids all raised suspicion for ANCA vasculitides. However, the renal biopsy findings were inconsistent with this diagnosis. Ultimately, his cat exposure, improvement with doxycycline, renal biopsy findings, B. henselae serology, and reported association with PR3-ANCA positive glomerulonephritis, altogether made B. henselae endocarditis the likely diagnosis.

IMPACT/DISCUSSION: B. henselae is a fastidious organism commonly implicated in culture negative endocarditis. Valve colonization may not be detected on echocardiography or tagged WBC scan making diagnosis difficult. Rheumatologic complications can further complicate the clinical picture. It is reported that ANCA positivity occurs in as much as 60% of cases of Bartonella spp. endocarditis, which often presents as a small vessel vasculitis. In these cases, a low serum complement and renal biopsy that is not pauci-immune both evidence against ANCA vasculitides.

¹Aslangul E, Goulvestre C, Mallat Z, Mainardi J-L. Human Bartonella infective endocarditis is associated with high frequency of antiproteinase 3 antibodies. J Rheumatol 2014;41:408–10.

²Beydon M, Rodriguez C, Karras A, et al. Bartonella and Coxiella infections presenting as systemic vasculitis: case series and review of literature. Rheumatology. 2022;61(6):2609-18.

CONCLUSION: 1. B. henselae is a common cause of blood culture negative endocarditis.

2. PR3-ANCA positive glomerulonephritis is a complication of B. henselae infection.

POSTOPERATIVE PARAPNEUMONIC EFFUSION AFTER CARDIAC ABLATION ASSOCIATED WITH ACTINOMYCES ODONTOLYTICUS

Parker Williams, Carlos Fagundo, Anas Bizanti. Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4064642)

CASE: A 74-year-old female with a history of Roux-en-Y gastric bypass with 110-pound weight loss, anemia, obstructive sleep apnea, hypertension, and treatment-resistant persistent A-fib/flutter presented to the emergency department with progressive dyspnea 1 week after cardiac ablation. Review of systems was only remarkable for sweats, weakness, and dyspnea, and negative for fever, chills, jaw pain, dysuria, chest pain, palpitations, and peripheral edema. Vitals were unremarkable except for elevated blood pressure. Initial exam was only remarkable for decreased breath sounds on the right lower lung field. Complete blood cell count revealed mild neutropenic leukocytosis, hemoglobin of 9.5 g/dL, and thrombocytosis. Chest radiograph and computed tomography angiography revealed a large right pleural effusion with complete right lower lobe collapse and subsegmental atelectasis. Echocardiogram revealed a normal ejection fraction and mild pericardial effusion without compromise. The patient underwent multiple thoracenteses with cloudy, red-orange aspirate consistent with exudative effusion, and a chest tube was ultimately placed due to the fast nature of fluid reaccumulation. Thoracentesis aspirate cultures did not show any growth. Thus, bronchoscopy was done and negative for endobronchial lesions. Bronchoalveolar lavage (BAL) was positive for Actinomyces odontolyticus and Candida albicans. Repeat examination revealed poor dentition with periodontal gum disease.

IMPACT/DISCUSSION: First described in 1958, Actinomyces odontolyticus is a filamentous Gram-positive facultative anaerobic bacterium found in the oropharynx, gastrointestinal tract, and genitourinary tract of humans. As of 2019, less than 100 cases have been reported. Actinomyces odontolyticus is one of the predominant bacteria responsible for dental biofilms and is commonly found in the esophagus, which provides an ideal environment. Although our patient presented without jaw pain, sulfur granules, or sinus tracts, oral examination revealed poor dentition with a possible nidus of infection, which may have been present during her intubation for anesthesia. Our patient additionally presented with a coinfection of Actinomyces odontolyticus and Candida albicans. Of note, postpericardial injury syndrome is a known complication of cardiac ablation procedures; however, predominant pulmonary involvement is rare and cultures are typically negative.

CONCLUSION: - Among patients with poor dentition and recent intubation, the appearance of unexplained postoperative shortness of breath with pleural effusion may be caused by Actinomyces species.

- Oral examination is important despite the absence of classically described examination findings

- BAL should be considered when presented with a postoperative parapneumonic effusion to guide treatment.

PRIMARY ADRENAL INSUFFICIENCY PRESENTING AS SUBACUTE SYMPTOMATIC HYPONATREMIA

Shawn Wen¹; Aron Mednick². ¹Internal Medicine, NYU Langone Health, New York, NY; ²Medicine, NYU Langone Health, New York, NY. (Control ID #4065067)

CASE: A 39 year-old male with a family history of autoimmune disease presented with nausea, lightheadedness and fatigue for 3 weeks. He had been evaluated by his primary care physician who referred him to the hospital for a sodium of 125 (normal 5 months prior). He reported adequate oral intake and no alcohol.

On admission, he was hypotensive 95/64 without shock. Sodium was 125 and K 5.5. Serum osmolarity was 261, consistent with hypotonic hyponatremia. Urine studies were consistent with active ADH (high UNa 200) and active renin-angiotensin-aldosterone system (RAAS) (high Uosm 764). Random urine potassium was 59 mmol/L. His urine transtubular potassium gradient (4) was lower than expected in the setting of hyperkalemia. He was not taking diuretics and had normal renal, cardiac, liver and thyroid function. His morning cortisol was low (2.8 mcg/dL, normal 3.7-19.4 mcg/dL before 10AM). He had an inappropriate response to cortisol stimulation (baseline cortisol 3.3 mcg/dL, 30 minutes later 2.6 mcg/dL, 60 minutes later 2.6 mcg/dL). Renin activity and aldosterone were low (35 ng/mL/hr, 3.2 ng/mL respectively). ACTH was significantly elevated (838 pg/mL, normal 7-63 pg/mL).

This data was consistent with primary adrenal insufficiency, confirmed with positive 21-hydroxylase antibody. TPO Ab was high (400 IU/mL, normal <5.6 IU/mL) but the patient was euthymic. After initiating hydrocortisone and fludrocortisone, the patient’s Na and K normalized and his symptoms resolved. He was feeling well on 4 month follow up in endocrine clinic.

IMPACT/DISCUSSION: This case had several key teaching points:

1) Contextualizing this patient’s symptomatic hypotonic hyponatremia in the absence of gastrointestinal, renal, cardiac, thyroid and liver dysfunction raised suspicion for adrenal insufficiency and prompted evaluation. His strong family history of autoimmune disease was also important to consider.

2) Utility of the urine transtubular potassium gradient (TTKG) in evaluation of hyperkalemia: When hyperkalemic (K > 5), normally functioning RAAS should be actively excreting potassium and the TTKG should be ≥7. An inappropriately low TTKG, as with this patient (TTKG was 4), reflects inappropriate renal response to hyperkalemia, which supports consideration of hypoaldosteronism due to primary adrenal insufficiency. A TTKG that appropriately increases with mineralocorticoid treatment supports this diagnosis.

3) Patients diagnosed with primary adrenal insufficiency should be screened for other autoimmune diseases, as 50-65% of patients have one or more other autoimmune endocrine disorder. This patient had positive TPO Ab (400) but was euthymic and did not have polyglandular autoimmune syndrome.

CONCLUSION: Acute adrenal insufficiency is a medical emergency that presents with hemodynamic instability. In contrast, chronic adrenal insufficiency is subtle, highlighting the importance of careful history taking and data synthesis in considering the diagnosis in the differential and pursuing confirmatory testing.

PRIMARY HYPERPARATHYROIDISM IN PREGNANCY

Nida Anwaar. Internal Medicine, Danbury Hospital, Danbury, CT. (Control ID #4044210)

CASE: We have a 37-year-old female who was referred for primary hyperparathyroidism at the end of second trimester of pregnancy.

She had hypercalcemia, kidney stones, polyuria, without polydipsia, mental status changes, any FH of kidney stones, calcium disorders or parathyroid disorders, history of radiation to the neck or face, FH of pituitary disorders, fractures, has not been followed up with her PCP.

Labs showed Ca 11.5 mg/dl, PTH 115 pg/ml, Vit D 23 ng/ml, ALK phosphatase 64 U/L, albumin 4.2 g/dl, TSH 0.87, FT4 0.94 ng/dl, Phosphorous 2.2 mg/dl. The USG of thyroid showed 1 x 1.9 x 0.4 cm hypoechoic nodular focus inferior to the left thyroid lobe.

She was seen by the endocrine surgeon and surgery was not considered as she was in 3rd trimester by that time, calcium was not severely elevated and plan was to monitor calcium levels, vitamin D3 supplementation along with oral hydration initially. Her calcium started going up (upto 11.8 mg/dl) and was started on weekly normal saline infusion which improved calcium levels. She underwent a planned c-section and parathyroidectomy postpartum without complications, and her pathology revealed a positive parathyroid adenoma.

IMPACT/DISCUSSION: Pregnancy management of PHPT should consider fetus effects, risk of hypercalcemia and hyperparathormonemia, patient symptoms, obstetric history, and fetus's gestational age. Medical treatment includes low calcium diet, hydration, diuretics, phosphates, vitamin D supplementation, and bisphosphonates, but Cinacalcet is recommended due to safety concerns.

PHPT in pregnancy is typically treated with parathyroidectomy, especially when serum calcium is above 11 mg/dL, especially in those with previous pregnancy loss or less severe hypercalcemia. This treatment avoids harmful medications and long-term effects of hypercalcemia and hyperparathormonemia, reducing preeclampsia and preterm labor rates. The surgical approach for this patient population relies on preoperative localization, with ultrasound and MRI being the most common imaging methods. Sestamibi scans are contraindicated during pregnancy, but can be selectively used.

The timing of parathyroidectomy surgery is debated, with some patients delayed due to fetal risks, imaging limitations, and anesthesia risks. If necessary, surgery should be performed in the second trimester. Medical treatment increases maternal complications and neonatal tetany, but surgical intervention reduces complications.

CONCLUSION: Primary hyperparathyroidism in pregnancy, affecting 0.15% to 1.4% of cases, poses significant risks to both mother and fetus due to physiologic changes such as hypoalbuminemia, increased glomerular filtration rate, and calcium transport. Pregnancy can lead to early symptoms like fatigue and weakness, leading to 67% of untreated maternal and 80% of untreated fetal or neonatal complications.

The diagnosis, monitoring and management of Primary hyperparathyroidism in pregnancy is challenging.

PRIMARY PSYCHOGENIC POLYDIPSIA REFERS TO AN EXCESSIVE AMOUNT OF WATER INTAKE DISPROPORTIONATE TO THE SENSATION OF THIRST. PRIMARY OR PSYCHOLOGICAL POLYDIPSIA CAN BE SEEN IN 6%–20% OF THE PATIENTS WITH UNDERLYING PSYCHIATRIC DISORDERS. WATER INTOXICATION CAN BE SEEN IN POLYDIPSIA, WHICH MAY LEAD TO DILUTIONAL HYPONATREMIA IN INADEQUATE ELIMINATION OF EXCESS FLUID FROM THE KIDNEYS, LEADING TO CONFUSION AND SEIZURES. HERE, WE PRESENT A RARE CASE OF POLYDIPSIA LEADING TO CEREBRAL EDEMA FROM ACUTE HYPONATREMIA.

Gabriel A. Ramos¹; Mishouri Paul²; Prodip Paul²; Syed Muhammad Hussain Zaidi³; Michael Madden³; Koushik Paul⁴. ¹Medicine, University of Virginia, Charlottesville, VA; ²Medicine, Geisinger Community Medical Center, Scranton, PA; ³Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ⁴Medicine, Gouripur Upazila Health COmplex, Scranton, PA. (Control ID #4057302)

CASE: A 25-year-old female with a past medical history of eating an disorder presented to ED for any evaluation of acute onset confusion, nausea, and vomiting. She was in her usual state of health in the morning of admission. While at work, she developed a sudden headache and started to vomit. She also became confused. She reported eight episodes of non-bloody vomiting. Her headache was generalized and more severe at bilateral temples, throbbing in nature, 7-8/10 in intensity. She denies intake of any illicit drugs or over-the-counter medications. In the ED, BP was noted to be elevated (150/117 mm Hg). Lab works revealed acute hyponatremia with sodium of 127 mmol/L.

A non-contrast CT head revealed diffuse cerebral edema. The neurologist, nephrologist, and ophthalmologist evaluated the patient. Fundoscopic examination was negative for papilledema. MRI of the brain with and without contrast revealed diffuse cerebral edema with no evidence of pseudotumor. MRA and MRV of the brain were unremarkable. The patient reported a history of postpartum depression and weight gain from binge eating. She had been drinking excessive water to mask hunger. In the morning on the day of admission, she admitted to excessive water intake with minimal solute intake. Initial workup revealed acute moderate hypo-osmolar hyponatremia. It was suspected that the symptoms were related to cerebral edema that resulted from acute hyponatremia from polydipsia. The patient was placed on fluid restriction, periodic neuro check, and close monitoring of BMP. The patient’s symptoms improved significantly with the correction of hyponatremia, and she was discharged in stable condition on the third day of hospital admission. Repeat MRI after two weeks revealed resolution of cerebral edema.

IMPACT/DISCUSSION: Cerebral edema resulting from hypotonic hyponatremia by primary polydipsia can result in severe neurologic complications. Excessive water intake that exceeds the body’s water excretion capacity results in hypotonic or dilutional hyponatremia. Symptoms of diffuse cerebral edema include headaches, nausea, vomiting, lethargy, altered mental status, seizure, seizure or even death. These symptoms are secondary to raised intracranial pressure that results from diffuse or focal cerebral edema. In our patient, the symptoms started after the patient had excessive water intake. CT head and MRI brain show diffuse brain edema, while MRA and MRV of the brain were unremarkable. Her symptoms gradually improved with gradual correction of serum sodium level while on free water restriction.

CONCLUSION: Clinicians should be aware of the potential side effects of polydipsia that can lead to cerebral edema from acute hyponatremia. A detailed history should be taken to look for underlying polydipsia so that appropriate intervention can be taken in time.

PROGRESSIVE GENITAL NECROSIS: A DEVASTATING CASE OF CALCIPHYLAXIS

Alena Gonzalez, Paige Rattner, Gisela Gonzalez, Shipra Shrestha, Jeanette Sanchez Trinidad, Jessica R. Lichter. Medicine, Mount Sinai Health System, New York, NY. (Control ID #4064402)

CASE: A 61-year-old man with a medical history of diabetes, ESRD, bilateral below-knee amputations, and CAD was admitted to the hospital for pulmonary edema due to missing multiple hemodialysis (HD) sessions. The patient received HD, which improved volume status. However, his hospital course was complicated by urinary retention and urinary tract infection (UTI) requiring foley catheter placement and broad-spectrum antibiotics. Subsequently, the catheter was removed, UTI cleared, but the patient developed purulent discharge at the urethral meatus and glans penis, accompanied by rising leukocyte levels. STIs testing and a CT of the abdomen and pelvis (CTAP) were negative. Despite extended inpatient care and antibiotics, the patient developed a discolored, foul-smelling black glans penis, suggestive of necrosis. Urology team revisited and provisionally diagnosed penile calciphylaxis (PC). The patient underwent a bedside dorsal slit procedure, and surgical intervention was initially deferred due to a lack of definitive corrective measures for penile calciphylaxis. However, a repeat CTAP indicated gas presence in the penis’s corpora cavernosa and scrotum, prompting the urology team to perform debridement and penectomy for infectious source control. Pathological examination revealed gangrenous penis, extensive tissue necrosis and arterial calcification, confirming PC. Sodium thiosulfate was not administered due to the patient’s prolonged QTc interval.

IMPACT/DISCUSSION: PC, also termed calcific uremic arteriolopathy, is a rare and severe condition characterized by small blood vessel calcification in the penis. It primarily affects individuals with ESRD, particularly those on HD, leading to vessel plaque formation and subsequent tissue damage causing necrosis. PC is associated with high morbidity and mortality rates. The pathophysiology is thought to be related to secondary hyperparathyroidism and elevated calcium phosphate levels, and parathyroidectomy has been studied as potential treatment which resulted in increased survival rate. Non-surgical interventions such as sodium thiosulfate, which acts via calcium ion chelation and deposit dissolution, have shown promise as well. Performing a penile biopsy or surgery for PC diagnosis should generally be avoided. Instead, conservative measures should be employed as the first line of therapy. However, for patients at high risk of gangrene progression and sepsis, penectomy can become a necessary measure for survival and a way to enhance quality of life. In our patient's situation, the choice to undergo surgical intervention was influenced by the severity and extent of the necrosis.

CONCLUSION: This case serves as a reminder of PC’s rare but severe nature, necessitating consideration in patients presenting with penile necrosis. Given its poor prognosis and surgical implications, a multidisciplinary approach and goals-of-care discussion with the patient is essential in managing PC.

PROSTATE CANCER METASTASIS: CAUTION REGARDING DISSEMINATED INTRAVASCULAR COAGULOPATHY.

Stephen A. Akinfenwa¹; Andrew Brown¹; Zachary Wright¹; Margaret Smythe¹; Rekha Kumari². ¹Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; ²Hospital of Central Connecticut at New Britain, New Britain, CT. (Control ID #4063448)

CASE: The patient is a 59-year-old male with a past medical history of prostate cancer with metastasis to the bone who presented to the emergency department after a syncopal episode resulting in a fall. Over the last few weeks prior to presentation, the patient experienced an overall functional decline, including severe fatigue and pain, which was initially attributed to the metastatic disease process. Upon presentation to the emergency department, the patient met the systemic inflammatory response syndrome criteria due to hypotension, leukocytosis, and tachycardia. Notable labs on presentation include hemoglobin of 8.9 g/dL, platelet count of 118 thou/uL, lactic acid of 12.2 mmol/L, and an elevated creatinine above the baseline of 1.5 mg/dL, and INR was elevated at 2.0 seconds. Because of fluid-unresponsive hypotension, the patient was admitted to the intensive care unit for further shock management. Esophagogastroduodenoscopy (EGD) was performed due to the patient's anemia. It was significant for an actively bleeding gastroesophageal junction ulcer, which was appropriately treated. No other source of bleeding was noted on physical exam or via abdomen/pelvis CT. Given the history of prostate cancer and elevated INR suggesting coagulopathy, additional labs were ordered to evaluate for potential DIC. Labs were significant for a D-dimer >69,000 DDU, a decreased fibrinogen of 74 mg/dL, a prolonged prothrombin time of 21.7 seconds, and a worsened thrombocytopenia from presentation of 17,000 thou/uL. The ISTH DIC criteria suggested overt DIC. In the setting of metastatic prostate cancer and no other identifiable causes of DIC, it is believed this is a case of paraneoplastic DIC secondary to prostate cancer. The patient received multiple units of packed red blood cells, fresh frozen plasma, cryoprecipitate, and vitamin K. He was eventually hemodynamically stabilized, and renal function returned to baseline. He was ultimately discharged for further outpatient management.

IMPACT/DISCUSSION: This case illustrates a relatively known complication of DIC in metastatic prostate cancer but has a relatively benign presentation. Thus, we can use this case to emphasize the importance of being vigilant for signs and symptoms of DIC in patients with metastatic neoplastic disease to decrease the delay in blood product resuscitations. The presence of Disseminated Intravascular Coagulation (DIC) is indicative of an unfavorable prognosis. Nevertheless, there are instances where hormone therapy can lead to a temporary state of remission. Enhancing the disease's outcome involves promptly identifying and treating DIC, thus ameliorating its overall impact.

CONCLUSION: Disseminated intravascular coagulopathy (DIC) is a well-described disease process of systemic coagulation cascade activation with a simultaneously increased fibrinolytic state. Prostate cancer can precipitate many different coagulopathies, most commonly being DIC, hence requiring high vigilance.

PSEUDOMONAS SURPRISE: P. PUTIDA LEFT-SIDED NATIVE VALVE ENDOCARDITIS IN A DIALYSIS PATIENT

Chloe Morgan. Internal Medicine, Tufts University School of Medicine, Boston, MA. (Control ID #4063642)

CASE: A 56-year-old man with type 2 diabetes mellitus, end-stage renal disease (ESRD) receiving hemodialysis 3 times weekly via tunneled central venous catheter (CVC), wheelchair dependence, and history of myocardial infarction presented to the emergency department (ED) with 1 day of nausea, vomiting, fever, and fatigue. Physical exam found left flank pain, patient-reported as secondary to injury sustained in a recent fall. ED labs were notable for a neutrophil-predominant leukocytosis. Non-contrast CT showed loculated right pleural effusion; chart review confirmed presence for ≥6 months. He was admitted and treated for parapneumonic effusion with ceftriaxone/azithromycin and chest tube placement. Fever subsided by day 2. Blood cultures from ED showed no growth after 4 days. Mild left flank pain persisted. During dialysis on day 6, patient had rigors and fever (39.2 °C). Labs showed doubling of white blood cell count over 3 hours. Trans-thoracic echocardiography showed 0.5x0.5cm mitral valve mobile vegetation; contrast CT revealed splenic infarctions concerning for septic emboli. New peripheral blood cultures grew susceptible Pseudomonas putida; tunneled CVC was removed. He met Duke Criteria for definitive IE but was not a candidate for surgical valve replacement. He received 6 weeks of IV cefepime post-dialysis with resolution of symptoms and bacteremia.

IMPACT/DISCUSSION: Patients receiving chronic hemodialysis, especially through CVC, are at increased risk for development of bacteremia and subsequent IE. Comorbidities associated with ESRD (eg, impairment of immune response) can further predispose patients to infection. Here, endocarditis was high on the initial differential given history of ESRD and CVC. However, chronic pleural effusion seen on imaging and no growth from initial blood cultures led to treatment of presumed parapneumonic effusion. The only initial physical exam finding suggestive of IE was left flank pain, which was a sequela of splenic infarction. Pseudomonal IE is uncommon and typically associated with intravenous drug use or prosthetic valves. Only 1 case report was identified of IE caused by P. putida. There is no literature consensus on use of 2 anti-pseudomonal agents versus monotherapy for treatment of pseudomonal IE. Limited case reports suggest medical therapy alone results in worse prognosis compared to combination of antimicrobial therapy and early surgical valve replacement in left-sided IE. Here, medical monotherapy was sufficient for resolution of bacteremia.

CONCLUSION: ESRD treated by chronic hemodialysis via indwelling catheter predisposes patients to gram-negative bacteremia and IE. Vigilant physical exam can help identify systemic signs of IE (eg, sequelae of septic emboli) in patients with multiple risk factors.

PSEUDOSEPSIS REPRESENTS A SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) OF NON-INFECTIOUS ORIGIN THAT MAY BE MISTAKENLY IDENTIFIED AS SEPSIS. THERE ARE INSTANCES WHERE ACUTE GOUTY ARTHRITIS HAS PRESENTED AS PSEUDOSEPSIS, CAUSING DELAYS IN THE APPROPRIATE DIAGNOSIS AND TREATMENT OF GOUT. THIS ARTICLE HIGHLIGHTS A CASE OF A POLYARTICULAR GOUT FLARE-UP THAT MANIFESTED AS PSEUDOSEPSIS.

Gabriel A. Ramos¹; Mishouri Paul²; Prodip Paul²; Syed Muhammad Hussain Zaidi³; Koushik Paul⁴; Julio A. Ramos^5,2. ¹Medicine, University of Virginia, Charlottesville, VA; ²Medicine, Geisinger Community Medical Center, Scranton, PA; ³Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ⁴Medicine, Gouripur Upazila Health COmplex, Scranton, PA; ⁵Medicine, Ramos Rheumatology, Avoca, PA. (Control ID #4057352)

CASE: An 82-year-old female with a past medical history (PMH) of hypertension (HTN), heart failure with preserved ejection fraction (HFpEF), and recently diagnosed myelodysplastic syndrome (MDS) on chemotherapy was sent to the emergency department (ED) with concerns of sepsis. In the outpatient setting, she displayed hypotension (BP 98/38 mm Hg), tachycardia (pulse of 120/min), and elevated white blood cell counts. She remained tachycardic in the ED, and her white blood cell (WBC) count was 24930/μL. An initial sepsis evaluation was initiated, and she was given IV cefepime due to an undetermined source of infection. She had noticeable swelling in her left middle finger without any history of recent trauma. X-ray and MRI of her left hand suggested early signs of osteomyelitis.

Consequently, her treatment was switched to Vancomycin. However, even under antibiotic treatment, her joint symptoms persisted and even spread. A hand surgeon's evaluation suggested the root cause was likely inflammatory rather than infectious. Her uric acid levels were high at 11.6 mg/dL. Further evaluation by a rheumatologist revealed tenderness and tophaceous deposits in specific joints. Joint aspiration confirmed the presence of crystals consistent with gout. She was then taken off antibiotics and started on prednisone, resulting in a notable improvement in symptoms. Blood tests showed no infection, and the elevated WBC count normalized. She was released with a tapered dose of prednisone and colchicine.

IMPACT/DISCUSSION: This case illustrates an atypical presentation of gout, initially misdiagnosed as sepsis, which led to delays in correct diagnosis and treatment. It was challenging to identify the patient's condition as gout due to her lack of a typical clinical history of gout. It's postulated that her MDS treatment, which causes rapid cell turnover, might have triggered the gout flare-up. The initial SIRS resembling sepsis is believed to result from the gout flare-up. Few cases have been documented where gout mimics pseudosepsis.

CONCLUSION: It is imperative for clinicians to recognize pseudosepsis as a potential presentation of gout. This knowledge will ensure timely and appropriate treatment, thereby avoiding the unwarranted use of antibiotics.

PULMONIC VALVE INFECTIVE ENDOCARDITIS FOLLOWING CYSTOSCOPY: A RARE CASE WITH COMPLEX CARDIAC SEQUELAE

Vaishvik Patel¹; Mahija Cheekati³; Syeda Hira Naqvi³; Billy Ding²; Cilian J. White³; Shakeeb Hakim³; Brian Forrestal³; Christopher Magovern³. ¹School of Medicine, St George's University, St George's, St George's, Grenada; ²New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY; ³Morristown Medical Center, Morristown, NJ. (Control ID #4062585)

CASE: One month after undergoing a cystoscopy for bladder cancer surveillance, the patient presented the emergency room with complaints of fatigue, fever, and night sweats going on for several weeks. Physical examination revealed a new diastolic murmur and triage laboratory demonstrated signs of early sepsis. A chest CT demonstrated left lung consolidation raising the suspicion for pneumonia as the source of sepsis for which empiric antibiotics were started and the patient was subsequently admitted. Blood cultures later yielded E. faecalis bacteremia. Transthoracic echocardiogram revealed a PV mass, right ventricular dilation, and elevated pulmonary artery systolic pressure; further characterized by transesophageal echocardiography, which confirmed a 2.4 x 1.4 cm pulmonic valve vegetation, severe pulmonary regurgitation and severe right atrial enlargement leading to acute right heart failure. Despite empiric IV antibiotic therapy, he developed further complications. Notably, repeat chest CT revealed septic pulmonary emboli and cardiac catheterization demonstrated moderate stenosis of proximal right coronary artery. He was evaluated promptly by cardiothoracic surgery and medically optimized for urgent bioprosthetic PV replacement, pericardial patch augmentation and coronary artery bypass grafting.

IMPACT/DISCUSSION: Pulmonic valve Infective endocarditis (PVIE) is a rare and potentially life threatening condition that comprises <2% of all infective endocarditis (IE) cases as typically IE affects the mitral and aortic valves. This case highlights the potential for PVIE following procedures like cystoscopy, even in patients without traditional risk factors. The lower incidence of PV IE is likely attributed to pressure differences between the two sides of the heart, with high-pressure flow on the left side predisposing the mitral and aortic valves to infection. Procedures like cystoscopy further increase the risk for IE, particularly in patients with malignancy who already have a 13% chance of acquiring Enterococcus IE with complications. This case emphasizes the importance of maintaining a high index of suspicion for IE in patients presenting with indolent, non-specific symptoms following procedures or recent infections. Our patient’s rapid clinical deterioration with severe complications underscores the need for prompt diagnosis and aggressive diagnostics and treatment of IE in all susceptible patients.

CONCLUSION: While early intervention aims to prevent complications, timely collaboration with specialists for diagnosis and treatment is crucial to improve patient outcomes.

RAPID ONSET BICYTOPENIA : HEMATOLOGICAL ADVERSE EFFECT OF PIPERACILLIN/TAZOBACTAM

SANYA BADAR¹; Lavleen Kaur¹; Aimen Iqbal¹; Ravleen Kaur¹; Salman Abdul Basit¹; Karim Djekidel². ¹Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ²Pulmonology/Critical Care, Geisinger Community Medical Center, Scranton, PA. (Control ID #4063622)

CASE: A 59 year-old-female was admitted to the Intensive Care Unit (ICU) for the management of septic shock and acute hypoxemic respiratory failure secondary to Community-Acquired Pneumonia. Admission blood work showed leukocytosis (WBC 23 x 103). Patient was started on broad spectrum coverage with IV Vancomycin and Piperacillin/Tazobactam (PTZ). Vancomycin was discontinued due to a negative MRSA screen. Within 48 hours of initiating antibiotics, the patient was noted to have a drop in WBC count to 2.56 and platelet count drop to 120K. Patient was empirically started on an antifungal regimen due to lack of improvement. Infectious diseases work up including blood/fungal culture, parvovirus B19, vibrio, yersinia, norovirus and rotavirus screening was negative. The hematology team was consulted. Patient received Neupogen but did not show significant improvement in cell counts. As per the Infectious Disease team, PTZ and anti-fungal were discontinued. The patient's cell count improved within 48 hours of piperacillin/tazobactam discontinuation.

IMPACT/DISCUSSION: Piperacillin/Tazobactam[PTZ] is a semi-synthetic ureidopenicillin and a beta-lactamases inhibitor and is the most widely used antibiotic. PTZ is a reliable option for empiric treatment for moderate to severe infections in hospitalized patients with an excellent safety and tolerability profile. A recognized adverse drug reaction of beta-lactam antibiotics is bone marrow suppression and a few systematic reviews have shown that piperacillin can also have such adverse effects. The exact incidence is not known to date due to the difficulty of definite diagnosis in clinical practice. PTZ-induced Neutropenia before 15 days of treatment is a novel finding. Theoretically, it is believed that piperacillin causes myelosuppression by arresting the proliferation of myeloid cells. Only one study has documented rich marrow with maturation arrest of all lineages in PTZ related pancytopenia. Various studies have also detected the presence of IgG antibodies against penicillins leading to immunologically mediated hemolytic anemia and thrombocytopenia. Bicytopenia as a result of PTZ may even occur after relatively shorter durations and low cumulative doses, therefore monitoring of hematological parameters in patients receiving this treatment is crucial. Neutropenia and thrombocytopenia usually improve drastically and immediately with the withdrawal of PTZ and initiation of steroids and immunoglobulins.

CONCLUSION: Cytopenia involving any of the myeloid lineages may occur with prolonged piperacillin/tazobactam treatment and early detection of this reversible adverse drug reaction by regular monitoring of blood count and vigilance by clinicians is of utmost importance.

RECOGNIZING AND TREATING IDIOPATHIC GRANULOMATOUS MASTITIS

Olivia Makos. Internal Medicine, University of Nebraska Medical Center, Omaha, NE. (Control ID #4047356)

CASE: A 22-year-old Hispanic female with no past medical or family history presented with a rapidly evolving left breast mass. Four months prior she was hospitalized for left breast erythema, swelling and tenderness after completing a 10-day course of trimethoprim-sulfamethoxazole for suspected mastitis. At that time breast ultrasound showed echogenic tissue with increased vascularity interpreted as likely cellulitis/mastitis with possible phlegmon. Bacterial cultures were negative. She was treated with vancomycin for suspected non-lactational bacterial mastitis followed by a 10-day course of linezolid and metronidazole. After discharge, the breast mass progressively enlarged and started to drain. Exam showed a large fungating mass medial to the left nipple with associated tenderness, inflammation, and serosanguinous discharge. The contralateral breast was normal and there were no associated axillary lymphadenopathy or nipple changes present. Vitals were normal. Repeat ultrasound was again interpreted as cellulitis/mastitis. Fungal, bacterial, and acid-fast bacillus cultures were negative. Biopsy showed suppurative granulomatous inflammation and fat necrosis. Findings were most consistent with idiopathic granulomatous mastitis (IGM). The mass was debrided, and the patient was treated with a 30-day course of prednisone. On four-week follow-up the patient reported marked improvement. However, two days after finishing prednisone she developed new erythema and swelling over the surgical site. There was concern for IGM flare off steroids and methotrexate (MTX) was started. Near complete healing occurred two weeks after starting MTX.

IMPACT/DISCUSSION: IGM is a rare benign disease of the breast that commonly occurs in young Hispanic women and has been associated with oral contraception use, pregnancy, and lactation.¹Our case highlights the challenges of diagnosing IGM. Breast biopsy is diagnostic. Histopathology shows chronic granulomatous lobulitis with non-caseous granulomatous necrosis and infiltration of giant cells, epithelioid cells, macrophages, and neutrophils.² Treatment includes combination of steroids, surgery, and MTX. Rates of IGM recurrence can be as high as 38%-60%.¹

CONCLUSION: IGM mimics other diseases leading to misdiagnosis and delayed treatment.Diagnosis of IGM considers presentation, imaging, and histopathology. Histopathology is the most critical element in diagnosis.Traditionally surgery and steroids were mainstay. MTX is an effective addition and can decrease steroid duration.

1. Barreto DS, Sedgwick EL, Nagi CS, Benveniste AP. Granulomatous mastitis: etiology, imaging, pathology, treatment, and clinical findings. Breast Cancer Res Treat. Oct 2018;171(3):527-534. doi:10.1007/s10549-018-4870-3

2. Kafadar MT, Bahadir MV, Girgin S. Low-Dose Methotrexate Use in Idiopathic Granulomatous Mastitis: An Alternative Treatment Method. Breast Care (Basel). Aug 2021;16(4):402-407. doi:10.1159/000513879

RECOGNIZING ATROPHIC LIVER FIBROSIS

David Iskhakov¹; Kelly L. Buchanan²; Gabrielle K. Bromberg¹. ¹Medicine, Massachusetts General Hospital, Boston, MA; ²Gastroenterology, Massachusetts General Hospital, Boston, MA. (Control ID #4056820)

CASE: A 61-year-old man presented with post-prandial abdominal pain, nausea/vomiting, and weight loss.

During a recent admission for the same symptoms, he was found to have radiographic evidence of cirrhotic morphology liver, portal hypertension (pHTN), and a PVT. Colonoscopy/EGD showed large esophageal and rectal varices and portal hypertensive gastropathy. The patient was started on nadolol and discharged.

Two weeks later, he returned to our ED with worsening abdominal pain. His meds were nadolol and pantoprazole. He denied any substance use. He had a remote history of hepatitis that self-resolved. He had no family history of liver disease or clots. He lived in Costa Rica until a recent move to Boston. He was a cattle farmer. He had a car accident resulting in blunt force abdominal trauma five years prior. He was chronically ill-appearing, with a soft but diffusely tender abdomen worst in the right upper quadrant.

A broad workup for cirrhosis was unrevealing. Repeat CTAP showed cirrhotic morphology liver, splenomegaly, occluded main portal vein with cavernous transformation, and extensive varices. A liver biopsy revealed portal fibrosis, fibrous bands, and vascular remodeling consistent with effects of PVT without features of cirrhosis. The hepatic venous pressure gradient was 7 mmHg, consistent with predominantly pre-hepatic pHTN. The patient was diagnosed with atrophic liver fibrosis secondary to chronic PVT. With trans-splenic portal vein recanalization, his symptoms of post-prandial abdominal pain improved.

IMPACT/DISCUSSION: Hepatotrophic substances carried by the portal system influence the morphology, function, and regenerative capacity of the liver. Endogenous insulin is the most important of these factors; relative hepatic insulinopenia is considered the most important element in liver injury. Other hepatotrophic substances include glucagon, hepatocyte growth factor, insulin like growth factor, and others. Several in vivo experiments have demonstrated the impact of depriving the liver of portal venous return, and that atrophy results from reduction in blood flow-containing hepatotropic substances, not absolute flow.

We theorize that in our patient with a chronic PVT, the altered liver morphology is caused by the diminished return of hepatotrophic substances. Importantly, this differs from cirrhosis, which is defined by regenerative nodules surrounded by fibrotic tissue and synthetic dysfunction. Our patient’s hepatic fibrosis without regenerative nodules on biopsy and preserved synthetic function support that the effects of portal venous hypertension (varices/splenomegaly) was the result of primary PVT rather than sinusoidal effects seen in cirrhosis.

CONCLUSION: Hepatic atrophy is a distinct pathologic and clinical entity characterized by non-cirrhotic pHTN and preserved synthetic function.

RECOGNIZING RARE INTRAVASCULAR TUMORS THAT CAN MIMIC A PULMONARY EMBOLISM

Juan Cerezo¹; Rachel Cohen¹; Justin Chan²; Kerry Hena³. ¹Internal Medicine, New York University Grossman School of Medicine, New York, NY; ²Cardiothoracic Surgery, New York University Grossman School of Medicine, New York, NY; ³Pulmonary and Critical Care Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4063997)

CASE: A 61-year-old woman presented to an outside hospital with 2 weeks of dyspnea and decreased exercise tolerance. Initial evaluation was notable for dyspnea and hypoxia. Despite a negative D-dimer, she was found to have extensive obstruction within the right pulmonary artery on CT with right heart strain on echocardiogram, so was transferred to Bellevue Hospital for further evaluation. On arrival, mechanical thrombectomy was deferred in favor of medical management because the negative D-dimer was discordant with the extent of the obstruction on imaging. A follow-up chest MRI showed near-complete obstruction of the right pulmonary artery by an irregular, lobulated structure abutted distally by bland-appearing thrombus. The team began to suspect a possible primary PAS and consulted CT surgery. Biopsy was obtained during right heart catheterization, but results were inconclusive. PET scan showed significant uptake within the right pulmonary artery. The patient eventually opted for surgical resection with subsequent chemoradiation. She underwent endarterectomy of her bilateral pulmonary arteries with successful removal of an undifferentiated spindle cell mass, followed by an uncomplicated post-op recovery.

IMPACT/DISCUSSION: Only several hundred cases of PAS have been reported in the literature. PAS often presents with nonspecific symptoms and objective findings that can mimic PE, CTEPH, or pulmonary hypertension. PAS is a high-grade tumor with a poor prognosis and mean survival rates of less than 2 months without surgical intervention, therefore requiring prompt surgical consideration. PAS should be on the differential for patients for whom there is a high clinical suspicion for PE but with a low D-dimer. Imaging with CT angiography or MRI can reveal irregularities that differentiate PAS from a bland thrombus but are not without flaws. Endovascular biopsy is the gold standard for diagnosis and can be obtained via right heart catheterization, however PAS is often interspersed with non-malignant tissue so there is little reported success. PET scans demonstrating increased uptake in the pulmonary artery can be diagnostic in the absence of biopsy-proven disease, though it is possible that the foci of tumor may be too small to identify.

Surgical resection with adjuvant chemoradiation is the most effective treatment regimen recorded, with a 1-2 year survival rate on average post-diagnosis, though 5-year mortality remains poor. Some recent cases have reported improved survival rates in cases with non-metastatic disease and successful complete tumor resection. We aim to contribute to the limited descriptions of this rare malignancy.

CONCLUSION: - PAS is a rare, high-grade tumor with dismal prognosis that requires early detection and prompt surgical consideration.

- PAS should be suspected in patients with suspected PE not improving on mainstay treatment.

RECREATIONAL KETAMINE’S TOLL ON THE LIVER, BLADDER, AND BEYOND: A CASE SERIES

Jerrin Bawa^1,2; Talwinder Singh^1,5; Mridula Karthikeyan^3,4; Kelly L. Cervellione⁶. ¹Internal Medicine, Flushing Hospital Medical Center, Flushing, NY; ²Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India; ³American University of the Caribbean School of Medicine BV, Cupecoy, Sint Maarten (Dutch part); ⁴Rutgers The State University of New Jersey, New Brunswick, NJ; ⁵Lake Erie College of Osteopathic Medicine, Erie, PA; ⁶Department of Clinical Research, MEDISYS Health Network, Jamaica, NY. (Control ID #4063474)

CASE: Seven patients from a community hospital in Queens, NY, who had admissions related to ketamine-induced cholestatic liver injury and cystitis were reviewed. The majority had a positive ketamine screen (5 of the 6 tested). All 7 self-reported ketamine use; 3(43%) reported polysubstance abuse. Most reported inhaled ketamine use (86%); one reported intramuscular (IM) injection.

Patient ages ranged from 28-53 years; 4(57%) were male. No patients reported significant medical history other than that related to substance abuse. The patient with IM ketamine use had chronic skin infections and resulting bacteremia.

The most presentations were hematuria (100%), epigastric pain (86%), and dysuria (71%). Patients reported symptom duration of between 1 month and several years, including 57% with prior admissions for related concerns. All had an increased ALP (range:113-3,349), ALT (70-1,122), AST (86-586), and/or creatinine (0.4-6.7). All had ultrasound or computed tomography scan findings of cystitis or cholestatic liver injury, including 5(71%) with hydronephrosis, 5 with bladder wall thickening, and 5 with biliary abnormalities. Despite urinary symptoms, all except the patient with bacteremia had negative urine cultures.

Some patients experienced very serious adverse events (AEs), including one with cardiac arrest, one with necrotizing fasciitis, and one with hepatic abscesses requiring transfer to a transplant center.

IMPACT/DISCUSSION: Recreational ketamine use is on the rise, especially in young adults. In turn, related urinary and hepatic dysfunction are increasingly reported. Recognizing characteristics of ketamine-related AEs is of utmost importance to hospitalists. We present several illustrative cases of ketamine-related cholestatic liver injury, urinary stasis, cystitis, and hepatic abscesses. Many patients had complicated hospital courses, exemplifying the importance of sharing information about this public health concern.

Though our sample was small, important trends were identified. The group consisted of relatively young, healthy individuals. This is a demographic in which to consider ketamine abuse when there are otherwise unexplained liver and bladder symptoms and imaging findings. Many substance users do not self-report drug activity at hospital admission. Therefore, timely urine and blood collection specifically for ketamine screening is important for quick and accurate diagnosis and treatment. In cases of pyuria in the setting of ketamine use, antibiotics may be avoided, given that sterile pyuria with negative urine cultures is common.

In addition, with growing use of ketamine for therapeutic purposes in anesthesia, analgesia, depression, and PTSD, there is an urgent need to understand the spectrum of potential AEs associated with chronic use.

CONCLUSION: Recreational ketamine use may have significant adverse effects on the liver and bladder, even in relatively young, healthy patients. Toxicology screens can help with rapid diagnosis. Differentiating from UTI is essential.

RECURRENT ENCEPHALOPATHY: INCOMPLETELY TREATED VIRAL MENINGITIS OR MOLLARET MENINGITIS?

Priyanka Solanki, Audrey Lim. Department of Medicine, UPMC, Pittsburgh, PA. (Control ID #4064851)

CASE: A 78-year-old male with past medical history significant for prior left cerebellar stroke and alcohol use disorder was admitted for altered mental status and persistent fevers. He began empiric treatment with broad spectrum antimicrobials for bacterial and viral meningitis. Subsequent lumbar puncture (LP) demonstrated elevated protein and WBC with lymphocytic predominance indicating probable viral meningitis. Unfortunately, CSF viral studies were not sent. He saw rapid improvement in his mental status with IV acyclovir and discharged to a rehabilitation facility. Four days later, the patient became persistently more encephalopathic and re-presented with confusion and dysarthria. On presentation, vitals: T 36.C, BP 162/84, HR 81, RR 23, Sat 98% on room air. Initial neuro exam was notable for minimal verbalization and inability to follow commands and intermitent full body rigidity and agitation. An extensive infectious workup, including blood and urine cultures, HIV, syphilis, tick-borne and myasthenia panels and LP, was conducted in addition to a neurological assessment with MRI and EEG. The results were largely unremarkable apart from minimally elevated CSF protein. As his mental status progressively continued to decline, he was empirically treated with IV acyclovir for recurrent viral meningitis, and IV thiamine for Wernicke’s encephalopathy. After one week of therapy, the patient had significant improvement to his mental status with eventual resolution to baseline.

IMPACT/DISCUSSION: Mollaret meningitis is a rare neurological condition characterized by episodes of recurrent aseptic meningitis with rapid (and often spontaneous) improvement between symptom free periods. Aseptic meningitis is consistent with a CSF profile characterized by elevated WBC with neutrophilic or lymphocytic pleocytosis, normal to slightly elevated protein, and normal glucose levels, along with negative cultures and serologies. While this patient had two LPs possibly consistent with aspetic meningitis and rapid improvement within just a few days from his initial encephalopathy presentation, the time span between his episodes of altered mental status is inconsistent with Mollaret meningitis, in which the asymptomatic intervals are typically between weeks to months. Possibly, the patient was incompletely treated during his first presentation and actually improved with additional antimicrobial therapy during his second episode. This case highlights the challenge of diagnosing Mollaret meningitis.

CONCLUSION: > Mollaret meningitis is difficult to diagnose and requires the combination of clinical symptoms with CSF analysis consistent with aseptic meningitis.

> While some episodes of Mollaret meningitis may resolve spontaneously with conservative management, other instances require treatment with empiric antiviral therapy.

RECURRENT SMALL BOWEL OBSTRUCTION IN AN IMMUNOCOMPROMISED HOST

Matthew J. Pisarcik, Matthew J. Townsend. Medicine, Duke University Medical Center, Durham, NC. (Control ID #4060465)

CASE: A 74-year-old female with B-cell acute lymphoblastic leukemia on hyper-CVD chemotherapy presented for nausea, vomiting, and abdominal pain. Ten days prior to arrival, she experienced 48 hours of non-bloody diarrhea. She was then unable to pass stool for one week before developing nausea, emesis, and abdominal pain. Surgical history included remote appendectomy and oophorectomy. Social history was notable for lifelong residence in a rural, lakeside southeastern U.S. town with no prior international travel. Physical exam revealed diffuse abdominal tenderness and distension. Labs revealed WBC 3900/uL with a normal differential and hypoalbuminemia without electrolyte or hepatic enzyme derangements. Testing for C. difficile, ova and parasites (O+P), stool culture, and H. pylori were negative. Abdominal CT revealed dilated proximal and mid small bowel with transition point consistent with small bowel obstruction (SBO).

A nasogastric tube was placed with nil per os diet leading to improvement in symptoms. Several days later, her symptoms recurred. PET-CT revealed nonspecific gastroenteritis. Her symptoms again improved and worsened; repeat abdominal CT demonstrated recurrent SBO. Exploratory laparotomy revealed nonspecific proximal small bowel dilation. A subsequent white blood cell differential revealed leukocytosis to 13400/uL with 64% eosinophils. Stool studies were obtained and helminth larvae were incidentally captured on a fecal leukocyte slide, suggestive of Strongyloides infection. The patient received ivermectin with resolution of her abdominal symptoms; repeat stool O+P testing was negative.

IMPACT/DISCUSSION: Strongyloidiasis is a soil-transmitted helminthic infection that is most often asymptomatic; when symptoms present, they are often delayed and nonspecific: abdominal pain, intermittent diarrhea and constipation, rash, dry cough. Transition from immunocompetent to immunocompromised may allow chronic asymptomatic infection to progress to clinical relevance. The majority of strongyloidiasis in the U.S. is among immigrants or travelers of the tropics, but autochthonous cases have been reported particularly in Appalachia and the southeastern United States. Several cases of strongyloidiasis-related SBO have been reported; to our knowledge, this is the first to report recurrent SBO due to autochthonous Strongyloides infection in the U.S. Risk factors include immunosuppression (steroid use, organ transplant) or impaired cell-mediated immunity (HIV, HTLV-1 infection, or hematologic malignancy as seen here). Peripheral eosinophilia and stool microscopy have limited sensitivity (<50%), as exemplified in this case, and may require repeat examination. Ivermectin is effective first-line treatment.

CONCLUSION: In the Southeastern United States and Appalachia, autochthonous Strongyloides infection may be underappreciated. The differential for small bowel obstruction in an immunocompromised host, particularly with eosinophilia or geographic risk factors, should include strongyloidiasis.

RECURRENT SUPERIOR MESENTERIC ARTERY SYNDROME IN A YOUNG WOMAN AFTER ABDOMINAL TRAUMA

Giselle Uwera, Jimin Hwang, Aakash Padakandla, Laura Marquez Loza, Brandon Winward, Jhee U. Lee. Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4054909)

CASE: A 24-year-old previously healthy woman presented with 2 weeks of postprandial emesis and abdominal pain. During this time, she presented to 2 separate emergency departments without symptom resolution. Immediately prior to symptom onset, she sustained a motor vehicle collision and was found to have a liver laceration that was managed non-operatively. The pain was located in the epigastrium and left flank and was aggravated by solid and liquid intake. She also had nausea, poor appetite, and unintentional weight loss of 28 pounds over the past 2 weeks. Abdominal examination was notable for fading ecchymoses extending along the lower abdomen and left-sided tenderness. There were no peritoneal signs. Vital signs and laboratory evaluation on admission were normal except for K of 3.1 mmol/L, ketonuria, and pyuria. Workup, including chest radiographs, computed tomography (CT) of the abdomen, and upper endoscopy, was unremarkable. CT angiography of the mesentery was ordered, which revealed a small aortomesenteric angle and aorto-mesenteric distance, suggestive of superior mesenteric artery (SMA) syndrome. Review of outside records later revealed that the patient was admitted with similar symptoms at age 14 and underwent an upper gastrointestinal barium study, which demonstrated duodenal obstruction between the 2nd and 3rd portions. With supportive care including ondansetron before meals and multimodal pain control, she was able to advance her diet and was discharged on hospital day 4 with outpatient follow-up.

IMPACT/DISCUSSION: Superior mesenteric artery (SMA) syndrome is caused by duodenal compression from the SMA due to a lack of retroperitoneal fat. It is often misdiagnosed as a functional disorder or anxiety due to non-specific symptoms of nausea, vomiting, and postprandial abdominal pain with normal endoscopy findings. The most common predisposing factor is significant weight loss causing loss of mesenteric fat, but surgery or trauma can also cause SMA syndrome. Diagnosis can be made through CT or magnetic resonance angiography to identify reduced aortomesenteric angle or distance. Initial management of SMA syndrome includes fluids, correction of electrolyte abnormalities, small bowel decompression, and nutritional support to restore retroperitoneal fat. Post-pyloric tube feeding can be considered. Occasionally, surgery (e.g. ligament of Treitz lysis, duodenojejunostomy) is required to relieve the obstruction. In this patient, abdominal trauma from the motor vehicle collision and subsequent weight loss may have triggered the recurrence of her SMA syndrome.

CONCLUSION: -SMA syndrome is a cause of postprandial abdominal pain in the setting of significant weight loss.

-Trauma can predispose patients to SMA syndrome.

-SMA syndrome is initially managed conservatively with nutritional support.

REFRACTORY HYPOKALEMIA IN A PATIENT WITH SMALL CELL LUNG CANCER

Julia Joseph, Paul Stockhammer. Internal Medicine, Yale New Haven Health System, New Haven, CT. (Control ID #4055347)

CASE: A 71-year-old woman with small cell lung cancer (SCLC) was admitted for asymptomatic refractory hypokalemia. Medical history was notable for well-controlled hypertension on hydrochlorothiazide (HCTZ) 25 mg and lisinopril 30 mg daily. She denied fatigue, muscle weakness, or palpitations. The patient had seen her outpatient oncologist two weeks prior to presentation with plan to start chemo-immunotherapy. Routine labs noted new hypokalemia 2.4 mmol/L. She was referred to the ED, where her blood pressure was incidentally noted to be 210/92. She was given oral potassium and discharged. The following day, she was noted to be persistently hypokalemic and hypertensive. She was given additional potassium and HCTZ was increased to 50 mg daily. Her hypokalemia continued to be refractory to supplementation, and she was referred for inpatient evaluation. On presentation, vitals were normal except for blood pressure 217/99. She was well-appearing and in no acute distress. She had no evidence of facial plethora, truncal obesity, or striae. Labs were notable for potassium 2.7 mmol/L, bicarbonate 34 mmol/L, glucose 201, A1C 6.4, 6AM serum cortisol 43.2 (6 – 18.3 ug/dL), ACTH 156 (7.2-63.3 pg/ml), 9 AM aldosterone level 2 ng/dL (3-16 ng/dL). High-dose dexamethasone suppression test noted serum cortisol 43.7 ug/dL and ACTH 156 pg/ml. 24-hour free cortisol urine collection was 1692.2 mcg (4-50 mcg/24 hours). She was initiated on spironolactone and HCTZ was switched to amlodipine. Her potassium and blood pressure improved and she was discharged with close follow-up.

IMPACT/DISCUSSION: Neuroendocrine tumors like SCLC account for about 50% of cases of ECS. Diagnosis can be made by clinical and laboratory evidence of hypercortisolism; MRI pituitary is not required. Despite its known association, ECS is likely underdiagnosed in SCLC due to the rapid rate of tumor growth not allowing recognizable Cushingoid features to develop. ECS may mimic Conn’s syndrome by presenting with metabolic abnormalities and new-onset hypertension. ECS in SCLC is also associated with poor outcomes due to higher rates of infection, diabetes, and hypertension. Besides cancer-directed therapy, diabetic and blood pressure control are crucial. Medications directed at hypercortisolism can also be considered. This case illustrates the importance of recognizing ECS in SCLC patients. It changes clinical practice by reminding clinicians that the lack of Cushingoid features does not rule out ECS, and provides an overview of the clinical features and laboratory data supporting the diagnosis. Given the association with poor prognosis, the importance of screening for hypercortisolism-related complications is highlighted.

CONCLUSION: ECS should be suspected in patients with SCLC presenting with new-onset hypokalemia and hypertension.

ECS is often underdiagnosed in SCLC patients; imaging is not required to make the diagnosis.

ECS in SCLC is associated with poor prognosis and its clinical manifestations should be treated aggressively.

REFRACTORY HYPONATREMIA: WHAT’S CAUSING IT?

Soobin Song^1,2; Samuel Hsu²; Imad Ud Deen². ¹Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ²Boston Medical Center, Boston, MA. (Control ID #4064040)

CASE: A 51-year-old woman with history of Stage 3 Tongue SCC s/p seven cycles of cisplatin presented to outpatient oncology for follow up; however, labs showed serum Na of 114. Patient was A&Ox4 with no history of seizures or confusion. She reported decreased oral intake, difficulty sleeping, and fatigue secondary to oral pain. Patient denied vomiting, weakness, numbness, or diarrhea. She was given 1L NS and 1L D5/NS, PO oxycodone for pain, olanzapine for sleep aid, then referred to the ED.

At this time, she was afebrile and hypotensive to 95/58. She appeared to be cachectic with a BMI of 18.20 kg/m². Her physical exam was notable for oral mucositis, dry mucous membranes, and decreased skin turgor. Notable labs included Na 120, Serum Osm 245, Urine Osm 150, and Urine Na 50.

She was subsequently admitted to the inpatient unit for management of hyponatremia in the setting of poor PO intake. However, despite initial improvement; hyponatremia was refractory with Na 122, Serum Osm 245, Urine Osm 387, and Urine Na 108 on day 5. Upon review of medications, hyponatremia seemed multifactorial in the setting of hypovolemia and SIADH, the latter likely due to initiation of olanzapine at time of admission. She was initiated on salt tabs, fluid restriction, and olanzapine was discontinued. Na improved to 136 at discharge on day 10.

IMPACT/DISCUSSION: Hyponatremia can be life-threatening leading to cerebral edema or demyelination with improper temporality of treatment. The cause of the patient's refractory hyponatremia was not obvious to her volume status. However, many drugs affect sodium and water homeostasis, which include psychotropic agents such as SSRIs, TCAs, and anti-psychotics like olanzapine. These agents are thought to cause SIADH by centrally increasing ADH secretion. Clinicians should be mindful of offending agents with thorough review of medications and their timing of initiation. Current guidelines encourage immediate discontinuation of the offending agent and correction of serum sodium concentration <12 mmol/L within the first 24h and <18mmol/L within the first 48h while staying <140 mmol/L.

CONCLUSION: Hyponatremia is one of the most common electrolyte imbalances seen among hospitalized patients, and etiology can be quickly narrowed with serum/urine osmolality and sodium levels. However, clinicians should remain mindful of multifactorial etiologies when hyponatremia persists after addressing the primary potential cause. This case highlights the importance of medication list review and mindfulness of initiating psychogenic agents in the setting of electrolyte imbalances.

REFRACTORY IMMUNE THROMBOCYTOPENIA SECONDARY TO IMMUNE CHECKPOINT INHIBITOR

Martin J. Kurian¹; Allyson Pishko²; Aaron Cheng²; Tara Azizi²; Ravi Amaravadi²; Charles Abrams²; Benjamin A. Bleiberg². ¹Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA. (Control ID #4062423)

CASE: A 69-year-old female with past medical history of breast cancer status post mastectomy, hypertension, and hyperlipidemia was diagnosed with stage III melanoma and treated with nivolumab. Three weeks following ICI administration, she presented to the hospital with one week of nausea, vomiting, progressive petechial rash, and one episode of moderate epistaxis. Initial labs were notable for a platelet count <4 k/μL, white blood cell count of 10.4 k/μL, and hemoglobin of 11.6 g/dL. On presentation, she was found to have a spontaneous intracranial hemorrhage. Ultimately, she was diagnosed with ICI-related ITP after relevant infectious, nutritional, and non-ICI iatrogenic causes were ruled out. Her diagnosis was supported by a subsequent unremarkable outpatient bone marrow biopsy. She was initially treated with a four-day pulse of 1 g methylprednisolone (then tapered to 1 mg/kg), two days of IVIG (total dose 2 g/kg), and several units of platelets. Her platelet count improved to 39 k/μL but fell to an undetectable level one day later. She was then initiated on weekly romiplostim (uptitrated to 10 mcg/kg) and rituximab for four weeks. Her platelet count remained <10 k/μL despite these interventions. Given the refractory nature of her thrombocytopenia and concern for recurrent hemorrhage she was evaluated for a splenectomy. To optimize the patient’s pre-operative platelet count, she received two days of methylprednisolone (1 g), an additional 2 g/kg of IVIG, and 1 mg of vincristine. Her platelet count improved to 64 k/μL and she subsequently underwent a successful surgery. Her immediate post-operative platelet count was 139 k/μL. Her counts stabilized in the following days, and she was discharged one-week post-splenectomy with a platelet count of 250 k/μL. Her treatment regimen at time of discharge included a prednisone taper, while romiplostim and rituximab courses were completed.

IMPACT/DISCUSSION: ICIs can be associated with severe, prolonged cases of ITP, refractory to traditional first and second-line therapies. In this case, a patient with refractory ICI-related ITP achieved a platelet count of 64 k/μL five days after vincristine was added to IVIG, steroids and TPO-RA.

CONCLUSION: - As the prevalence of ICI use increases in oncologic practice, ICI-related ITP may be encountered with greater frequency

- Further study is needed to identify the optimal combination and sequencing of therapies for refractory cases

REMEMBER THE MYOCYTES: A RARE CASE OF HYPONATREMIA-INDUCED RHABDOMYOLYSIS

Devon S. Scott, Chadane Thompson, Yu-Han Chen, Karishma Narain, Dipal R. Patel. Department of Internal Medicine, Englewood Hospital and Medical Center, Englewood, NJ. (Control ID #4055477)

CASE: A 71-year-old male with paranoid schizophrenia presented with confusion for one day. He was discharged from a psychiatric hospital two weeks prior and had self-discontinued his antipsychotics. His wife had noticed him drinking gallons of water over a five-day course, as he was “trying to purify the blood of toxins.” There was no fall, seizures, fever, illicit drug use, overexertion, or additional medication use reported. Vital signs were normal. Physical exam revealed normal hydration status, no signs of injury, and disorientation. CT head was normal. Lab tests showed: serum sodium (Na) 116 (136-145 mmol/L), serum osmolality 242 (275-300 mosm/kg), urine osmolality 145 mosm/kg, urine Na < 20 mmol/L, dipstick-positive hematuria with negative microscopy, and creatinine kinase (CK) 2117 (30-200 U/L). There were no other laboratory derangements. He was diagnosed with rhabdomyolysis and profound hypoosmolar hyponatremia secondary to psychogenic polydipsia and poor solute intake. Initial treatment consisted of Na correction with a 100ml bolus of 3% saline. Subsequently, Na improved to 121 mmol/L and mental status returned to baseline. Thereafter, fluid restriction led to normalization of Na and clearance of CK over the following two days. He was discharged to a psychiatric hospital for management of schizophrenia.

IMPACT/DISCUSSION: Hyponatremia is a common electrolyte disturbance with myriad causes such as water intoxication, often related to psychogenic polydipsia seen with schizophrenia spectrum disorders. In severe hyponatremia, prevention of neurological sequelae is often the primary focus of treatment due to the risks of morbidity and death. However, less commonly encountered complications, such as rhabdomyolysis, must be considered when caring for these patients. Rhabdomyolysis is characterized by enzyme release from skeletal muscle destruction and is often caused by trauma, overexertion, or drugs. However, either as a direct result of water intoxication or rapid Na correction, rhabdomyolysis occurs rarely in 7% of cases of hyponatremia due to myocyte cell volume dysregulation and fragility. Our patient's urinalysis results gave initial clues to the possible presence of myoglobinuria. If not recognized early, inappropriate fluid management may exacerbate rhabdomyolysis, leading to harmful outcomes. Treatment usually involves aggressive fluid resuscitation. Interestingly, in this case of hyponatremia-induced rhabdomyolysis from water intoxication and poor solute intake, we successfully treated by addressing the root cause with a hypertonic saline bolus followed by fluid restriction.

CONCLUSION: Rhabdomyolysis is a rare but important complication of hyponatremia or rapid Na correction rate. Monitoring for markers of rhabdomyolysis, such as myoglobinuria and elevated CK, should be considered in the guidelines for hyponatremia. Prompt recognition of and appropriate fluid management in hyponatremia-induced rhabdomyolysis can abate potentially life-threatening systemic complications.

RENAL BIOPSY IN A PATIENT WITH ACUTE ON CHRONIC KIDNEY DYSFUNCTION REVEALS IGG4-RELATED DISEASE

Ellery Koelker-Wolfe¹; Alex Iyer¹; Erin Truitt². ¹Medicine, Harvard Medical School, Boston, MA; ²Hospital Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4059792)

CASE: A 69-year-old male with HTN, T2DM, and CKD was referred to the ED after routine lab testing revealed a significant increase in serum creatinine over six months (from 1.2 to 6.5 mg/dL).

The patient reported two months of fatigue and unintentional weight loss. Medications included insulin and irbesartan. Vital signs were notable for BP 185/91 mmHg and HR 127 bpm. Physical exam was normal. Blood count revealed anemia (Hb 7.7 g/dL) and eosinophilia (AEC 840). Serum bicarbonate was low (15 mEq/L); electrolytes were otherwise normal. Estimated GFR was 11 mL/min (from 72 mL/min one year prior). Urinalysis revealed proteinuria (72 mg/dL). Hemoglobin A1c was 6.6%.

Further workup included hemolysis studies, iron studies, urine sediment, and renal ultrasound. Investigation of common infectious and autoimmune causes was negative. Serum protein electrophoresis was normal. Serum IgG was 2129 mg/dL (ref. 700-1600 mg/dL). Renal biopsy revealed chronic interstitial nephritis with abundant IgG4-positive cells, consistent with IgG4-related disease (IgG4-RD).

The patient was discharged on a three-month prednisone taper. Six months later, creatinine decreased to 1.9 mg/dL and hemoglobin improved to 10.6 g/dL.

IMPACT/DISCUSSION: General practitioners often assess whether worsening renal function in a patient with CKD reflects chronic disease progression or a secondary, potentially reversible cause. Patients with CKD secondary to DM or HTN typically demonstrate a decline in eGFR ranging from 2-20 mL/min/year. This patient demonstrated a decline of 61 mL/min in six months, raising concern for a secondary insult.

Consensus guidelines regarding the appropriate use of renal biopsy remain sparse. Several indications have been proposed: 1) nephrotic-range proteinuria or renal impairment in the absence of long-standing DM; 2) presence of another illness commonly associated with kidney disease (e.g., lupus); 3) unexplained microscopic hematuria or AKI; 4) rapidly worsening renal function in a patient with previously stable renal function. Given this patient’s rapid decline in renal function, peripheral eosinophilia, and otherwise unrevealing workup, renal biopsy was performed, revealing IgG4-RD and providing the basis for successful immunosuppressive therapy.

Isolated renal failure is a known but uncommon presentation of IgG4-RD. The pancreas, ocular adnexa, and salivary glands are more commonly affected, though the condition can affect any system. Diagnosis of IgG4-RD requires histopathologic confirmation; prior to biopsy, it is often misdiagnosed as a malignancy (e.g., pancreatic) or infection (e.g., chronic otitis media). Patients require multidisciplinary care; providers who encounter a new diagnosis of IgG4-RD should coordinate appropriate follow-up at discharge.

CONCLUSION: Renal biopsy may be warranted in patients with rapidly progressive CKD to identify a secondary, potentially reversible cause.

IgG4-RD is an immune-mediated fibroinflammatory disease with many manifestations, including renal dysfunction.

RENAL CALCULI, PLEURAL EMPYEMA, AND PROTEUS MIRABILIS: AN UNUSUAL TRIAD

Jesse E. Doyle¹; Margaret Beliveau². ¹Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; ²Mediicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #4064841)

CASE: A 67-year-old female with history pertinent for non-obstructive renal calculi and recurrent urinary tract infections presented to the emergency room from clinic for suspected dehydration. Over the prior three months, she experienced frequent vomiting with associated odynophagia, weight loss, and weakness. She denied abdominal pain, fevers, or dysuria. Vital signs and lab work were unremarkable. She was discharged after IV fluids. That evening, she returned with a right proximal humerus fracture after a mechanical fall and was admitted. Her urinalysis suggested infection. Culture grew Proteus mirabilis sensitive to Ceftriaxone. Ultrasound and x-ray imaging identified a right renal stone, prompting urologic consultation. CT scan confirmed a right staghorn calculus with mild hydronephrosis and 20x9 mm obstructing left ureteropelvic junction stone. The left kidney had a complex 10 cm perinephric fluid collection and a contiguous 6 cm pleural fluid collection extending into the posterior chest wall. Interventional radiology successfully drained the perinephric abscess and left a pleural and overlying subcutaneous abscess drain in place. Pleural fluid grew P. mirabilis. Urology placed bilateral ureteral stents and planned subsequent definitive stone treatment. Infectious disease recommended indefinite suppressive antibiotics until then. Follow-up CT showed reduced fluid collections. Drain was removed and the patient was discharged on antibiotics.

IMPACT/DISCUSSION: Pleural empyema secondary to ascending urological infection are typically associated with Escherichia coli or P. mirabilis. This condition can arise from nephropleural fistulae, as a complication following urological procedures, or less commonly, from perinephric abscesses leading to pleural fistulae. Notable risk factors for perinephric abscesses include lithiasis, urological procedures, pregnancy, diabetes, immunosuppression, and malignancy. Symptoms may include back pain, fever, nausea, vomiting, or weight loss. Presentations may lack classical urinary symptoms, obscuring diagnosis. Complications can be severe, including sepsis, renal failure, and extension into adjacent structures. P. mirabilis in pleural fluid is rare, with limited case reports. Absence of urinary symptoms aligns with previous cases of Proteus-related lung infections. Thorough investigation is necessary when atypical pathogens are detected and intra-abdominal sources are possible. Contrast-enhanced CT is the choice modality to identify the source. Management strategies involve prompt drainage of pyogenic collections, coupled with appropriate extended course antibiotics. While nephrectomy is traditionally considered definitive treatment, some centers suggest conservative management or stenting as alternatives in cases with preserved kidney function.

CONCLUSION: Pleural infections stemming from ascending urological infections are rare. Early diagnosis with imaging, prompt drainage, and appropriate antibiotics, are important for effective management.

RENAL REPLACEMENT THERAPY FOR SEVERE HYPERAMMONEMIA AND HEPATIC ENCEPHALOPATHY IN A PATIENT WITH ACUTE DECOMPENSATED CIRRHOSIS AND UPPER GASTROINTESTINAL BLEED

Farha N. Ebadi^2,1; Christelle Nzugang³. ¹On Lok SeniorHealth Inc, San Francisco, CA; ²Internal Medicine, Kent Hospital, West Warwick, RI; ³Beth Israel Lahey Health, Cambridge, MA. (Control ID #4016051)

CASE: A 50-year-old woman with a history of diabetes mellitus and heavy alcohol use presented after being found minimally responsive. Laboratory tests were notable for hemoglobin of 9.1 g/dL, total bilirubin 5.9 mg/dL, AST 52 IU/L, ALT 26 IU/L, INR 2.3, and ammonia of 210 umol/L. Toxicology screening was positive for cannabinoids and otherwise negative for ethanol, salicylates, and acetaminophen. MELD-Na score and Maddrey discriminant function were respectively 25 and 69. Shortly after admission, the patient developed massive hematemesis and hemorrhagic shock. She was immediately intubated, sedated with Propofol, resuscitated with blood products, crystalloids, and vasopressor in addition to parenteral proton pump inhibitors and octreotide. Upper endoscopy demonstrated 2 antral gastric ulcers (Forrest class Ib and II). The largest lesion of 20 mm was treated with epinephrine injection and bipolar cautery. As the patient continued to be hypotensive, she underwent emergent arteriography and transcatheter embolization of the gastroduodenal artery. She then presented with generalized tonic-clonic seizure activities refractory to high doses of benzodiazepines and Propofol. Thus, she received a loading dose of Levetiracetam and Phenytoin. Ammonia level was found to be 666 umol/L. In addition to Rifaximin and Lactulose, urgent hemodialysis was initiated to accelerate ammonia clearance. CT of the head demonstrated loss of gray-white differentiation and effacement of basilar cisterns consistent with cerebral edema and concern about transtentorial herniation. CT of the abdomen pelvis revealed cirrhotic liver morphology with evidence of portal hypertension. Ammonia level went down to 126 but the patient remained comatose. Hyperammonemia is an independent risk factor of cerebral edema and associated life-threatening complications including intracranial hypertension (ICH), brain hypoxia, and cerebral herniation (CH). Here, we report a case of CH and status epilepticus in a patient with a remarkable ammonia level of 666 treated with hemodialysis in the setting of acute on chronic liver failure (ACLF).

IMPACT/DISCUSSION: This case illustrates the challenge of managing a patient with ACLF and significant hyperammonemia level leading to cerebral edema and herniation despite pharmacological therapy and hemodialysis. Further studies are required to investigate the role of renal replacement therapy in the management of hyperammonemia due to liver diseases.

CONCLUSION: Hyperammonemia is an independent risk factor of cerebral edema and associated life-threatening complications including intracranial hypertension (ICH), brain hypoxia, and cerebral herniation (CH). Here, we report a case of CH and status epilepticus in a patient with a remarkable ammonia level of 666 treated with hemodialysis in the setting of acute on chronic liver failure (ACLF).

RESPIRATORY SUPPORT MANAGEMENT IN ATYPICAL ACUTE MEDIASTINITIS

Scott Wagner²; Ana M. Jimenez¹. ¹Psychiatry, Albany Med Health System, Albany, NY; ²Albany Medical College, Albany, NY. (Control ID #4063937)

CASE: A 53-year-old woman presented for pleuritic chest pain with flu-like prodrome and found with mediastinitis. Due to suspicion for sepsis, patient was admitted to the general medical service. Despite supplemental oxygen, patient remained tachypneic. CXR showed interval increase of the left pleural effusion leading to placement of a surgical chest tube. Although adequately draining, patient remained in respiratory distress. Due to need for BiPAP and maturing pleural effusions, patient was upgraded to ICU. An emergent decortication found blood and purulence in the left hemithorax. Post-operatively, patient had decreasing symptoms, oxygen requirements, and leukocytosis. Due to persistent mediastinal inflammatory changes with an unrevealing work-up, a six-week course of piperacillin/tazobactam was recommended upon discharge on day 20.

IMPACT/DISCUSSION: Acute mediastinitis refers to a sudden inflammatory response within mediastinal structures classically due to infection from thoracic surgery, tracheo-esophageal injury, and descending necrotization from head/neck trauma and odontogenic processes. A rapidly progressive disease, it is known to result in substantial long-term morbidity and mortality. Complications can include pericarditis, pneumonia, sepsis, multiorgan failure, and death. A presumed diagnosis of acute mediastinitis requires early and empiric therapy to improve the likelihood for clinical success.

Although this patient did not meet the criteria for acute respiratory failure, the combination of infection, atelectasis, and body habitus perpetuated the patient’s respiratory distress. Due to borderline hypoxemia, NC and HFNC were trialed but failed due to tolerability. BiPAP, a non-invasive positive pressure ventilatory mechanism more commonly used in critical care settings due to need for close monitoring and titration, provided the most relief. Because ICUs are equipped with the vigilance and equipment required for patients whose condition are at risk of imminent decline as in this patient, they must be upgraded to the level of care they need. In patients with acute respiratory failure, BiPAP and early admission to the ICU has demonstrated reduced intubation and reduced in-hospital mortality. Internists who encounter patients with an atypical mediastinitis picture must recognize the signs of impending clinical deterioration and be prepared to escalate care to critical care services promptly.

CONCLUSION: A patient diagnosed with acute mediastinitis whose condition remains unchanging warrants close monitoring, specifically in an ICU setting. These patients are at risk of a rapidly progressive course and delay in care can expose them to greater harm. It is imperative that all contributory factors are considered and optimized to expedite time to recovery. Initial evaluation may include various specialties to determine the underlying etiology, but there should be one overarching agreement among all providers: appropriate treatment must start right away.

RHIZOBIUM RADIOBACTER: AN EMERGING OPPORTUNISTIC PATHOGEN IN CATHETER-ASSOCIATED INFECTION IN A PATIENT WITH HBSC

Grayson D. White, Archana Regmi, Shristi Nepal, Tasnuva A. Mahmud. Internal Medicine Residency, AdventHealth Orlando, Orlando, FL. (Control ID #4063930)

CASE: A 57-year-old African American woman with hemoglobin SC disease, and history of hemorrhagic stroke with residual right-sided deficits presented to the emergency department for evaluation of pain throughout her entire body. She was initially found to be in sickle cell pain crisis and was treated accordingly with pain medications. Admission lab workup revealed leukocytosis, for which blood cultures were drawn. One of the two blood cultures came back positive for Rhizobium radiobacter. To rule out concomitant infective endocarditis, the patient underwent echocardiogram, which was normal. The suspected source was attributed to a port in the right chest which was used for blood draws given poor vascular access due to hemoglobin SC disease. The port was removed by interventional radiology, and the patient was treated with a five-day course of intravenous meropenem. Subsequent blood cultures were negative.

IMPACT/DISCUSSION: Rhizobium genus, reclassified from Agrobacterium genus and Allorhizobium undicola, is an aerobic gram-negative, oxidase-positive, non-spore-forming rod primarily found in soil. While uncommon in causing human infections, it is strongly associated with infections involving foreign material or devices such as central venous catheters, nephrostomy tubes, intraperitoneal catheters, and prosthetic cardiac valves mainly in immunocompromised individuals. Infections include bacteremia, peritoneal dialysis peritonitis, and urinary tract infections, with rare occurrences like endophthalmitis, endocarditis, brain abscess, and pneumonia. The mode of transmission remains uncertain to date. Patients with sickle cell disease are susceptible due to their compromised immunity through factors like impaired complement activation, reduced opsonization, and decreased neutrophil function. While the SS form is the most severe, even HbSC patients experience diverse disease manifestations due to various genetic and mechanical factors. Preventive measures for high-risk patients involve using antimicrobial-impregnated cuffed and tunneled catheters, subclavian catheter insertion rather than internal jugular, and judicious and sterile use of catheters. Treatment typically involves catheter removal and antibiotic administrations guided by culture and susceptibility including minimal inhibitory concentrations due to varied susceptibility patterns and lack of standardization. Although recent studies have shown resistance to aminoglycosides like gentamicin, third generation cephalosporins, cefepime, fluoroquinolones, extended-spectrum beta-lactams, carbapenems, and tetracyclines have shown effectiveness in previous literature. Mortality rates associated with Rhizobium infections are exceedingly rare, with an overall favorable prognosis.

CONCLUSION: Rhizobium radiobacter is an opportunistic pathogen that commonly infects immunocompromised patients, including patients with HbSC disease. It is treated with appropriate antibiotics guided by susceptibility testing and removal of catheters or devices.

RISK BENEFIT ANALYSIS: TREATING THROUGH A RARE CASE OF METHADONE-INDUCED THROMBOCYTOPENIA IN SEVERE OPIOID USE DISORDER

Sofia Celli¹; Michael K. Jones²; Brandon McMahon¹. ¹School of Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #4064736)

CASE: A 33-year-old female with a history of fentanyl use disorder (FUD) was admitted for acute dyspnea in the setting of chronic fatigue and pallor, found to have severe iron deficiency anemia without an obvious bleeding source. Initial hemoglobin was 2.5 g/dL, ferritin of 1 ng/mL, TIBC 575 mg/dL, and iron 10 mg/dL. She was treated with PRBC transfusions and iron dextran infusion, with hemoglobin improving to 7.6 g/dL and normal platelets hospital day 3.

Methadone was started on day 2 of hospitalization for mild withdrawal symptoms and long-term treatment of FUD, after which her platelets began to decrease, at 140,000/μL on day 5. Evaluation was unremarkable, with no bleeding or bruising, no platelet clumping or abnormal morphology on peripheral smear, no infectious symptoms, negative HIV and Hepatitis C screening, and negative DIC and hemolysis studies. Her platelets reached a nadir of 70,000/μL on day 9. After discussions with Hematology and Addiction Medicine, it was agreed that the benefits of methadone outweighed the potential risks of mild thrombocytopenia, as she was awaiting placement into a substance use treatment program. Her platelets spontaneously stabilized to 78,000/μL on day 10 and normalized three days later. Thrombocytosis was apparent after 2 weeks with platelets of 938,000/μL, commonly seen in iron deficiency. Four months later, she had no evidence of thrombocytopenia or anemia.

IMPACT/DISCUSSION: This was a rare presentation of thrombocytopenia following methadone initiation. Given the lack of findings to support etiologies such as hemolysis, DIC, infection, HIT, or splenic sequestration, methadone-induced thrombocytopenia was given as a diagnosis of exclusion. From our review, this is the first case report of drug-induced thrombocytopenia related to therapeutic methadone.

A previous case found thrombocytopenia after a toxic methadone ingestion; however, as the patient’s baseline platelet count was unknown, the potential mechanism remains unclear.¹ Reports of thrombocytopenia secondary to other opioids have been attributed to the addition of polyethylene oxide in the formulation, which is not in methadone formulations.² There are reports of methadone activating pathways resulting in apoptosis in leukemic cell lines, raising the possibility of a similar mechanism affecting megakaryocytes at least transiently in this patient, and perhaps others who may be susceptible.^3,4

With the prevalence of opioid use disorder, this is an important adverse effect of methadone for providers to recognize. However, unless clinical bleeding arises, treatment through transient thrombocytopenia may be appropriate.

CONCLUSION: This case aims to raise awareness of methadone, a common medication used for the treatment of chronic pain and opioid use disorder, as a potential cause of drug-induced thrombocytopenia.

ROUTINE BECOMES RARITY: YOUNG, HEALTHY FEMALE DEVELOPS RARE THROMBOTIC DISEASE

Matthew Nguyen¹; Ashley Meyer¹; Kathryn Uchida¹; Dong Ren³; Kenny Vongbunyoung¹; Minh-Ha Tran²; Omar Darwish¹. ¹Department of Internal Medicine, University of California Irvine School of Medicine, Irvine, CA; ²Department of Transfusion Medicine, University of California Irvine School of Medicine, Irvine, CA; ³Department of Pathology and Laboratory Medicine, University of California Irvine School of Medicine, Irvine, CA. (Control ID #4043199)

CASE: Our case features a postpartum patient who developed complement mediated aHUS after a laparoscopic cholecystectomy. A previously healthy 20-year-old patient presented two months post-partum to an outside hospital with 4 days of abdominal pain, elevated transaminases, and total bilirubin. Post laparoscopic cholecystectomy, she developed thrombocytopenia, anemia, and extensive decline in renal function labs requiring multiple units of blood transfusions and dialysis. Results of renal biopsy were suggestive of cm-TMA and acute tubular necrosis. On genetic testing, this patient had a negative complement aHUS genetic panel that predisposed her to this disease process. The patient was treated with complement inhibition therapy, eculizumab, with noticeable improvement inpatient and at outpatient follow-up. Due to clinical improvement and stable renal function on eculizumab therapy, hemodialysis was stopped two weeks following discharge.

IMPACT/DISCUSSION: Our case features an exceedingly rare case of aHUS occurring post laparoscopic cholecystectomy with an improvement in hemolytic labs, thrombocytopenia, and renal function post eculizumab therapy. We believe that our patient’s aHUS presentation was multifactorial, likely driven by her most recent child delivery and minimally invasive surgery. To our knowledge, this is the first reported case of an elective procedure precipitating this rare disease process in an otherwise healthy patient with no genetic predisposition to the condition. Our case emphasizes the importance of a high degree of clinical awareness and judgment surrounding complement-mediated TMA, aHUS subsets, and nosocomial events as a precipitator for the disease. One growing treatment option, although expensive, is immunotherapy via a C5 blockade such as eculizumab. However, the length of treatment remains controversial amongst current literature due to its high cost and thus requires further exploration. Furthermore, our case stresses the importance of the impact of multidisciplinary teams for the rapid diagnosis and appropriate treatment of this otherwise deadly condition.

CONCLUSION: In conclusion, our case emphasizes the importance for clinicians to have a high degree of clinical awareness and judgement surrounding complement-mediated TMA, aHUS its subsets, and to recognize that the post-partum period (up to 3 months after delivery) as a risk factor for HUS and that minimally invasive procedures such as a cholecystectomy done during the post-partum period (up to 3 months after delivery) can precipitate HUS. Although new literature is growing regarding the diagnosis of cm-TMA and the many influencers of TMA, there still exists a paucity of data on the timing and maintenance for the use of C5 blockade. Thereby, this case stresses the importance of exploring the length of treatment for C5 blockades and the establishment of multidisciplinary teams to address the complexities of TMA.

RUPTURED MITRAL CHORDAE TENDINEAE AS A POSSIBLE NIDUS FOR CARDIOEMBOLIC STROKE

Colin M. Kulick-Soper¹; Andrew Wade¹; Benjamin Khazan². ¹Medicine, Pennsylvania Hospital, Philadelphia, PA; ²Cardiology, Penn Medicine, Philadelphia, PA. (Control ID #4064116)

CASE: A 76-year-old woman with a past medical history of CAD and HFrEF presented to the ED with 1 day of waxing and waning confusion, dysarthria, word-finding difficulty, and one episode of vomiting, with no other reported symptoms. She had undergone dental surgery 3 weeks before admission. Physical exam including NIH Stroke Scale was unremarkable. CT scan was notable for a chronic-appearing occipital infarct that was not seen on imaging 1 year prior. Initial labs were concerning for urosepsis, prompting admission to the hospital. Subsequent brain imaging noted additional new, small bilateral infarcts and old areas of hemorrhage. A TTE revealed a 3.7 cm highly mobile mass associated with the posterior mitral valve apparatus concerning for a vegetation and associated with moderate mitral regurgitation, as well as a newly reduced LV EF of 20-25%. Empiric antibiotic coverage for infective endocarditis was started and she was transferred to the Cardiothoracic surgery service for consideration of surgical intervention. A TEE was ordered, and after significant scrutiny, it was felt that the visualized mass more likely represented a ruptured mitral chorda tendineae (MCT) without vegetation. Blood cultures were negative and she remained clinically free of infection, thus antibiotics were discontinued. The patient was managed medically and was discharged on anticoagulation for stroke prevention and appropriate guideline-directed medical therapy for heart failure. Her reduced EF did place her at higher risk of LV thrombus due to low output, but no LV thrombus was seen on contrast-enhanced echo, and no arrhythmia or other definitive source of cardioembolic stroke was identified.

IMPACT/DISCUSSION: Ruptured MCT is a rarely reported nidus for cardio-embolic stroke, with only a small number of suspected cases described. We present a case of a ruptured MCT, which initially appeared to be a large valvular vegetation based on imaging and clinical history, that was ultimately thought to be a potential source of thrombus for her bilateral cortical infarcts. While ruptured MCT specifically is not well-characterized as a risk factor for stroke, mitral valve prolapse is a known risk factor for ischemic stroke. Ruptured MCT is not uncommon amongst patients with mitral valve prolapse. It is often minimally symptomatic or asymptomatic, and may go unnoticed unless incidentally found on imaging. As much as 30-40% of ischemic strokes are cryptogenic, and ruptured MCT may be a rare and/or poorly characterized risk factor for cardioembolic stroke, possibly serving as a nidus for thrombus formation.

CONCLUSION: -Cardio-embolic sources for stroke extend beyond atrial fibrillation and should be a major consideration for any cryptogenic stroke, especially when multiple or bilateral infarcts are present

-Multi-disciplinary evaluation is often crucial for determining the source of cryptogenic stroke

-Ruptured Mitral Chordae may be a rare risk factor for cardioembolic stroke, although the exact mechanism remains unknown

S. CANIS BACTEREMIA IN AN IMMUNOCOMPETENT PATIENT: A CASE PRESENTATION

Razia Sultana²; Kaitlyn Ruffing^3,1; Rayeed Islam³; Roderick Go³. ¹Pediatrics, Stony Brook University Hospital, Stony Brook, NY; ²Stony Brook University Renaissance School of Medicine, Stony Brook, NY; ³Internal Medicine, Stony Brook University Hospital, Stony Brook, NY. (Control ID #4062671)

CASE: The patient is a 91-year old male who presented to an academic center in the Mid-Atlantic region with fatigue, generalized body aches, flank pain, and persistent fever. Medical history was significant for atrial fibrillation, coronary artery disease, renal cell carcinoma with left-sided nephrectomy, B-cell lymphoma in remission, iron deficiency anemia, hypertension, benign prostate hyperplasia, stage lII chronic kidney disease, and recurrent multi-drug resistant urinary tract infections.Home medications included allopurinol, furosemide, rivaroxaban, clopidogrel, amlodipine, carvedilol, hydralazine, spironolactone, and finasteride. He recently completed an EGD and colonoscopy. On physical exam, the patient was febrile, lethargic and noted to have a chest port. Laboratory work-up was normal except for urinalysis with >250 white blood cells and positive leukocyte esterase. CT imaging of the chest, abdomen, and pelvis was unrevealing. Blood cultures were positive for Streptococcus canis growth in 3 out 4 bottles. He endorsed recently adopting a new puppy and sustaining small hand wounds. He was then started on IV ceftriaxone 2 grams every 12 hours. Subsequent transthoracic and transesophageal echocardiography (TTE, TEE) were negative for endocarditis. He declined MRI testing for osteomyelitis. He symptomatically improved during his week-long admission. He received a peripheral inserted central catheter line on discharge to complete the antibiotic course for a total of 4 weeks. He made a full recovery back to his baseline and did not experience recurrence.

IMPACT/DISCUSSION: We present a case of S. canis bacteremia in an elderly male with recent canine exposure. S. canis is usually considered a zoonotic pathogen and infections are rare, with reported cases mainly described in immunocompromised persons. The patient in this case was an immunocompetent male in cancer remission, adding a novel presentation to current literature. Though the patient here presented with a sepsis-like presentation secondary to possible UTI infection, subsequent lab testing and history revealed a different etiology. The source of spread for the S canis is likely secondary to the puppy exposure, with the patient’s chronic port placement possibly related to the spread. GI translocation was considered as another possible source given his recent EGD and colonoscopy, but this is much less likely. Clinicians should thus conduct thorough clinical work-up to pinpoint source and spread of infection including environmental and animal contacts. The treatment of choice is with an aminoglycoside or beta-lactam, such as ceftriaxone. Future research is necessary to determine sequelae of this disease in immunocompetent hosts.

CONCLUSION: S. canis bacteremia can present with a generalized sepsis-like presentation in immunocompetent patients. Prompt antibiotic treatment with ceftriaxone can reduce progression to severe invasive disease.

SALMON COLORED RASH AND JOINT PAIN

Pranay Gupta¹; Raagini Yedidi¹; Abhishek B. Vadher¹; Avis Ware². ¹Internal medicine, Garden City Hospital, Garden City, MI; ²Rheumatology, University of Cincinnati, Cincinnati, OH. (Control ID #4015438)

CASE: A 28-year-old woman with past medical history of childhood asthma presented with 2 weeks of sore throat, bilateral knee pain, diaphoresis without measured fevers, and migratory nonpruritic rash on the inner thighs, face, palms, and chest. She denied any other symptoms. She had no relevant exposures or travel. She was sexually active with one partner and denied substance use. There was no pertinent family history. Her only medication was a rescue inhaler for asthma. She presented to two other hospitals before presenting to our hospital and had received low dose prednisone and diphenhydramine due to concern for allergic reaction. On physical exam, she was afebrile and hemodynamically stable but diaphoretic. She had decreased range of motion at the bilateral knees limited by pain with medial and lateral joint line tenderness of both knees. Faintly erythematous and pink-appearing rash consisting of 6 salmon-colored macules was present on the right arm. In the ED, she received one dose of 125 mg IV methylprednisolone, famotidine, and diphenhydramine. Laboratory workup revealed leukocytosis to 17.10 with greater than 80% polymorphonuclear cells, ESR of 48 and CRP of 178. LDH was 332. Blood cultures; treponema pallidum total antibody; coxsackie A7, A9, A16, A24 IgM; Rocky Mountain Spotted Fever serology; and acute hepatitis panel were all negative. ANA and RF were negative. P-ANCA and c-ANCA were negative. AST was 28, ALT was 74, and GGT was 156. Her ferritin was >1,650, which was above the laboratory maximum. A diagnosis of adult-onset Still’s disease was suspected. She received 40 mg oral prednisone daily and ibuprofen for joint pain with improvement of symptoms and plan for outpatient follow up with rheumatology.

IMPACT/DISCUSSION: Diagnosis of Still’s disease is challenging because though fever, classic rash, joint pain, and high ferritin can raise diagnostic suspicion, presentations may vary as they did in our patient who was afebrile. The two most commonly used diagnostic criteria in clinical practice are the Yamaguchi classification criteria and the Fautrel criteria. A study of 54 AOSD and 278 control patients comparing the criteria showed Fautrel criteria to have sensitivity of 87% and specificity 97.8% and Yamaguchi criteria to have sensitivity of 96.3% and specificity of 97.8%. Our patient met diagnostic criteria for the Yamaguchi classification and the Fautrel criteria.

CONCLUSION: This case demonstrates a rare diagnosis and shows disease may be present even in the absence of features thought to be typical for the disease (as this patient was afebrile). This case also shows the utility of the Yamaguchi criteria or Fautrel criteria in helping to establish a diagnosis of AOSD once other diagnoses have been ruled out in the clinical setting.

SALMONELLOSIS: SWIMMING UPSTREAM FROM ENTERITIS TO SPLENIC ABSCESS AND GALLBLADDER COLONIZATION

Meghali Singhal, Ginearosa Carbone. Internal Medicine, Santa Barbara Cottage Hospital, Santa Barbara, CA. (Control ID #4064158)

CASE: A 73-year-old man with a history of type 2 diabetes presented with dysarthria, ataxia, and vomiting for one week. CT brain revealed a subacute infarct in the superior right cerebellar hemisphere. CT abdomen showed a 6.5 cm hypoattenuating lesion in the inferior spleen and smaller hypoattenuation in the superior spleen concerning for abscess. The patient met SIRS criteria and blood cultures were positive for Salmonella species. No vegetations were noted on transthoracic echocardiogram (TTE). He was treated with Ceftriaxone and underwent a CT-guided aspiration of the splenic abscess with drain placement. Concurrently, he developed right upper quadrant pain with a cholestatic pattern noted in his labs. HIDA scan revealed poor gallbladder ejection fraction, suspicious for a cystic bile duct obstruction. A percutaneous cholecystostomy tube was placed with fluid cultures positive for Salmonella species. The splenic drain was removed and the cholecystostomy tube was maintained for 6 weeks after discharge. He was transitioned to Bactrim and infectious disease follow-up.

IMPACT/DISCUSSION: Non-typhoidal Salmonella infections often manifest as self-limiting gastrointestinal symptoms. The patient consumed raw oysters within the prior months, which may have been a nidus for his infection.The patient also had a CT four months prior with none of the aforementioned splenic changes. Splenic abscesses are rare complications of Salmonella bacteremia seen in immunosuppressed individuals, diabetics, and those with prothrombotic conditions. Occasionally, splenic infarcts can progress to abscesses. The CT brain showed acute versus subacute infarction in the right cerebellum. These findings were suspicious for infectious endocarditis (IE) and splenic infarcts from septic emboli. It should be emphasized that IE cannot be excluded despite negative findings for vegetation, such as those seen on TEE.

Salmonella species often colonize the gallbladder, which serves as an apt reservoir for bacterial colonization and subsequent inflammation and cystic duct obstruction. The development of splenic abscess is rare, noted in the third to fourth week of infection, and confirmed on CT with areas of central, higher attenuation and ring enhancement. Treatment includes antibiotic therapy with four to six weeks of treatment with third-generation cephalosporins with drainage or splenectomy. This case also emphasized the importance of vaccination against infections with encapsulated bacteria.

CONCLUSION: Splenic abscesses and obstructive gallbladder pathologies are rare complications of Salmonellosis. When assessing Salmonella bacteremia, it is crucial to consider risk factors such as IE and prothrombotic states as etiologies of organ seeding. Antibiotic therapy includes third-generation cephalosporins for four to six weeks along with vaccination against opportunistic infections from encapsulated bacteria.

SAY YES TO THE DRESS: RECOGNIZING THE SIGNS OF MULTI-ORGAN INVOLVEMENT IN DRESS SYNDROME

Ana Maria Davila Morales, Arti A. Narsinghani. Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4034689)

CASE: A 57 year old female with history of failed back surgery s/p spinal cord stimulation and intrathecal pump c/b paraspinal abscess and removal of devices presented with RUQ abdominal pain and fevers. Two months prior, abscess cultures grew MRSA and pt was treated with Vancomycin. Due to intolerance, pt was switched to Daptomycin and then Bactrim which she was taking up until readmission. On arrival, CBC with eosinophilia up to 0.76 K/uL, sCr 4.03 umol/L (baseline 0.6), AST/ALT 795/558, Tbili 0.4, Alk Phos 507. CTAP with IV contrast showed slightly increased size of paraspinal fluid collection. RUQ US and MRCP showed stable CBD dilation to 11mm without gallstones or strictures. IR did not intervene on fluid collection as it was not large enough to cause symptoms. ID recommended to stop all antibiotics as she completed adequate course for prior abscess. Hepatology suspected Bactrim-related drug-induced liver injury while Nephrology suspected acute interstitial nephritis. On Day 2 of admission, patient developed fever to 102.2F and was empirically started on Vancomycin and Zosyn. 30 minutes into Vancomycin infusion, she developed hives, pruritus, and wheezing that resolved after therapy. Dermatology and Allergy were consulted due a persistent diffuse maculopapular rash and Bactrim-induced DRESS Syndrome with separate allergy to Vancomycin were diagnosed. Both antibiotics were added to allergy list and she received a short course of oral prednisone with improvement in rash, eosinophilia, kidney and liver function.

IMPACT/DISCUSSION: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome is a severe drug-induced reaction associated with multiple antibiotics including TMP-SMX and Vancomycin. It is challenging to diagnose due to multiple organ involvement including cutaneous, hepatic, renal, and hematologic manifestations as were seen in our patient. DRESS has a later onset and longer duration than other drug reactions, with a latent period of 2 to 6 weeks. It has an incidence ranging from of 1 in 1,000 to 1 in 10,000 patients and has a 10% mortality rate, most commonly from fulminant hepatitis with necrosis. Our initial concern was drug-induced liver injury given previous Bactrim use for 6 weeks with superimposed acute interstitial nephritis. However, further workup revealed eosinophilia and a persistent diffuse maculopapular rash that pointed diagnosis towards DRESS Syndrome due to Bactrim versus Vancomycin. Management includes culprit drug withdrawal and corticosteroids as was done with our patient.

CONCLUSION: DRESS Syndrome is a severe drug-induced reaction linked to multiple antibiotics. It may be difficult to diagnose due to multiple organ involvement including cutaneous, hepatic, renal and hematologic manifestations, however quick recognition may prevent liver failure and mortality.

SCLERODERMA RENAL CRISIS IN A RHEUMATOID ARTHRITIS (RA)/SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PATIENT?

Divya Vundamati¹; Tiffany Lin²; Carmen Campbell². ¹Internal Medicine, University of Wisconsin-Madison, Madison, WI; ²Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4063877)

CASE: A 44yo woman with a history of pre-eclampsia and newly diagnosed RA/SLE overlap presented with headaches, digital ulcerations, dysphagia, AKI, and arthralgias. Her SLE manifested with +ANA, +CCP, +SSA, inflammatory arthritis, malar rash, Raynaud's, serositis, and hemolytic anemia. She was treated with hydroxychloroquine and prednisone 80 mg daily. Vitals were notable for significant hypertension of 180/100 which improved with IV hydralazine and nifedipine. Exam showed cutaneous erythematous rash over bilateral cheeks, digital ulcerations, abnormal capillary nailfold exam, digital pitting, and active synovitis over bilateral MCP/PIP joints. Labs indicated AKI (Cr 3.75, bl 0.6), leukocytosis, negative Scl-70, UA with hematuria and proteinuria, and elevated protein/creatinine ratio which raised concern for SLE nephritis. She was treated with lV solumedrol 250 mg for three days. Kidney biopsy showed acute thrombotic microangiopathy (TMA). Findings of TMA, hypertensive emergency with recent steroid use, severe Raynaud's, and dysphagia raised concern for SRC which was further supported by + RNA polymerase 3. ADAMTS13 activity was low. Antiphospholipid syndrome (APS) was considered given her worsening renal function and proteinuria although was thought to be less likely given she had negative APS labs and no history of vascular thrombosis or pregnancy morbidity. She was treated with captopril, azathioprine, and steroids were tapered with improvement of her symptoms.

IMPACT/DISCUSSION: We present a rare case of a patient with RA and SLE overlap, who went on to develop acute renal failure mimicking SLE nephritis. However, her workup demonstrated that her acute renal failure was caused by SRC. Consider SCR and atypical HUS in patients with AKI and microangiopathic hemolytic anemia (MAHA). SRC typically presents with abrupt hypertension, MAHA, and rapidly progressive oliguric renal failure. Factors predictive of SRC include diffuse skin involvement, + RNA polymerase 3, steroid therapy in doses greater than 15 mg a day, friction rubs, new onset anemia, pericarditis, and congestive heart failure. The clinical and histological picture is TMA. Laboratory findings in SRC include elevated plasma Cr (96%), MAHA (60%), and thrombocytopenia (50%). UA can show hematuria, proteinuria, and granular casts. Renal biopsy is not necessary but may be needed to exclude other etiologies of renal failure. First-line treatment in SRC is aggressive blood pressure control with an angiotensin esterase inhibitor (ACEi) as it has shown a >60% reduction in mortality. No proven benefit is seen with using ACEi prophylactically and its use is associated with poorer renal outcomes.

CONCLUSION: SRC is a serious condition and early diagnosis and prompt initiation of ACEis is essential for better outcomes. Treatment involves vasodilation of the renal arterioles to increase blood flow to the kidneys. ACEi is warranted and may lead to eventual recovery of renal function.

SECONDARY MEMBRANOUS NEPHROPATHY AND ABDUCENS NERVE PALSY IN A MAN WITH NEUROSYPHILIS

swecha p. potharaj²; Warda Zaman¹; Nicholas Nelson². ¹Nephrology, Alameda Health System, Oakland, CA; ²Internal Medicine, Alameda Health System, Oakland, CA. (Control ID #4043780)

CASE: The patient is a 58-year-old male with opioid use disorder on methadone and BPH who presented to the emergency room with bilateral lower extremity swelling and nausea for 2 weeks. Physical exam was remarkable for bilateral cranial nerve 6 palsy, 2+ pitting edema up to knees; and diffuse, pruritic maculopapular rash over arms and legs, however, palms were spared. Labs were notable for creatinine 0.9mg/dL, albumin 1.3mg/dL, total cholesterol 213. Urine toxicology was positive for cocaine. Complements C3 and C4 were normal. Hep C, Hep B, and HIV were negative. Urinalysis revealed >1000mg/dL protein, with urine red blood cell 21-50 /HPF and urine white blood cell count of 6-20/HPF. The urine albumin-creatinine ratio was 5352.98 mcg ALB/mg CR. Anti-PLA2R, proteinase-3, and myeloperoxidase antibodies were all negative. The treponemal enzyme immunoassay antibody was reactive and rapid plasma reagin 1:256. MRI brain showed Chiari 1 malformation with cervical syrinx, hence lumbar puncture was deferred. Kidney biopsy revealed glomeruli with normal cellularity with weak immune complex deposition along the capillary membranes that were positive for IgG, IgA (weak), C3, C1q, kappa, and lambda. The diagnosis was membranous nephropathy secondary to syphilis. He was treated for secondary syphilis with penicillin G Benzathine 4 mU intramuscularly for 2 weeks, with improvement of proteinuria.

IMPACT/DISCUSSION: The incidence of membranous nephropathy is 8 to 10 cases per 1 million population worldwide and 12 per 1 million population per year in the USA. Membranous nephropathy or membranous glomerulopathy is characterized by massive proteinuria (> 3.5 grams/day). Etiology can be primary or secondary to infections, malignancy, drugs, or autoimmune diseases. Clinical presentation includes peripheral edema, hypertension, frothy urine, and may also have manifestations of thromboembolic phenomena. Lab findings are significant for hypoalbuminemia, dyslipidemia, albuminuria, and acute kidney injury. The pathology in nephrotic syndrome is due to podocyte injury and membrane anionic charge barrier loss, causing albuminuria, unlike the inflammatory process in nephritic syndrome.

CONCLUSION: The initial step in managing newly diagnosed membranous nephropathy is to evaluate for secondary causes of the disease. Testing for anti-phospholipase A2 receptor (PLA2R) antibody is used to help distinguish primary (PLA2R antibody–positive) from secondary (PLA2R antibody–negative) forms of membranous nephropathy. This distinction is crucial because secondary (PLA2R antibody–negative) forms are expected to remit if the underlying systemic disease responsible for the lesion is successfully treated. As the incidence of syphilis in the United States has been on the rise consistently since 2017, a new onset membranous nephropathy warrants syphilis to be high on differential diagnoses for secondary causes.

SECONDARY SCLEROSING CHOLANGITIS (SSC): A LATE COMPLICATION OF SEVERE COVID-19 PNEUMONITIS

Victoria Kusztos¹; Mariya Pogorelova². ¹Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4057649)

CASE: A 43-year-old male presented for evaluation of alkaline phosphatase predominant elevation of liver enzymes. He had no medical comorbidities other than hypertension, until he developed severe COVID-19 pneumonitis requiring prolonged ICU stay and intubation. After discharge, he had no overt signs of hepatic decompensation, but had newly elevated LFTs persisting one year later with alkaline phosphatase 637, AST 116, ALT 147, indirect hyperbilirubinemia, total BR 2.0. Two months later, he presented to a local ER with RUQ pain. He was diagnosed with acute cholecystitis and choledocholithiasis, and underwent ERCP with stent placement, cholecystectomy, and liver biopsy, and his symptoms resolved. His LFTs remained elevated, and he was diagnosed with autoimmune hepatitis and started on CellCept and prednisone. Despite 3 months of therapy, LFTs remained elevated with alkaline phosphatase 226, AST 56, ALT 103. MRCP revealed chronic parenchymal liver disease with stage 3-4 fibrosis. Liver biopsy showed bridging fibrosis in a biliary pattern with ductular proliferation and mixed inflammation and cholestasis, suggesting chronic biliary disease, without signs of autoimmune hepatitis. He was diagnosed with SSC due to severe hypoxia during COVID infection. His steroid was tapered and immunosuppression was discontinued. His LFTs improved, and annual MRCP with LFTs every 3 months is planned.

IMPACT/DISCUSSION: This case highlights an underrecognized entity known as SSC-CIP, which typically occurs within months of prolonged ICU care most commonly in patients treated for infection, burns, and trauma. Patients are more commonly male in the 4-5th decade of life and lack prior liver disease. Contributing factors include bile duct ischemia in the setting of low mean arterial pressures, microcirculatory blood flow disturbances due to hypercoagulable states induced by critical illness, and use of vasopressor norepinephrine which can reduce splanchnic blood flow. Ventilation with high positive end-expiratory pressure is also thought to cause biliary ischemia. Ischemia and inflammation are also thought to downregulate secretion of phospholipids, which protect cholangiocytes from hydrophobic bile acids, furthering bile duct injury. Radiologic findings include focal strictures in intrahepatic bile ducts. Prognosis for SSC-CIP is poor, with mean transplant-free survival ranging from 17-40 months. A variant of SSC-CIP called post-COVID cholangiopathy, has also been identified. Cholangiocytes are known to have high ACE2 receptor expression, and SARS-Cov-2 RNA and nucleo-capsid protein has been found in cholangiocytes of patients with severe COVID-19, suggesting direct viral damage.

CONCLUSION: Physicians should consider critical illness including COVID-19 as a potential etiology of prolonged cholangiopathy presenting months after ICU admission in patients without other risk factors presenting with new persistently elevated LFTs.

SEQUENTIAL PD-(L)1 BLOCKADE AND OSIMERTINIB INDUCED PNEUMONITIS IN NON-SMALL CELL LUNG CANCER.

Niveditha popuri¹; Govind Jha²; Kellie Jones². ¹Internal medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK; ²Pulmonary and critical care medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK. (Control ID #4064909)

CASE: A 55-year-old woman with a 10-pack-year smoking history was diagnosed with Stage IV Non-small cell lung cancer (NSCLC) after she presented with recurrent pleural effusions. She started chemoimmunotherapy with carboplatin, pemetrexed and pembrolizumab, however, pembrolizumab was discontinued within a month of initiation due to concern for drug induced pneumonitis (DIP). In the interim, next-generation sequencing (NGS) revealed exon 19 deletion in EGFR (endothelial growth factor receptor) and she was initiated on 80 milligrams (mg) Osimertinib daily after completing four cycles of carboplatin and pemetrexed. However, three days after Osimertinib initiation, she was admitted to the intensive care unit with acute hypoxic respiratory failure requiring non-invasive ventilation with bilevel positive airway pressure (BiPAP). Extensive infectious work-up was negative and a high-resolution CT chest revealed diffuse granular opacities and reticulations in the left lung sparing the subpleural margins, suggestive of DIP. Osimertinib was stopped and she was treated with 60mg methylprednisolone every six hours which led to dramatic clinical improvement. She was weaned off BiPAP to high-flow nasal cannula and subsequently discharged home with home-oxygen and a steroid taper.

IMPACT/DISCUSSION: Pembrolizumab is an anti-PD-1 antibody that is routinely used as front-line therapy in metastatic NSCLC. Osimertinib is an irreversible EGFR-TKI (tyrosine kinase inhibitor) that is selective for patients with mutant EGFR and also has activity against the T790M point mutation that results in resistance to the first-generation EGFR TKIs. Although DIP is a well-known complication of both medications, one retrospective study found that PD-(L)1 blockade followed by Osimertinib was associated with severe immune-related complications including pneumonitis especially when initiated within 3 months of PD-(L)1 blockade. Similar complications were not noted with sequential Osimertinib and PD-(L)1 usage, likely due to the short half-life of Osimertinib. Our patient was initiated on Osimertinib within 3 months of pembrolizumab discontinuation and developed DIP requiring hospitalization. Although a diagnosis of DIP necessitates discontinuation of Osimertinib, there have been multiple case reports of patients that were successfully rechallenged with Osimertinib after recovery.

CONCLUSION: Although more research is warranted to develop specific guidelines regarding sequential usage of these medications, it is important to exercise caution while treating patients with sequential PD-(L)1 blockers and Osimertinib.

SERRATIA MARCESCENS BACTEREMIA SECONDARY TO MIGRATORY EPICARDIAL PACER WIRE PERFORATING THE TRANSVERSE COLON

Nirmala Ghimirey¹; Jacob Fling¹; Akhinav Raval¹; Aimee Mandapat^2,1. ¹Internal Medicine, Summa Health System, Akron, OH; ²Infectious Disease, Summa Health System, Akron, OH. (Control ID #4064620)

CASE: Introduction

In major cardiac surgeries, a temporary epicardial pacing wire is routinely utilized to treat postoperative arrhythmias. There have been documented cases of this generally innocuous intervention leading to fatal infections due to the migration of the temporary epicardial pacing wires into unexpected regions. Serratia marcescens is an anaerobic, Gram-negative, bacillus responsible for nosocomial and injection-drug-use-related bacteremia. We report a case of epicardial pacer wire migration with perforation of the transverse colon leading to Serratia marcescens bacteremia.

Case Report

A 70-year-old male with an unremarkable history presented to ED with acute onset “sharp” chest pain. On presentation, he was normotensive and tachycardic at 119 beats/min. Lab work significant for WBC of 17,100/μL with elevated troponin at 0.042 ng/mL. EKG showed sinus tachycardia. CT angiography of the chest showed a type A ascending thoracic aortic dissecting aneurysm. The patient was emergently taken to the operating room for ascending aorta repair with #32 tube graft and aortic valve repair. Postoperatively the patient developed atrial fibrillation. One week after the surgery, the patient developed abdominal bloating with an elevated WBC of 21,000/μL. Chest x-ray showed pneumoperitoneum. The patient was started on empiric antibiotics and taken for emergent exploratory laparotomy. During the procedure, an epicardial pacer wire was found entering the transverse colon through a pinpoint colotomy. Furthermore, colotomy communication at the subxiphoid was noted with foul-smelling murky brown fluid emanating from the subxiphoid space around the pericardium. The transverse colon perforation was repaired. The patient underwent repeat sternotomy and chest washout. Serratia marcescens was isolated from 2/2 preoperative blood cultures. Once the patient's blood culture cleared, he was discharged home on intravenous meropenem via PICC line for 30 days.

IMPACT/DISCUSSION: Temporary epicardial pacing wire is often placed following a major cardiac surgery. These pacing wires are sutured to both the right atrium and right ventricle. The removal of wire is often performed on the 4th or 5th postoperative day. During the extraction process, if the wire meets resistance, it is cut with the rest left to retract inside. The reported incidence of temporary epicardial wire causing major complications is about 0.4% which includes hemorrhage and tamponade. In PubMed and Google Scholar searches, we found only two other cases of colonic perforation reported from the migration of an epicardial pacing wire.

CONCLUSION: This case highlights potential complications associated with temporary epicardial pacer wire migration. Furthermore, this is the first case where migration of pacing wire not only caused colonic perforation but also was heralded by Serratia marcescens bacteremia.

SEVERE RHABDOMYOLYSIS FOLLOWING TONGUE MACERATION IN THE SETTING OF A SIMPLE SEIZURE

Samantha Lo¹; Saad Malik¹; Jesus Javier Rubio Castillon¹; Alfredo Astua^2,1. ¹Internal Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY; ²Pulmonary and Critical Care, New York City Health and Hospitals Corporation, New York, NY. (Control ID #4064896)

CASE: A 29 year-old woman presented with altered mental status and was found to have a right ear laceration and blood in the oropharynx. In the emergency department, the patient had a brief seizure and became obtunded. Her venous blood gas showed a pH of 7.0 and pCO2 of 82 mmHg and she was emergently intubated and treated with levetiracetam, lorazepam, and intravenous fluids. Physical exam revealed a left-sided 4 cm x 5 cm tongue laceration. Labs showed a hemoglobin of 9.7 g/dL, serum creatinine (Cr) of 0.9 mg/dL, and creatine kinase (CK) of 2,300 U/L, with urine toxicology positive for cocaine and opiates. CT of the brain was normal.

Patient was sedated with propofol and dexmedetomidine and started on antibiotics for the oral laceration. On hospital day (HD) 2, the patient’s tongue swelled and bled profusely, requiring ENT consultation. She was treated with oral packing with kaolin and transfused with one unit of pRBCs, increasing her hemoglobin from 6.8 to 8.1 g/dL. Patient’s CK uptrended with a peak on HD 4 at 20,955 U/L. Patient was aggressively hydrated with Lactated Ringers at 200mL/hr for 96 hours. Cr levels remained stable. On HD 4, the patient was extubated, and IV hydration was continued. The patient was also treated for opioid withdrawal. She had no further seizures and was discharged on HD 11.

IMPACT/DISCUSSION: Rhabdomyolysis is the breakdown of skeletal muscle tissue from traumatic and non-traumatic causes with potential to cause acute renal failure (ARF). Breakdown of skeletal tissue spills cellular components into the systemic circulation, notably CK and myoglobin. Myoglobin causes rhabdomyolysis-induced ARF through nephrotoxic effects via myoglobin cast formation and decreased release of nitric oxide leading to renal vasoconstriction and further ischemia. While management of AKI is supportive, enzymes including CK hold a prognostic role in guiding management. A previously reported case of rhabdomyolysis in a patient with tongue laceration following a seizure resulted in AKI. Despite severe tongue maceration, our patient's Cr remained normal despite an increase in CK levels of ~20,000. This may be attributed to the patient’s younger age and higher baseline glomerular filtration rate. Monitoring CK levels, even in patients with first-time simple seizures, helps identify occult rhabdomyolysis. Early triaging and aggressive IV hydration prevents AKI and possibly reduces hospital stay.

It is known that simple seizures can cause CK to rise. In this case, our patient’s brief seizure and relatively low CK on admission does not obviate how trauma from a seemingly innocent tongue laceration can cause significant rhabdomyolysis.

CONCLUSION: Isolated traumatic injury to the tongue can result in acute rhabdomyolysis. Recognition of injuries to small muscles and their potential to cause severe rhabdomyolysis is conducive to good patient outcomes. Aggressive and early intravenous fluid hydration is paramount in treating rhabdomyolysis and reducing the risk of acute renal failure.

SHORTNESS OF BREATH AS PRESENTING SYMPTOM OF GRAVES’ DISEASE IN OLDER MALE PATIENT

Sarita Sooklal, Cary Blum. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4047546)

CASE: An 87 year old male with a history of compensated NASH cirrhosis, prediabetes (A1C 6.3%) and well-controlled hypertension presented with eight weeks of mild exertional dyspnea. On review of systems, he reported neck fullness and chart review revealed weight loss of 7 pounds over 4 months. He denied orthopnea, wheezing, chest pain, palpitations, cough, fever, edema, dizziness, melena, or hematochezia. He also denied anxiety, tremor, insomnia, fatigue and heat intolerance. The patient had no known cardiac or pulmonary disease and a normal TTE prior to presentation. On exam, there was no lid lag or tachycardia, and the thyroid was nontender and not enlarged. His oxygen saturation was normal, as were his heart and lung exams. Bloodwork showed a normal hemoglobin, a hemoglobin A1C increased to 8.3%, new hypercalcemia to 11.2, and newly decreased TSH of < 0.008 with T4 of 1.43. TRAb testing was positive and sonography showed a hyperemic thyroid with no nodules, confirming a diagnosis of Graves’ Disease. Endocrinology recommended starting methimazole and a beta blocker. Shortly after initiating treatment for Graves’, the patient’s shortness of breath resolved.

IMPACT/DISCUSSION: The typical presentation of hyperthyroidism, and particularly Graves’ Disease, is that of a young (25-60 year old), female (5:1 female to male ratio) with symptoms including tremors, palpitations, heat intolerance, fatigue, mood changes, and weight loss. This classic illness script can be misleading when it comes to diagnosing hyperthyroidism in older adults, who tend to have fewer symptoms of overt hyperthyroidism, yet more frequently present with shortness of breath and weight loss compared to their younger counterparts. The patient’s hypercalcemia and acute rise in previously well controlled A1C also point towards a diagnosis of Graves’ Disease. Increased thyroid hormone causes hypercalcemia by directly stimulating bone resorption by osteoclasts and increases A1C by inducing a state of relative insulin resistance. This case also demonstrates the utility of creating a broad diagnostic framework when evaluating patients with shortness of breath. While cardiopulmonary disease accounts for the majority of pathology in patients with dyspnea, extra-cardiopulmonary etiologies such as hyperthyroidism must be ruled out, especially in the context of an unremarkable cardiac and pulmonary history and physical exam.

CONCLUSION: In older adults, hyperthyroidism presents with fewer symptoms, but is more likely to feature shortness of breath as a presenting symptom.

The presence of hypercalcemia and hyperglycemia on routine labs should prompt thyroid function tests to rule out hyperthyroidism.

In addition to anemia and acidosis, hyperthyroidism is an important extra-cardiopulmonary cause of dyspnea.

SICKLE CELL DISEASE SERENDIPITOUSLY CAUGHT IN LIGHT OF AN ACUTE PERITONSILLAR ABSCESS EVALUATION

Anna Cassell²; Maya Sayarath¹; Abdikarin Abdullahi²; Vatsal Y. Bhatt¹. ¹Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; ²Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4062011)

CASE: A healthy 37-year-old male presented to the emergency department with one day of acute onset sore throat and fever. Notably, he was born in Haiti, moved to Chile in 2017, then to the United States in 2021. He had not established medical care since immigrating.

On evaluation, he was afebrile with normal vital signs. Initial labs were notable for white blood cell count 42,220 K/uL, hemoglobin 12.9 g/dL, total bilirubin 2.6 mg/dL, lactate dehydrogenase 368 U/L, procalcitonin 0.77 ng/mL. Viral respiratory panel and rapid strep tests were negative. Exam showed an erythematous and hemorrhaging region near the left tonsil. CT chest showed diffuse opacifications bilaterally with superimposed cavitary nodules and a small spleen with high attenuation suggestive of auto-splenectomy. CT neck showed left tonsillitis with peritonsillar abscess with mild airway narrowing. Evaluation for tuberculosis with sputum AFB and mycobacterium PCR was negative. Otolaryngology was consulted for fiberoptic laryngoscopy, which revealed a non-purulent caseating mass in the left tonsillar fossae with necrotic tissue with cultures growing streptococcus anginosus. Intravenous ampicillin-sulbactam was initiated with symptom improvement.

He was also noted to have an auto-splenectomy, which combined with hemolytic anemia with associated Howell Jolly bodies and target cells were concerning for hemoglobinopathy. Initial sickle cell screening was positive with hemoglobin electrophoresis, showing Hemoglobin SC disease. His cavitary lung lesions were thought to be related to transient bacteremia complicated by septic thromboemboli. He received encapsulated vaccines and was scheduled for hematology follow-up.

IMPACT/DISCUSSION: Patients with profound leukocytosis and sore throat should prompt an urgent evaluation for peritonsillar abscess to prevent life-threatening complications. This case was unique because the appearance of the abscess was not characteristically purulent but rather presented as a caseating mass with septic thromboembolic spread leading to lung cavitary lesions. In addition to reviewing the various clinical manifestations of peritonsillar abscess, this case highlights the importance of considering undiagnosed chronic health conditions that are routinely screened for on newborn screens for patients who have immigrated to the United States from more resource-poor settings. Maintaining a broad differential and diagnostic approach allowed for the diagnosis of hemoglobin SC disease, which resulted in the appropriate vaccination and follow-up care for this patient.

CONCLUSION: 1. Case highlights the importance of developing a clinical framework to consider undiagnosed chronic health conditions that are routinely screened for on Newborn Screens for patients who have immigrated to the United States from more resource-limited settings.

2. Case reviews the importance of maintaining a broad differential for the evaluation of profound leukocytosis and highlights the management of peritonsillar abscess.

SICKLE CELL HEPATOPATHY – A RARE AND POTENTIALLY FATAL COMPLICATION OF SICKLE CELL DISEASE

Simone Prather¹; Peggy B. Leung²; Helene Strauss¹. ¹Internal Medicine, Weill Cornell Medicine, New York, NY; ²Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY. (Control ID #4064479)

CASE: A 43yo man with sickle cell disease (SCD) c/b frequent vaso-occlusive pain episodes, AVN, iron overload, CVA, and DVT/PE presented to the ED for acute chest pain. After thorough work-up pt was admitted and treated for suspected vaso-occlusive pain episode. Pt's course was further c/b E. Cloacae bacteremia and he remained hospitalized for several weeks for ongoing pain management. Subsequently his LFTs began to steadily uptrend, Tbili 4.6 to 15.4, Dbili 1.3 to 11.1, AST 84 to 572 and ALT 42 to 354 over several days. A RUQ US revealed a mildly dilated common bile duct w/ no visible calculus. A MRCP showed mild intra and extrahepatic biliary ductal dilatation w/o choledocholithiasis. The pt then developed scleral icterus, increased lethargy, AMS and asterixis. He was started on rifaximin, lactulose, and was given additional blood transfusions. INR increased from 1.6 -> 3.7, ammonia was 73, lactic acid 3.7. Given worsening hepatic dysfunction pt was transferred to the ICU. Transfusion exchange was considered, but deferred given HbS percentage. Given progression to liver failure pt was evaluated and determined not to be a transplant candidate. Palliative care was consulted.

IMPACT/DISCUSSION: Sickle Cell Hepatopathy (SCH) is a general term which encompasses a variety of acute and chronic pathologic processes. These include acute vaso-occlusive crisis, acute hepatic sequestration, acute intrahepatic cholestasis, iron overload/deposition, viral hepatitis, gallstone disease, and sickle cell cholangiopathy. SCH can be seen in approximately 10% of patients with SCD. Abnormal LFTs are found in one-third of people w/ SCD, and cirrhosis in 16 to 29% of autopsies.

On physical exam pts may exhibit RUQ pain, tender hepatomegaly, fever, jaundice, encephalopathy, malaise, ascites, GI bleeding, pruritis, light-colored stools, or dark urine. This case highlights the importance of assesing for signs of cholestasis when examining pts w/ SCD, particularly if a pt has not had recent LFTs.

Lab findings associated w/ SCH include elevated LFTs, elevated INR, worsening anemia, and worsening renal function. Once suspected, further imaging w/ RUQ US, CT, MRI may be warranted and in some cases liver biopsy is necessary to confirm diagnosis.

Treatment of SCH depends on suspected mechanism for hepatic injury. This may include IV fluids, supplemental oxygen, exchange transfusion (when HbS is below 30%), fresh frozen plasma, iron chelation, ERCP, cholecystectomy and liver transplant. The timing and rapid utilization of interventions may impact a pt’s treatment course and outcomes, therefore early recognition of SCH is extremely important.

CONCLUSION: SCH is a potentially fatal complication of SCD that encompasses a variety of pathophysiologic processes.

Careful assessment for new symptoms, changes in pain, new physical exam findings and changes in mental status should be performed for all patients who are hospitalized for SCD. Early recognition of SCH and intervention may lead to improved patient outcomes.

SICK SINUS SYNDROME: A POTENTIAL DEADLY SEQUELA OF COVID

Isaac Stevens¹; Steven Gadd²; Laurel Fick¹. ¹Internal Medicine, Ascension St Vincent, Indianapolis, IN; ²Internal Medicine, Ascension St Vincent Hospital - Indianapolis, Indianapolis, IN. (Control ID #4063911)

CASE: An 84-year-old female with history of diet-controlled type 2 diabetes mellitus, chronic kidney disease IIIb, hypertension, hyperlipidemia, and recent COVID-19 infection requiring hospitalization presented for recurrent syncopal episodes.

Her initial imaging and lab work such as echocardiography, chest x-ray, thyroid stimulating hormone, complete metabolic panel and complete blood count were unremarkable. Electrocardiogram upon admission revealed sinus bradycardia with a rate in the 50s. Atrioventricular nodal blocking agents were held upon admission without improvement in her ventricular rate. Of note, she did experience two syncopal episodes during her last hospital stay which were attributed to being “vasovagal” in etiology. Despite these original attributions, she was discharged with a Biotel Mobile Cardiac Telemetry (MCOT) device to monitor for potential arrhythmogenic causes of her syncope. Upon interrogation of her MCOT, it was revealed that she was experiencing episodes of asystole lasting up to 10.6 seconds. Electrophysiology was consulted, and a diagnosis of Sick Sinus Syndrome (SSS) was made. Once reversible causes were excluded, she went for Medtronic permanent pacemaker (PPM) placement and was ultimately able to be discharged home with close outpatient follow-up.

IMPACT/DISCUSSION: Many phenomena secondary to COVID-19 have been discovered since the onset of the pandemic. However, per our review of the literature, sinus node dysfunction attributed to COVID-19 has only yielded a handful of case reports to the best of our knowledge.

There are several different proposed mechanisms of conduction system disease and myocardial pathophysiology related to COVID-19. First, hypoxia and electrolyte abnormalities are known to precipitate arrhythmias. Secondly, viral invasion of the central nervous system and the cardiorespiratory center through a series of specific chemo- and mechano receptors can lead to autonomic dysfunction including the induction of arrhythmias such as sick sinus syndrome.

The overall percentage of patients with cardiac arrhythmias post-COVID range from 10-20%. The most common pathologic arrhythmias associated with COVID are atrial fibrillation, atrial flutter and ventricular tachycardia. However, a smaller portion of patients develop SSS, as seen in our patient. This case illustrates the need for hospital-based physicians to monitor patients with COVID-19 infections for dysrhythmias while hospitalized and potentially after discharge for those felt to be at high risk for cardiac complications.

CONCLUSION: COVID-19 is largely viewed as a pulmonary disease, but it is important to remember that it can have severe extrapulmonary manifestations including high-risk cardiovascular sequelae. It is imperative to have a high-level of clinical suspicion for these phenomena and have appropriate data-collection systems in place so patients can receive early and effective medical intervention.

SILENT VIRUS, HIDDEN IMBALANCE: ASYMPTOMATIC COVID-19 AND PROFOUND HYPONATREMIA

Sanjay V. Pujar¹; Mandvi Pandey¹; Karina Gomez¹; Saad Malik¹; Anunaya Aashish¹; Richard Ward¹; David R. Martin^1,2. ¹Internal Medicine, Texas Health Resources, Arlington, TX; ²Nephrology, Texas Health Resources, Bedford, TX. (Control ID #4044935)

CASE: 60-year-old woman with a past medical history of asthma, essential hypertension, fibromyalgia, hypothyroidism, and SLE who presented to the emergency department from an orthopedic rehabilitation facility for slight confusion and slowresponsiveness for two days. She was in the facility since more than a week for vertebral fracture but not requiring any analgesics. She tested positive for COVID-19 the same day she was noted to have some confusion but did not have any associated fever, chills, chest pain, shortness of breath, vomiting or diarrhea. The patient had no history of dementia and was alert and oriented x4 which was her baseline. CT head and CT chest were negative, however laboratory findings were significant for profound hyponatremia with serum sodium of 100 mEq/L and hypochloremia with serum chloride of 69 mEq/L. Labs done just 4 days prior recorded a serum sodium level of 133 mEq/L. Her serum osmolality was 217 mOsm/kg, urine osmolality 692 mOsm/kg, and urine sodium 58 mmol/L. Further workup of hyponatremia was normal suggesting SIADH as the cause of such profound hyponatremia.

Management: Patient was admitted to the ICU and was started on 3% hypertonic saline with DDAVP clamp as initial management. Once sodium began to improve, hypertonic saline was stopped and therapy was changed to urea tablets and fluid restriction. Even after extensive review of her chart including medications and work up, no other etiology for her hyponatremia could be identified, except the COVID-19 infection. She did not require oxygen and was saturating 100% on room air.

Outcome: After a period of 48 hours her sodium started to rise from <105 (laboratory limit) to 107 and over a gradual period of 12 days, her sodium came back to the normal range. On extensive chart review, the patient has been to health care facilities, before and after this admission, with normal sodium levels throughout. Her hospital stay lasted 19 days.

IMPACT/DISCUSSION: Hyponatremia is not an infrequent complication of severe COVID-19 infection, however, it is usually mild to moderate and associated with severe COVID-19 infection and pulmonary involvement. There have been rare case reports of severe hyponatremia. Even on extensive search of the database, we believe profound hyponatremia, with sodium of 100, has never been reported in either mild or severe COVID-19 infection. The mechanisms underlying hyponatremia in COVID-19 are not fully understood but are thought to involve dysregulation of the renin-angiotensin-aldosterone system, inappropriate antidiuretic hormone secretion (SIADH), and increased capillary permeability. Severe hyponatremia can lead to life-threatening neurological complications, including seizures and coma.

CONCLUSION: This case highlights the potential for severe hyponatremia as a complication of even a mild COVID-19 infection, particularly in the context of SIADH. Further research is needed to better understand the underlying mechanisms and optimal management of electrolyte disturbances in COVID-19.

SJS/TEN AND EMM: DISTINGUISHING THE CRITICAL FROM THE BENIGN

Hannah Roach¹; Sarah Jones². ¹Internal Medicine/Pediatrics, UPMC, Pittsburgh, PA; ²General Internal Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4063323)

CASE: Our patient was a 26-year-old female with autoimmune cirrhosis started on ciprofloxacin for spontaneous bacterial peritonitis prophylaxis 10 days prior to presenting with a pruritic rash for one day that was preceded by sore throat. Initially afebrile but tachycardic with leukocytosis to 22.6 and lactate of 3.8, she responded well to IV fluids. Physical exam was notable for diffuse, erythematous maculopapular rash with targetoid lesions on trunk, extremities, and face without mucosal involvement. Ciprofloxacin was discontinued. Skin biopsy revealed erythema multiforme (EM). The rash progressed with large bullae forming from coalesced vesicles, and painless bilateral conjunctival injection developed. IV fluids were resumed given insensible losses. Infectious disease recommended cefazolin to prevent secondary infection. Dermatology and plastic surgery recommended continued medical care. By day 5, sloughed skin reached 40% BSA and worsening mucosal involvement. She was transferred to a burn unit then the ICU where she developed multisystem organ failure over the next 3 days and unfortunately died with Toxic Epidermal Necrolysis (TEN) as the cause of death.

IMPACT/DISCUSSION: Stevens-Johnson Syndrome (SJS) and TEN are rare diseases of overlapping features with incidence of 1-10 cases per million persons per year. Increasing BSA involvement is associated with mortality as high as 50%. In contrast, EM is a rare self-limited skin condition. EM is classified as EM minor if affecting only skin and EM major (EMM) with mucosal involvement.

Differentiation of SJS/TEN and EM has been controversial with similarities on dermatopathology complicating diagnosis. Cytotoxic cell-mediated immune response causes keratinocyte death with medication provoking SJS/TEN while medication or infection provokes EM. Ciprofloxacin is not an antibiotic commonly associated with either, but discontinuation of provoking medications is recommended for both.

Given the vast differences in mortality, distinguishing between SJS/TEN and EM is critical. Rash progression or clinical change must prompt reconsideration of the diagnosis. While EMM is managed through supportive treatment, SJS/TEN often requires early transfer to burn-unit or ICU with high dose-steroids or IVIG.

CONCLUSION: Most internists have some discomfort with diagnosing rashes; SJS/TEN and EM are rare rashes which many internists may never have diagnosed. SJS/TEN and EMM both include mucosal involvement and are similar on dermatopathology, creating opportunity for anchoring bias. The prognosis is gravely different; the internist should maintain clinical suspicion for SJS/TEN and escalate care with increasing BSA skin sloughing or mucosal involvement.

SMALL CELL LUNG CANCER WITH SUBACUTE CUTANEOUS LUPUS ERYTHEMATOSUS

Nehaal Ahmed¹; Savannah Liddell²; Kaushal Parikh³. ¹Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Department of Oncology/Division of Hematology, Mayo Clinic Minnesota, Rochester, MN; ³Oncology, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4032609)

CASE: A 63-year-old male with a recent diagnosis of limited-stage small-cell lung carcinoma, GERD on omeprazole and pulmonary emboli (PE) six months ago on warfarin was admitted for hyponatremia and management of large volume disease via initiation of cycle one of carboplatin and etoposide. On exam, an erythematous, silvery, pruritic rash was visible on the arms and back that had been present for two months. Absent findings included proximal muscle weakness, neurologic deficits, and cardiac murmurs. A punch biopsy of the rash demonstrated interface dermatitis and immunofluorescence noted granular deposition of IgM and C3 consistent with SCLE. MRI of the brain visualized innumerable foci of microhemorrhages in the white matter concerning for early cerebral amyloid angiopathy (CAA) versus embolic hemorrhagic infarcts. Transthoracic echo noted a small pericardial effusion. Workup was notable for a weakly positive ANA, positive anti-SSA and SSB antibodies and unremarkable anti-double stranded DNA antibodies, complement levels, creatine kinase, aldolase, and antiphospholipid antibodies. Omeprazole was held and plan for outpatient transesophageal echocardiogram (TEE) to evaluate for valvular vegetations was made as the patient elected for discharge against medical advice after completing chemotherapy.

IMPACT/DISCUSSION: Given that the rash appeared shortly after the small-cell carcinoma, this patient’s SCLE was likely paraneoplastic. Paraneoplastic SCLE has been linked to various malignancies, including small cell carcinoma, and commonly has positive SSA antibodies. Omeprazole induced SCLE has also been reported and typically has positive ANA and SSA antibodies. It is recommended that patients with SCLE undergo cancer screening and medication reconciliation. Potential offending medications should be discontinued. If a malignancy is uncovered, patients should receive prompt treatment, as delay may worsen outcomes. Given the presence of SCLE, pericardial effusion, recent PE, and cerebral microhemorrhages, there was concern for systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). However, this is less likely given the only weakly positive ANA and reassuring double stranded DNA antibodies, complement levels, and antiphospholipid testing. Marantic endocarditis must be ruled out on TEE. However, in this case the use of warfarin in early CAA is more likely the cause of cerebral microhemorrhages. If TEE fails to demonstrate valvular vegetations, it will be crucial to analyze the risks and benefits of anticoagulation given CAA carries up to a fivefold increased risk of intracerebral hemorrhage.

CONCLUSION: SCLE can be paraneoplastic, drug induced, or an isolated autoimmune condition.

In patients with CAA, evaluation of indications for systemic anticoagulation is crucial, as CAA carries an increased risk of intracerebral hemorrhage.

SOMETHING IN THE WATER: AN UNLIKELY CAUSE OF ENCEPHALOPATHY AND RHABDOMYOLYSIS

Lily Nguyen¹; Cameron Palmer¹; Joseph Carton³; Elsie Amoako-Kissi³; Cayleigh M. Blumrick³; James R. Wyant²; Sami G. Tahhan¹; Waleed Kassabo¹. ¹Internal Medicine, Eastern Virginia Medical School, Norfolk, VA; ²Sentara Norfolk General Hospital, Norfolk, VA; ³Eastern Virginia Medical School, Norfolk, VA. (Control ID #4059538)

CASE: A 50-year-old male with no significant medical history was admitted with altered mental status and difficulty speaking. He was found unconscious at home, experiencing malaise, dizziness, and speech impairment. Upon evaluation, he was febrile to 103°F, disoriented to place, noticeably dysarthric, and demonstrated 4/5 lower extremity weakness. Initially, stroke was suspected, but a non-contrast head CT showed no abnormalities. He was subsequently admitted to internal medicine for management. His initial laboratory results were concerning; transaminitis (aspartate transaminase 208, alanine transaminase 845), troponinemia (reaching 88), acute renal failure (creatinine 2.1), and significantly increased creatine phosphokinase (CPK 116,476). Consultations were requested from nephrology, neurology, and infectious disease specialists. Despite intravenous fluids, CPK continued to rise, peaking at 163,200, and renal function worsened.

Additional information was obtained from the patient’s family; they had recently returned from a cruise to the Bahamas, two weeks prior to admission. Since returning home, the patient became progressively withdrawn. A comprehensive workup was conducted. Toxicology screening was negative. Chest X-ray showed right lower lobe pneumonia and MRI head without contrast was concerning for multiple sclerosis lesions. Among the various infectious disease tests, Legionella urine antigen was positive. Azithromycin was initiated before hemodialysis, with a corresponding decrease in CPK level. Lumbar puncture results showed increased protein and neutrophils, while other test results were within normal limits. A multiple sclerosis profile and MRI head with contrast confirmed an incidental diagnosis of multiple sclerosis. Meanwhile, the patient showed significant improvement with azithromycin, high-dose intravenous steroids for multiple sclerosis flare, and hemodialysis. His dysarthria and encephalopathy resolved, and he was discharged with arrangements for outpatient hemodialysis.

IMPACT/DISCUSSION: This case represents an exceptionally rare presentation of Legionnaire’s disease. Legionella pneumophilia, the bacteria responsible for this condition, is transmitted through contaminated water, such as in air conditioning or cruise ships. Typical presentations of Legionella infection include pneumonia, hyponatremia, and occasionally, acute encephalopathy. Rhabdomyolysis has been linked to Legionella in multiple reported cases since 1980, with observed improvement after antibiotic treatment targeting the underlying source of muscle breakdown. The recommended course is azithromycin 500 mg daily for 10-14 days. This case contributes to the existing literature, emphasizing the importance of early diagnosis and highlighting that Legionella infection can present with encephalopathy and rhabdomyolysis.

CONCLUSION: Rhabdomyolysis has a broad differential, including infection.

Legionella can present with encephalopathy and rhabdomyolysis, which improve after antibiotic treatment.

SORE THROAT: AN ATYPICAL PRESENTATION OF GIANT CELL ARTERITIS

Akhila Padi¹; 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 #4063983)

CASE: A 55-year-old female with a PMH of breast cancer, GERD, allergic rhinitis, prediabetes and migraine headaches presented with one week of left-sided neck and throat pain. Pain was initially associated with swallowing but progressed to occurring at rest and radiating down to her chest and upper abdomen. She endorsed a headache, bilateral shoulder pain, mild left jaw tenderness, bilateral eye pain, and a black bowel movement. She denied temporal pain, vision changes, fevers, chills, nausea and vomiting.

She was afebrile with a HR of 86, BP of 174/114 and an O2 sat of 97% on room air. She appeared in mild distress with left-sided neck and jaw tenderness, posterior oropharynx and left nasal turbinate erythema, and left upper quadrant abdominal tenderness. Her laboratory studies were remarkable for Hgb 10.6, MCV 76.4, ESR 130 and CRP 8.7. Ophthalmology found no evidence of Giant Cell Arteritis (GCA) on their exam, however, due to high clinical suspicion, Rheumatology was consulted. Based on her symptoms of odynophagia, jaw pain and visual pain and a markedly elevated ESR of over 100, Rheumatology diagnosed GCA. She was initiated on high dose empiric prednisone daily with immediate symptom improvement. Subsequent temporal artery biopsy and ultrasound were both inconclusive. She was discharged home with 80mg prednisone daily, monthly follow-up with Rheumatology, and plan for large artery imaging.

IMPACT/DISCUSSION: The use of erythrocyte sedimentation rate (ESR) as a screening test in asymptomatic individuals is limited due to its low sensitivity and specificity. However, an elevated ESR can serve as a key diagnostic criterion for polymyalgia rheumatica and temporal arteritis. Extremely elevated ESR (>100) is typically associated with infection, malignancy, or temporal arteritis.

Respiratory symptoms in GCA, such as cough, sore throat, and hoarseness, are frequently overlooked, with an estimated 9% of GCA patients experiencing prominent respiratory manifestations and 4% presenting initially with these symptoms. In some cases, respiratory symptoms may precede other findings of arteritis by up to a month. Awareness of respiratory symptoms in GCA is crucial to prevent delays in diagnosis and treatment.

The ACR introduced new GCA diagnosis guidelines in 2022; three or more variables out of 11 suggests GCA with a sensitivity of 87% and specificity of 94%. Our case fulfills the age criteria, morning stiffness in shoulders and neck, and ESR > 50. Temporal artery biopsy remains the gold standard for diagnosing GCA, but it can yield false negatives due to skip lesions, specimen length, and the effect of glucocorticoid therapy. Treatment with systemic steroids should not be delayed pending biopsy results.

CONCLUSION: It is crucial to understand that the diagnosis of temporal arteritis is primarily clinical and is not affected by negative temporal artery biopsy or ultrasound. Thus, patients with clinical manifestations of temporal arteritis but negative biopsies should receive aggressive treatment.

SORROW’S SILENCE: THE ENIGMA OF SINOATRIAL ARREST INDUCED BY SADNESS

Emmanuel Oundo. Internal Medicine, University of Kansas - Wichita, Wichita, KS. (Control ID #4064032)

CASE: A 56-year-old otherwise healthy gentleman, without significant past medical and family history, presented with one day history of two syncopal episodes at home about 4 hours prior. He had an aura of thinking about his deceased mother and then had two episodes of feeling faint and dizzy, and losing and quickly regaining consciousness, lasting about 2 minutes. He did not have seizure-like activity. Immediately after the episode, he regained full consciousness. He was not incontinent. He was not given any medication but was immediately transferred to the emergency department.

Upon presentation to the emergency department, his BP was 126/88 mmHg, heart rate 78, and SPO2 100% on room air. He had another syncopal episode in the emergency department; when normal saline was started at 75 ml/hr., his heart rate decreased from mid 80s to sinus bradycardia in the 40s to asystole. After about 30 seconds, he was in sinus rhythm again with heart rate in the mid-80s, and regained consciousness. After about an hour, he had another syncopal episode with sinus bradycardia in the mid 40s, associated with nausea, but he did not lose consciousness. During all episodes, he reported the preceding feeling overwhelming emotion and sadness about thoughts of his late mother.

Echocardiogram did not reveal any valvular or structural disease, with an ejection fraction of 70-75%. Heart catheterization revealed normal coronaries and normal left ventricular end diastolic pressure. A dual-chamber pacemaker was placed, and he did not have other syncopal episodes while in hospital.

He was started on dopamine infusion at 2.5 mcg/kg/min and transferred to the ICU. He had another sinus pause and sinus arrest episode, shown in the images below.

IMPACT/DISCUSSION: Syncope and sinus pause are common presentations in inpatient and outpatient settings. However, sinus pause and sinus arrest causing syncope and non-sustained cardiac arrest is rare and needs more exposure to increase awareness.

Syncope is a transient loss of consciousness caused by low cerebral blood flow, often due to abrupt drop in blood pressure. Our patient’s presentation was vasovagal in nature, due to the preceding overwhelming emotional nature and aura.

A sinus pause can be a few seconds to several minutes. When longer, it can cause dizziness, presyncope, syncope, or even death. Interestingly, the duration of the pause was not a multiple of the base rhythm e.g., 2:1 or 3:1. There may be escape rhythms or escape beats.

Sympathetic overdrive and catecholamine surge is associated with Takotsubo cardiomyopathy, and they commonly present with chest pain, dyspnea, and syncope. Our patient’s echocardiogram did not have any features of Takotsubo cardiomyopathy.

CONCLUSION: Descriptions of emotional surge preceding sinus arrest and asystole are seldom described. This case highlights the importance of a high index of suspicion which will help channel patients to appropriate care, that would otherwise have been missed.

SPONTANEOUS HEMORRHAGIC PERICARDIAL EFFUSION AS CONSEQUENCE OF APIXABAN UTILIZATION FOR NEW-ONSET ATRIAL FIBRILLATION

Dhaval Trivedi, Samir Shah. Internal Medicine, New York Presbyterian - Brooklyn Methodist Hospital, New York, NY. (Control ID #4064720)

CASE: A 79-year-old male, former smoker, with past medical history of asthma, CKD-3A, hypertension, hyperlipidemia, type 2 diabetes mellitus, and recently diagnosed atrial fibrillation presented to the emergency department with dyspnea on exertion and positional orthopnea. On ED evaluation, patient was hemodynamically stable with EKG findings remarkable for low voltage QRS and atrial fibrillation to ventricular rate 107. CXR revealed normal cardiac silhouette. Initial echocardiogram studies revealed large pericardial effusion with right atrial and ventricular diastolic compromise. Subsequently, the patient was moved to CCU for evaluation, but developed worsening hypotension with physical exam findings of cold extremities, faint heart sounds, and jugular venous distension consistent with cardiac tamponade and catheterization lab was prepped for pericardiocentesis. On arrival, patient became unresponsive with PEA arrest and ACLS was performed with ROSC achieved in 8.5 minutes. During arrest, pericardiocentesis was performed with 500cc bloody output and pericardial drain was placed. Additionally, right heart catheterization was performed which indicated normal pulmonary artery pressure, wedge pressure, and cardiac output. Pericardial fluid analysis and cytology revealed only blood products. Repeat EKG revealed atrial fibrillation without low voltage criteria and echocardiogram revealed no pericardial effusion or right atrial/ventricular compromise.

IMPACT/DISCUSSION: Since the introduction of direct oral anticoagulants (DOACs), the incidence of pericardial hemorrhage is 0.05%. With concern of cardiac tamponade, the prognosis depends on prompt recognition and management of the tamponade. Echocardiography and EKGs may help provide information by delineating the degree of effusion and indicating distinct voltage changes, respectively. Without intervention, untreated cardiac tamponade is rapidly and universally fatal. Given the rarity of hemorrhagic pericardial effusions after DOAC initiation, suspicion of any tamponade physiology must be rapidly evaluated in these patient populations

CONCLUSION: Initiating direct oral anticoagulants (DOACs) can, in rare instances, lead to a serious complication—pericardial hemorrhage. While uncommon, this adverse effect underscores the importance of vigilant monitoring and awareness during DOAC initiation. In response to such challenges, the imperative for further exploration emerges. Specifically, delving into the realm of DOAC reversal therapy gains significance, particularly in the context of pericardial hemorrhage. Investigating and understanding the intricacies of reversing DOAC effects in the presence of this rare but consequential complication is crucial for refining treatment strategies and ensuring patient safety.

SPONTANEOUS PARASPINAL MUSCLE HEMATOMA: A RARE CAUSE OF SEVERE FLANK AND BACK PAIN

Toshiro Goto, Kohei Horiuchi, Jennifer Hui. Department of Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4054319)

CASE: A 73-year-old female with a history of hypertension, diabetes mellitus, gastroesophageal reflux disease, and prior transient ischemic attack on aspirin presented with epigastric abdominal pain and nausea with emesis. She was found to have acute kidney injury (BUN 110 and creatinine 7.97mg/dL) with uremic encephalopathy and was initiated on hemodialysis. Workup for glomerulonephritis was positive for perinuclear anti-neutrophil cytoplasmic antibody, and aspirin was discontinued for a planned kidney biopsy, while prophylactic subcutaneous heparin was maintained. While awaiting biopsy, the patient’s course was complicated by aspiration pneumonia, followed by an acute, severe left flank and back pain without any reported trauma. Physical exam was notable for new tachycardia to 110s, a 3cm tender superficial ecchymotic abdominal mass and new left costovertebral tenderness. Laboratory findings indicated a hemoglobin decrease from baseline 8.1 to 6.7 over 24 hours, APTT 35.5 seconds (reference range 25.4 - 34.9), normal INR, and negative guaiac. CT abdomen and pelvis with contrast identified a new left lower quadrant abdominal wall hematoma likely due to subcutaneous heparin and an 8.1 x 3.9 x 4.4cm left paraspinal muscle hematoma with extravasation. The patient was managed conservatively with a red blood cell transfusion and temporary cessation of heparin. She ultimately stabilized with no further bleeding and improvement of flank pain.

IMPACT/DISCUSSION: Spontaneous muscle hematoma, or the accumulation of blood within muscle without trauma, often goes unrecognized but can be life-threatening. Commonly affecting the abdominal rectus sheath and gluteal muscles, paraspinal muscle hematoma is exceptionally rare. Factors like anticoagulants, surgery, vigorous activity, and systemic diseases like atherosclerosis and hypertension may predispose individuals to this condition. In this case, vigorous cough from pneumonia and impaired renal function with uremia likely contributed. With the low incidence of paraspinal muscle hematoma, site-specific risk factors remain underexplored. Diagnosis is typically via CT or MRI, and treatment depends on clinical status and underlying factors like anticoagulant use. Most cases resolve with medical treatment; however, some require surgical or interventional radiology intervention. This case emphasizes the importance of considering spontaneous paraspinal hematoma in the differential diagnosis of sudden and severe flank and back pain in the hospital setting, especially in elderly patients with risk factors, to ensure prompt and appropriate management.

CONCLUSION: Paraspinal muscle hematoma is an uncommon condition that can present with sudden and severe flank and back pain, requiring a high index of suspicion for prompt and accurate diagnosis and appropriate management.

SPONTANEOUS RECURRENT NON-TRAUMATIC RHABDOMYOLYSIS AFTER IRON INFUSIONS IN A PATIENT WITH SJOGRENS SYNDROME

Roop S. Parlapalli¹; Nikitha Dalavai¹; LAKSHMI R. GOLLAMUDI¹; QI SHI². ¹Hospital Medicine, Geisinger Community Medical Center, Scranton, PA; ²internal medicine, Geisinger Community Medical Center, Scranton, PA. (Control ID #4054142)

CASE: 39-year-old female patient presented to emergency room with chief complaints of generalized body aches. Patient denies fevers, chills, injuries or falls. Patient recently had IV iron (iron sucrose) transfusion done at outpatient Hematology office 2 days before ED visit. Patient has past medical history of gastric bypass surgery, alcoholic liver disease with cirrhosis, Sjogren’s disease on long term immunosuppressive therapy with oral prednisone and mycophenolate mofetil, anxiety disorder, severe malnutrition with iron and zinc deficiency. On physical examination vitals were stable, no signs of bruising or focal areas of swelling noted anywhere in the body. Laboratory results significantly abnormal were Creatinine Kinase (CK) levels 65,046 u/l, troponin level 1503 ng/l, aspartate transaminase 1509 u/l, alanine transaminase 239 u/l. Urine studies positive for myoglobin and no RBCs. The patient was initially started on IV dexamethasone and IV fluids with NaHCo3. Rheumatology followed, discontinued IV steroids, managed convservatively with home dose of prednisone and mycophenolate mofetil. Myositis panel sent during hospital stay was negative. Laboratory valves trended towards normal range in three days and two weeks after hospital discharge, labs were in normal range. Patient had history of similar hospitalization with non-traumatic rhabdomyolysis after intravenous iron administration, resolved after steroids and supportive care.

IMPACT/DISCUSSION: Our patient developed spontaneous recurrent nontraumatic rhabdomyolysis 24 hrs after intravenous iron (iron sucrose) administration at outpatient hematology office for chronic iron deficiency anemia with significantly elevated levels of creatinine kinase, resolved with conservative management. She has history of malabsorption, status post gastric bypass surgery and also on long term immunosuppression for her Sjogren's Syndrome. Myositis panel was negative and patient was on long-term steroid therapy for Sjogren's Syndrome. A case of nontraumatic rhabdomyolysis were reported after intramuscular iron administration in patients with malabsorption and micronutrient deficiencies and two case reports of rhabdomyolysis noted after intravenous administration of iron. These case reports suggest association of administration of parenteral iron supplementation with free radical formation and oxidative injury to muscles. Future reports of case series and further mechanisms leading to spontaneous rhabdomyolysis are needed and will facilitate earlier identification and preemptive approaches for this debilitating condition requiring hospitalization.

CONCLUSION: Patients receiving parenteral iron supplementation are at increased risk for spontaneous nontraumatic rhabdomyolysis. If symptoms are persistent or recurrent especially in immunocompetent patients consider rhabdomyolysis which need to be anticipated and future treatments needs to be planned appropriately while administering parenteral iron supplementation during outpatient appointments.

STEMI IN A PATIENT WITH METATSTAIC PANCREATIC CANCER RECEIVING 5 FU

Joseph H. Than¹; Gowtham Anche²; Daniela Garcia Perez²; Dipon Dey¹; Aleksandre Toreli³. ¹Internal Medicine, New York City Health and Hospitals South Brooklyn Health, Brooklyn, NY; ²Touro College of Osteopathic Medicine Harlem Campus, New York, NY; ³Cardiology, New York City Health and Hospitals South Brooklyn Health Cardiology and Heart Health, Brooklyn, NY. (Control ID #4064141)

CASE: The patient is a 78 years old female with a past medical history of DM, hypertension, hyperlipidemia, CKD, CVA in March 2023, and actively receiving chemotherapy (5-fluorouracil) for metastatic pancreatic cancer. She presented to the ED with left-sided chest pain rated as a 7-8 in intensity since the day prior. The chest pain was described as crushing with radiation down the left arm; the pain was accompanied by nausea and diaphoresis. Patient reported she last received chemotherapy the day prior. EKG showed ST elevations in leads I, avL, and V4-6 with ST depressions in leads II, III, and avF. STEMI code was activated. POCUS showed preserved ejection fraction. Patient was not a candidate for thrombolysis due to recent CVA. Patient was loaded with ASA, Plavix, and heparin and transported to a second hospital for catheterization. At the second facility, the EKG showed less prominent ST changes and the patient reported improved chest pain, though troponins were elevated. Left heart catheterization was performed showing mild nonobstructive CAD. Patient was started on amlodipine to manage coronary vasospasms and recommended chemotherapy modifications. A follow-up echocardiogram was performed which showed normal cardiac function; the patient was discharged with new amlodipine and metoprolol.

IMPACT/DISCUSSION: 5-Fluorouracil is an antimetabolite drug used for the management of multiple cancers especially those related to the gastrointestinal tract, renal, and bladder. 5-FU acts during the S phase of the cell cycle, its active metabolite 5-FdUMP inhibits thymidylate synthase. This prevents DNA synthesis and interferes with RNA processing and function. Patients commonly experience bone marrow suppression and side effects such as nausea, vomiting, and diarrhea. A less common reaction but life threatening is coronary vasospasms due to cardiac toxicities. Although the mechanism is still unclear, it is believed to be the result of endothelial dysfunction caused by the active metabolites, releasing endothelin-1 leading to vasoconstriction. Coronary vasospasms has been a reported complication of 5-FU and in this case study we have presented an associated cardiac ischemia with ST elevations.

CONCLUSION: The use of 5-FU is correlated with transient ischemia due to coronary vasospasms. It can present with ST elevations that need to be distinguished from ACS and require prompt recognition and treatment.

SUCCESSFULLY TREATING THROMBOTIC THROMBOCYTOPENIC PURPURA DESPITE REFRACTORY THROMBOCYTOPENIA

Thomas Chen. Department of Medicine, Mount Sinai Health System, New York, NY. (Control ID #4064881)

CASE: Patient is a 66-year-old female with PMHx of Sjogren’s, hyperlipidemia, type 2 diabetes, hypertension, presenting to the emergency department after several hours of slurred speech, dizziness, and right arm weakness. Subsequent MRI brain showed acute punctate infarcts and a left cerebellar infarct concerning for a thromboembolic etiology. Initial labs were significant for normocytic anemia (hemoglobin 9.2 g/dL), severe thrombocytopenia (9,000/uL), acute kidney injury (creatinine 2.0 mg/dL from a baseline of ~1.0 mg/dL), elevated LDH (1,363 U/L), low haptoglobin (<8 mg/dL), borderline high total bilirubin (1.2 mg/dL), normal PT/INR, high fibrinogen (576 mg/dL). PLASMIC score was 5, and subsequent peripheral blood smear showed schistocytosis. The constellation of patient’s thrombocytopenia, microangiopathic hemolytic anemia with schistocytes, evidence of organ ischemia on MRI, and elevated creatinine, was highly concerning for thrombotic thrombocytopenic purpura. The diagnosis was eventually confirmed by ADAMTS13 testing (low ADAMTS13 levels, <5%, suggestive of severe deficiency, and high ADAMTS13 inhibitor levels). Hematology was urgently consulted, and patient was quickly started on plasma exchange (PLEX). Daily steroids and weekly Rituximab were also started with resolution of neurologic symptoms and normalization of kidney function. Goal response for patient was platelet level greater than 150,000/uL for 2 consecutive days, which the patient only transiently achieved before levels fell below goal. Given that the patient’s platelet level stopped responding to treatment for a span of 2 weeks, the decision was to recheck patient’s ADAMTS13 levels. ADAMTS13 was within normal limits and ADAMTS13 inhibitor level was no longer detectable.

IMPACT/DISCUSSION: This case highlights the importance of recognizing and diagnosing TTP early, as untreated disease has a high mortality rate. A multidisciplinary approach involving hematology, transfusion medicine, and vascular surgery should promptly be used to expedite treatment. Patients should see improvement shortly after treatment initiation. In existing literature, refractory TTP is defined as failure of platelet response after up to 7 days of PLEX and immunosuppression. However, providers may consider repeating ADAMTS13 studies to confirm whether patients have responded to treatment.

CONCLUSION: TTP is a hematologic emergency and should be suspected when patients present with a constellation of microangiopathic hemolytic anemia, thrombocytopenia, neurologic deficits, and renal injury. Full workup should include calculating the PLASMIC score which has a high negative predictive value. ADAMTS13 labs should also be sent, but treatment should not be delayed while confirmatory tests are pending. Treatment modalities of TTP include plasma exchange, steroids and Rituximab with careful monitoring for refractoriness.

SUCCESSFUL MEDICAL THERAPY OF A SPONTANEOUS RIGHT CORONARY ARTERY DISSECTION IN YOUNG FEMALE PATIENT: A CASE REPORT

Shreena Kamlesh Gandhi¹; Carine A. Tabak²; Hussam Farhoud¹. ¹Internal Medicine, The University of Kansas School of Medicine Wichita, Wichita, KS; ²School of Medicine, The University of Kansas Medical Center, Kansas City, KS. (Control ID #4064495)

CASE: We present the case of a 33-year-old African-American female with a medical history of hypertension, anxiety, and substance use disorder who presented to the emergency department with sub-sternal chest discomfort radiating to the back for the past three days. Her electrocardiogram showed ST-segment elevations and Q waves in the inferior and lateral leads. The initial troponin I level was elevated to 34.15 [normal range: 0-0.04 ng/mL].

She underwent an emergent cardiac catheterization that revealed a dominant right-sided circulation, ectasia of the left and right coronary arteries (LCA, RCA), and dissection of the RCA from ostium to the distal end, with nil-to-mild obstructive disease. She was diagnosed with spontaneous coronary artery dissection (SCAD). The cardiology and cardio-thoracic surgery teams opted for medical therapy, initiating a low dose of beta-blocker, aspirin, and clopidogrel before discharging her.

A few weeks later, she returned to the hospital with recurrent chest discomfort. Her EKG and serial troponin studies during this visit were negative. A repeated coronary angiogram revealed a completely healed prior RCA dissection. Her medical therapy was continued without any further interventions.

IMPACT/DISCUSSION: SCAD, an emergency condition resulting from arterial wall tears, can hinder blood flow to the heart, potentially causing a heart attack, irregular rhythms, or sudden death. Typically affecting women in their 40s-50s, SCAD's occurrence spans ages and genders, often lacking conventional heart disease risk factors like hypertension, high cholesterol, or diabetes. Its precise cause remains elusive, likely tied to arterial irregularities, genetics, hormonal influences, and inflammation.

Our case is distinctive due to the patient's younger age, absence of typical risk factors, and remarkable response to medical therapy. Management for SCAD lacks definitive guidelines, commonly necessitating case-specific decisions between medical and surgical options. Our patient's significant recovery under medical care, coupled with the absence of recurrent dissection, corroborates existing literature advocating for favorable outcomes with medical management.

CONCLUSION: Though SCAD presentations are rare, its consideration becomes crucial in young female ACS patients lacking significant risk factors. This case augments our understanding of SCAD presentation and diagnosis while contributing valuable insights into the efficacy of medical therapy in its management.

SUCCESSFUL PERORAL ENDOSCOPIC MYOTOMY (POEM) IN A PATIENT WITH MEGAESOPHAGUS SECONDARY TO TYPE 1 ACHALASIA

Vishwajit Kode¹; Frances Lee². ¹Internal Medicine, California Pacific Medical Center, San Francisco, CA; ²Hepatology, California Pacific Medical Center, San Francisco, CA. (Control ID #4064996)

CASE: A 76-year-old male with a history significant for esophageal ectasia in his 40s presented with hematemesis. A CT was done that revealed moderate distension of the esophagus with debris and fluid. An EGD was done that showed a massively dilated and tortuous esophagus. Biopsies for H. Pylori were negative and T Cruzi IgG was also negative. However, biopsies did show chronic gastritis. Esophageal manometry was also done that confirmed type 1 achalasia. At this time, esophagectomy was discussed with the patient but was declined. He was then offered POEM which was successfully completed. Follow-up esophagram was done that showed no obstruction or leak with slow material transition. Diet was then progressed from clear liquid diet to a mechanical soft diet and patient was discharged.

IMPACT/DISCUSSION: Achalasia is a rare disorder (1:100,000) characterized by a failure in relaxation of the lower esophageal sphincter. The mechanism is thought to be due to loss of inhibitory neurons in the myenteric plexus of the esophagus. These neurons contain vasoactive intestinal peptide and nitric oxide synthase that inhibit smooth muscle contraction of the esophageal sphincter. The most common etiology in the US is primary idiopathic achalasia. Patients generally present with progressive dysphagia to both solids and liquids. In rare situations, achalasia can lead to severe dilation and peristaltic failure of the esophagus leading to a condition called megaesophagus. Treatment is generally an esophagectomy. This case describes the management of a patient with megaesophagus with Peroral Endoscopic Myotomy (POEM).

While the classic presentation of progressive dysphagia to solids and liquids was not present, given the CT, EGD and manometry findings, the diagnosis of achalasia was made. Furthermore, the severity of dilation on EGD suggested megaesophagus. In cases with megaesophagus, standard of care is an esophagectomy due to the lack of peristaltic function and severity. While it is the standard of care, an esophagectomy is a life altering procedure where the entire esophagus is excised, and the patient’s stomach is elevated above the diaphragm with an anastomosis between the proximal esophageal remnant and stomach. After this procedure a patient is never able to lay down flat again without severe reflux due to absence of a lower esophageal sphincter. Given these risks, this patient declined this procedure and underwent a successful POEM and was able to avert these complications.

CONCLUSION: - Achalasia is caused by loss of inhibitory neurons in the myenteric plexus of the esophagus and there are 3 subtypes.

- Achalasia can lead to megaesophagus which is generally treated with an esophagectomy.

- Recently POEM can also be done to treat achalasia.

SUDDEN CARDIAC ARREST LEADING TO THE DIAGNOSIS OF ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY IN A YOUNG PATIENT

Numaan S. Mahmood, Aaron Bertolo, Paulina Kuzmin, Vannessa Adams, Andrew Barr, Tom Marco, Chelsea Takamatsu. Internal Medicine, Banner - University Medical Center Tucson, Tucson, AZ. (Control ID #4064154)

CASE: We present an 18 year old female with no significant past medical history who presented to the emergency room after suffering a cardiac arrest in her dorm. She was found to be in ventricular fibrillation and underwent multiple rounds of CPR and defibrillator shocks before achieving ROSC. The patient had a GCS of 3 and was intubated for airway protection. She was acidotic upon presentation, with significantly elevated serum lactate, hyperglycemia, and hypokalemia. Additionally, the patient had elevated troponins, and initial ECG showed ventricular bigeminy with possible epsilon waves and a prolonged Qtc. She required vasopressor support and was transferred to the cardiovascular ICU for further management.

While in the CVICU, she was started on amiodarone for further control of ventricular ectopy. Transthoracic echocardiogram was performed and showed right ventricular wall hypertrophy with dyskinesia. Due to concern for Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC), she underwent Cardiac MRI which showed a dilated RV with mild RV dysfunction and possible hypokinesis of the mid-apical RV segments. The patient met borderline ARVC Cardiac MRI criteria; EP was consulted and placed a secondary prevention ICD. The patient improved and was extubated. She was discharged home with cardiology follow up and genetic testing.

IMPACT/DISCUSSION: Sudden cardiac death (SCD) is defined as “sudden cessation of cardiac activity so that the victim becomes unresponsive, with no normal breathing and no signs of circulation.” ARVC accounts for ~ 11% of SCD in young patients; yet, it is oft-underrecognized. ARVC is best described as a cardiac muscle disease, characterized by fibrofatty replacement of the RV myocardium. Clinical manifestations of ARVC include ventricular arrhythmias of RV origin including VTach and VFib, and regional wall motion abnormalities. Often there is a genetic component, with one study identifying 35% of 1st-degree relatives of patients with ARVC who were also diagnosed with the disease. This case illustrates how sudden cardiac arrest (SCA) may be the initial presentation in patients with ARVC. Diagnostic criteria includes elements of history, conduction abnormalities such as epsilon waves, and findings on Cardiac Echo or MRI which indicate RV dysfunction and wall motion abnormalities. Prompt diagnosis in cases of SCA may dictate management; in our case, the diagnosis led to the placement of a secondary prevention ICD and referral for appropriate genetic testing.

CONCLUSION: Unexplained SCA particularly in young patients warrants extensive consideration for underlying structural heart disease. ARVC accounts for a significant proportion of these patients, and our case shows how a proper diagnosis of ARVC can guide a clinician in optimizing the short and long-term management of these patients.

SUSTAINED VENTRICULAR TACHYCARDIA IN YOUNG HEALTHY FEMALE WITH BICUSPID AORTIC VALVE (BAV) COMPLICATED BY SEVERE AORTIC REGURGITATION

Marisa Wu¹; Sandhiya Ravichandran¹; Miranda Melici²; Sheilah Bernard³. ¹Department of Internal Medicine, Boston Medical Center, Boston, MA; ²Boston University, Boston, MA; ³Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston, MA. (Control ID #4061159)

CASE: A 39 year old athletic female presented with chest palpitations and was found to have sustained monomorphic VT requiring cardioversion in the field. She reported a remote history of valve disorder but was subsequently lost to follow up. Exam was notable for 5/6 diastolic and 1/6 systolic murmur, with quincke’s, ciliary and water hammer pulses. Transthoracic echocardiogram (TTE) demonstrated BAV with severe aortic regurgitation (AR) and a severely dilated left ventricular cavity with an ejection fraction of 50%. She underwent left heart catheterization, which revealed a left anterior descending artery myocardial bridge with near-complete systolic flow occlusion and no significant coronary disease. Cardiac magnetic resonance imaging (MRI) showed no evidence of myocardial scar, and an electrophysiology study demonstrated no inducible sustained VT. Her presenting VT and subsequent non-sustained VT was thought to be secondary to dilated cardiomyopathy, and she was started on metoprolol with placement of an implantable loop recorder. Due to severe AR, she underwent mechanical aortic valve replacement with unroofing of the myocardial bridge.

IMPACT/DISCUSSION: This case highlights the importance of identifying a wide differential for young adults with VT, tools for diagnostic evaluation, and the value of screening guidelines in the primary care setting. VT differentials can be divided into several categories: structural, ischemic, genetic, medications, and idiopathic. Among young adults, structural etiologies may include familial CM, like hypertrophic CM or arrhythmogenic right ventricular CM, left ventricular noncompaction CM, infiltrative diseases, or dilated CM. In patients with structurally normal hearts, ischemia (including spontaneous coronary artery dissection or myocardial bridge), genetic conditions (i.e. long QT and Brugada syndromes), medications, and idiopathic should be considered. Patients with first-degree relatives with BAV or with known BAV should undergo screening with TTE for assessment of valve gradients and aortopathy, with more frequent imaging if aortic diameter ≥ 4 cm or presence of worsening severity of aortic stenosis (AS) or regurgitation. While this patient maintained a high level of exercise capacity that may have compensated for her chronic severe AR, she presented with a malignant arrhythmia as a complication of cardiac remodeling that may have been prevented with adequate screening.

CONCLUSION: Broaden differentials for VT in young adults to include structural, ischemic, genetic, medications and idiopathic etiologies and utilize advanced diagnostics like cardiac MRI and EP study for further evaluation.

Screen patients with first-degree relatives with BAV with a TTE to evaluate for AS, AR, or aortopathy; presence of these features should trigger more frequent monitoring with serial TTE.

SWEET SURRENDER: A CASE OF ALPELISIB-INDUCED DIABETIC KETOACIDOSIS (DKA)

Shim Roh, Kemar Barrett, Doo Woong Choi, Shalva Eliava, Irha Jamshed, Stephanie Rosales. Internal Medicine, Englewood Hospital and Medical Center, Englewood, NJ. (Control ID #4063245)

CASE: An 84-year-old woman presented with 2-weeks of left upper quadrant abdominal pain. She denied fever, dysuria, or respiratory symptoms. She had a history of metastatic breast cancer [hormone receptor (HR)+, HER2-, and PIK3CA mutated)] with cervical node, lung, and bony involvement. She failed tamoxifen therapy and started alpelisib 300 mg/day and fulvestrant two months prior to admission. One month after starting alpelisib, she developed polyuria, diarrhea, vomiting, and 10-lb weight loss.

On admission, she was afebrile but hypertensive at 160/99 mmHg. On physical exam, she appeared ill with dry mucus membranes, decreased breath sounds to left lung fields, and diffuse abdominal tenderness. Labs showed blood glucose 591 mg/dL, anion gap 20, large ketones in urine, positive acetone in serum, and new acute kidney injury with serum creatinine 1.42 mg/dL (>1.11). The glycosylated hemoglobin (HbA1c) was 11.5% (5.6% 1 year prior). CT abdomen showed splenic infarct and left pleural effusion. Alpelisib was held, and she was treated with enoxaparin, intravenous insulin, and hydration. She was transitioned to a subcutaneous basal/bolus insulin regimen. Pancreatic islet cell and GAD-65 antibodies were negative. She was discharged on apixaban and insulin glargine. Two weeks after, alpelisib was resumed at 150 mg/day. Metformin and empagliflozin were later added.

IMPACT/DISCUSSION: Alpelisib is an oral drug approved by the FDA in 2019 for post-menopausal women with HR+, HER2-, PIK3CA mutation advanced or metastatic breast cancer refractory to endocrine-based regimen. In combination with fulvestrant, it has shown to decrease the risk of progression or death by 35%. Side effects shown in the SOLAR-1 trial included hyperglycemia, gastrointestinal toxic effects, rash, nausea, fatigue, and weight loss. Hyperglycemia grade 3 [fasting plasma glucose (FPG) >250-500 mg/dL] and grade 4 [FPG >500 mg/dL] were reported in 33% and 3.9% of cases, with DKA in only 0.7%. Alpelisib induces hyperglycemia by disrupting the insulin signaling pathway, leading to glycogen breakdown in the liver and inhibition of glucose uptake in skeletal muscle and adipose tissue.

We present a case of alpelisib-induced DKA in a patient with no personal or family history of diabetes, HbA1C 5.6% the year prior, and negative autoantibodies. She also experienced many of the side effects reported in the SOLAR-1 trial. While data is limited, the manufacturer recommends checking FPG and HbA1c prior to initiation, while monitoring FPG and HbA1c levels during active therapy. Given the severity of unexpected hyperglycemia, lower threshold for basic labs such as blood glucose, basic metabolic panel, and urine study, is beneficial for patients with persistent symptoms.

CONCLUSION: Alpelisib is a promising drug for advanced, resistant, PIK3CA mutated breast cancer. It can cause new onset hyperglycemia, or rarely, life-threatening DKA. Early symptom recognition, glucose monitoring, and multidisciplinary care is key to decreasing morbidity.

TAKE MY BREATH AWAY - A CASE OF POSTOPERATIVE HYPOXIA

Saloni K. Maharaj. Medicine, Stanford University School of Medicine, Stanford, CA. (Control ID #4031295)

CASE: A 66-year old woman with a history of obesity and hypertension presented with a right femoral neck fracture. She underwent right total hip arthroplasty and had transient hypoxia during cement placement. Postoperatively, the patient was hypotensive, tachycardic and hypoxic requiring up to 4 liters of oxygen. A bedside echo showed an underfilled and hyperdynamic left ventricle with normal right ventricular function and no obvious wall motion abnormalities. A chest x-ray was normal. The patient had a blood transfusion for a hemoglobin of 7.8 g/dL and intravenous fluids after which her hypotension improved. On postoperative day one, the patient still required 3 liters of oxygen and remained tachycardic to 120 beats per minute. A chest CT angiogram showed no pulmonary embolism. A transthoracic echo showed a right ventricular systolic pressure of 35 mmHg but no other abnormalities. The patient had a normal venous blood gas. On postoperative day two, the patient was requiring 2.5 liters of oxygen and was tachycardic to 100 beats per minute. The pulmonary service recommended a transthoracic echo with agitated saline which was negative wtih a normalized right ventricular systolic pressure. By postoperative day three, the patient's hypoxia was down to 1 liter of oxygen and her tachycardia improved to 90 beats per minute. The patient’s diagnosis was thought to be consistent with bone cement implantation syndrome given her clinical improvement with minimal medical intervention. By postoperative day five, the patient’s hypoxia had resolved.

IMPACT/DISCUSSION: The patient’s hypoxia improved with minimal intervention. There was no clear etiology of her hypoxia on radiographic or cardiac imaging. She was diagnosed with bone cement implantation syndrome (BCIS) which is a diagnosis of exclusion. The incidence of BCIS ranges from 28-37% in patients undergoing cemented arthroplasties with a higher percentage in patients undergoing hip hemiarthroplasty or with a malignancy. The most common findings are hypoxia and hypotension but pulmonary hypertension, arrhythmias, loss of consciousness, and cardiac arrest can occur. The symptoms occur primarily at cementation, prosthesis insertion, joint reduction, and tourniquet deflation. The pathophysiology is thought to be due to an embolic effect or a hypersensitivity activation pathway. The prognosis depends on the severity of the patient’s symptoms but typically, it is reversible and time-limited with patients having normalization of pulmonary artery pressures within the first 24 hours. Treatment is primarily supportive with providing 100% oxygen and maintaining euvolemia.

CONCLUSION: BCIS is a rare phenomenon but should be considered in patients with unexplained hypoxia and hypotension postoperatively after cement placement. The mainstay of treatment is supportive, but hospitalists need to be aware of this phenomenon given the high incidence of BCIS and the growing field of perioperative medicine where hospitalists are managing orthopedic surgery patients.

TAKING YOUR BREATH AWAY: INVASIVE PULMONARY ASPERGILLOSIS FOLLOWING AN ASTHMA EXACERBATION

Marcella Christina Sousa Barreto, Daniel Mozell, Jan Hoffman, Klaus Meinhof. Medicine, Elmhurst Hospital Center Department of Medicine, Icahn School of Medicine at Mount Sinai, New Yok, NY, United States, Flushing, NY. (Control ID #4065119)

CASE: A 78-year-old woman presented with one week of worsening shortness of breath and cough. On arrival, she had an oxygen saturation of 70% on room air. Her exam was notable for diffuse expiratory wheezes, and CT of the chest showed scattered areas of ground glass opacities and bibasilar mosaicism. The patient was intubated and started on high-dose steroids for status asthmaticus.

Three weeks into her hospitalization, the patient was afebrile but unable to wean off mechanical ventilation; due to persistent tachycardia and hypoxemia, a CTA chest was obtained, which revealed a large cavitation with an air-fluid level in the right lower lobe as well as bilateral irregular solid nodules. On repeat CT one week later several of these also began to cavitate. Beta-D-glucan was highly elevated at over 500pg/ml. Bronchoalveolar lavage cultures grew Klebsiella pneumoniae, Staphylococcus lugdunensis, and Aspergillus fumigatus. The patient was treated with caspofungin and then isavuconazole, ceftriaxone, and metronidazole with infiltrate resolution; the large cavity had shrunk half a month later. After the tracheostomy, she was weaned off the ventilator and is now tolerating the tracheostomy collar.

IMPACT/DISCUSSION: Aspergillosis is caused by a ubiquitous fungus and can manifest in several ways, the most feared of which is invasive pulmonary aspergillosis (IPA). IPA usually occurs in severely immunocompromised hosts. Neutropenia and T-cell impairment increase susceptibility to fungal infection. Case reports of IPA after asthma exacerbations suggest short courses of steroids as a rare and under-recognized risk factor for this infection.

IPA is a rapidly progressive disease with a mortality ranging from 30 to 95%. It is thought to be one of the most frequently missed diagnoses in the ICU, often only found on autopsy. Recognition of IPA hinges on the identification of host risk factors and evidence of invasive infection. Diagnosis is supported by isolation of aspergillus from sputum, bronchoalveolar lavage, or biopsy and determination of galactomannan and beta-D-glucan blood levels. However, only a biopsy can prove invasion. COPD is an established risk factor for fungal infection, due to changes in lung architecture, impaired mucociliary clearance, and frequent steroid usage. Our case suggests that even limited steroid use in asthma exacerbations should be considered a risk factor for invasive fungal infections.

CONCLUSION: 1. Growing use of steroids for bacterial and COVID-19 pneumonia may increase the risk of invasive fungal infections in hospitalized patients without classic risk factors.

2. A high index of suspicion is needed as IPA remains underdiagnosed.

TB OR NOT TB: AN INTERESTING PRESENTATION OF PLEURAL TB

Hamdi Abdeen¹; Julie M. Chen². ¹Internal Medicine, Kaiser Permanente, Oakland, CA; ²Internal Medicine, Kaiser Permanente Mid-Atlantic States, McLean, VA. (Control ID #4064251)

CASE: 25-year-old female G2P1 at 14 weeks from Central America with a recently positive IGRA on outpatient follow up presented to urgent care for worsening rightsided chest pain and shortness of breath for the past 4 days with associated intermittent fevers, night sweats and mild cough. Patient was found to have an elevated d-dimer, for which a CT Angiogram was done which revealed moderate sized right pleural effusion and a calcified granuloma in the left lower lung. The effusion was deemed to be parapneumonic, thus patient was given fluids and started on empiric antibiotics to cover community-acquired pneumonia.

The patient was admitted to the hospital for thoracentesis and work up of fever. It should be noted that the initial impression of infectious disease and pulmonology was that imaging findings were not consistent with TB. Patient underwent a right thoracentesis which revealed lymphocytic predominant exudative effusion. At this time the suspicion for TB was increased with a differential including malignancy and atypical fungal infection. As a result, the patient underwent extensive testing including three induced-sputum AFB smear/cultures, cytology, and fungal testing, all of which were negative.

The Patient further developed a recurrent right sided effusion requiring placement of a chest tube. Pleural fluid samples were taken and again tested for AFB smears/cultures, adenosine deaminase, cytology, and fungal cultures. The adenosine deaminase result came back elevated at 69. At this time TB was considered the likely cause, however, given that the patient was pregnant and would likely need a prolonged course of anti-TB therapy, confirmation through pleural biopsy was favored. Ultimately pleural biopsy was deferred given the high-risk for intra-operative complications. Following discussion with the state Department of Health (DOH), the patient was started on Rifampin, Isoniazid, Pyrazinamide, Ethambutol (RIPE) therapy and discharged to continue follow up with the state DOH and outpatient infectious disease.

IMPACT/DISCUSSION: Here we demonstrate an unusual presentation of pleural TB in which a combination of high clinical suspicion along with supportive laboratory markers were used to make the correct diagnosis without initial objective microbiological confirmation.^[3,4] Having a strong understanding of different TB presentations and the diagnostic tools of laboratory testing using biochemical markers proved essential in making a diagnosis without the use of invasive techniques ultimately avoiding complications and minimizing patient harm during pregnancy.

CONCLUSION: While the usual presentation for TB includes a history of fevers, night sweats, weight loss, and productive bloody cough, often many of these symptoms are not concurrently present or commonly overlooked by patients.⁵ Thus, physicians should be keen in eliciting the patient’s history to aid in the diagnosis of presentations that may be an atypical presentation of TB.

TENOSYNOVITIS AND RASH IN THE IMMUNOCOMPROMISED

Kristine Pearl Rubi¹; Maria Jesusa Gracia De Guzman². ¹Research Institute for Health Sciences, University of the East Ramon Magsaysay Memorial Medical Center Inc, Quezon City, Philippines; ²Department of Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4064953)

CASE: A 37-year-old female with morbid obesity and human immunodeficiency virus (HIV), unknown CD4 count, and recently non-compliant with Bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy) went to the Emergency Department (ED) due to finger and wrist pain after hand trauma. The patient was discharged after a negative x-ray. The next two days, she subsequently developed acute onset painful widespread pustular, erythematous lesions in different stages of healing, associated with bilateral lower extremity and right-hand swelling, high fever, dyspnea, and oral thrush.

She returned to the ED, meeting the criteria for systemic inflammatory response syndrome. Given the unknown CD4 count and suspected infection, sepsis protocol and infectious workup for fever in the immunocompromised were initiated. The principal differentials were disseminated Varicella Zoster and Herpes Simplex Virus. Due to the broad differentials, extensive empiric drug coverage was started.

Blood cultures, pulmonary testing, and initial infectious disease workup returned negative. Sexually transmitted infection testing for N. gonorrhea (NG) and trichomonas were positive, the CD4 count was 154, and the HIV viral load was 261,000. She was diagnosed with a case of disseminated gonococcal infection (DGI) and trichomoniasis and was treated with IV ceftriaxone and oral metronidazole. For HIV and Pneumocystis jiroveci pneumonia prophylaxis, she was restarted on oral Biktarvy and dapsone, respectively. The patient improved during the hospital stay and regained full range of motion of the wrists and ankles. She was discharged to home with a follow-up with infectious disease.

IMPACT/DISCUSSION: DGI is a complication that develops in 0.5 to 3% of patients with acute untreated gonorrhea¹. The mean CD4 count in patients infected with NG is 415², while trichomonas is 304³. The incubation period of NG is 1 to 14 days, with a hematogenous spread occurring in 2 to 3 weeks of the primary infection⁴. As in this case, the patient had an acute course with a sexual encounter three weeks prior.

The classic presentation of DGI can be divided into (1) a triad of tenosynovitis, dermatitis, and polyarthralgia without purulent arthritis and (2) purulent arthritis with or without associated findings⁵. The patient originally consulted with tenosynovitis and was initially diagnosed as trauma-related.

DGI is diagnosed by identifying NG on a specimen of blood, synovial fluid, tissue, skin lesion, and non-mucosal sites⁵. However, frequently, there is no growth, and symptomatic genital infection is uncommon⁵. The patient had negative blood cultures and a positive vaginal RNA swab. Hence, an extensive workup and a high index of suspicion in patients uncompliant with antiretrovirals and in those who have unknown CD4 count could avoid the delay in diagnosis, preventing systemic and potentially life-threatening complications⁶.

CONCLUSION: DGI should be high in the differentials in an immunocompromised patient with tenosynovitis and disseminated rash.

THAT SODIUM IS LOW, BUT WHY THOUGH?

Hinal Rathi, Christian Motley, Pranayraj Kondapally, Nessy Abraham - Phillip. Internal Medicine, The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL. (Control ID #4019974)

CASE: 62-year-old female with PMH of hypothyroidism, PE on Xarelto, chronic lumbar pain, and optic nerve sarcoidosis treated with radiation that caused pituitary gland damage. She presented with a three-day history of bilateral lower extremity swelling, intractable low back pain, and severe leg cramping. She had seen several specialists, undergone multiple scans, and had not received a diagnosis. She actively denied fever, chest pain, SOB, trauma, or injury. Vitals & Measurements T: 36.8 °C HR: 84 RR: 19 BP: 147/70 SpO2: 98%. Labs were notable for Na of 120 mmol/L. IV fluids initially corrected her sodium level. TTE was performed and ruled out CHF for her lower extremity edema. By day 3, her sodium levels began to drop into the low 120's. Endocrinology was consulted given her worsening sodium levels in the setting of pituitary radiation. MRI brain revealed a partial empty Sella. AM Cortisol was 2.1, ACTH <3.0, TSH 0.07, Free T4 0.77, FSH and LH <1.0. She was started on hydrocortisone and her levothyroxine was adjusted. The patient noted immediate improvement. Over the next 48 hours, the patient reported to be feeling better and regaining her strength. She showed dramatic improvement with PT and was discharged home with outpatient endocrinology follow-up.

IMPACT/DISCUSSION: Secondary adrenal insufficiency (SAI) occurs when the pituitary gland fails to signal the adrenal gland to produce hormones. The most common causes of this condition are the use of exogenous glucocorticoids or sellar and suprasellar masses such as pituitary adenomas. It has a prevalence of 150 – 280 cases per 1 million people. Recent studies show that men are more likely to develop this condition than women. Often, SAI remains a challenging diagnosis due to its nonspecific physical manifestations and insidious onset. Symptoms may include fatigue, loss of energy, low libido, nausea/vomiting, and hyponatremia. Diagnosis is established with basal cortisol levels <18 mcg/dL or AM cortisol of <3 mcg/dL. The insulin tolerance test is the gold standard for diagnosis. The standard treatment is glucocorticoid replacement. Hyponatremia is a challenging diagnosis with a broad differential. Understanding the physiology is vital for the correct diagnosis. In this patient, lower back pain in the setting of new-onset bilateral lower extremity swelling directed our team to first consider cardiovascular or MSK causes. Secondary adrenal insufficiency is rare but in the case of persistent hyponatremia with a history of pituitary dysfunction, it was essential to work it up.

CONCLUSION: It is important to consider adrenal insufficiency as a cause of persistent hyponatremia - especially with a history of pituitary dysfunction. Prompt diagnosis and treatment can reduce the chance of developing adrenal shock and can shorten medical stay.

THE CHRONICLES OF THE HOMEMADE CHEESE

Ami K. Patel¹; Katherine M. Cooper¹; Salwa Khedr²; Geeda Maddaleni¹. ¹Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA; ²Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4063465)

CASE: 54-year-old male with a medical history of cirrhosis secondary to alcohol use, portal hypertension and recently diagnosed neuroendocrine tumor presented for transjugular intrahepatic portosystemic shunt (TIPS) prior to surgical resection of his tumor with hemicolectomy to lower the risk of perioperative hepatic decompensation. During TIPS evaluation a computed tomography scan of his abdomen and pelvic (CTAP) demonstrated an 8.4 cm x 2.2 cm heterogenous mass within the left upper quadrant that was contiguous with a 2.3 cm x 3.0 lesion within the spleen. Preliminary biopsy results were negative for malignancy, and he proceeded with TIPS. Subsequently, biopsy cultures grew Listeria Monocytogenes. Blood cultures were negative and an echocardiogram was without vegetations. He received 7 days of intravenous (IV) ampicillin for focal Listeria infection; and was transitioned to Bactrim on discharge due to lack of insurance coverage for home IV antibiotics. Repeat CTAP 1 month later showed minimal reduction in mass at which point he was transitioned to amoxicillin 500 mg 3 times daily and scheduled for a repeat CTAP in 3 months. Without improvement, he will likely require splenectomy. Questioning revealed patient makes his own cheese from pasteurized milk, which may have served as the source of infection.

IMPACT/DISCUSSION: Listeria infections are typically seen in individuals that are immunocompromised, pregnant and have a bimodal age pattern. Listeriosis can manifest as gastroenteritis, or invasive disease-causing meningitis and rarely focal infection. Listeriosis is the 3rd leading cause of death from foodborne illness, with a case fatality rate of 20%. Current literature consists of a hand full of case reports discussing focal Listeria infections and its management. Literature supports higher rates of Listeria infection in patients with cancer, which may have put our patient at greater risk. There is limited data available on optimal management of focal Listeriosis, due to its rarity. Generally, ampicillin is considered 1^st line therapy and in the setting of vascular, bone or joint infection gentamicin is added. Given the complex nature of listeria infections and high mortality, patients should be treated on a case-by-case basis and followed closely.

CONCLUSION: This highlights the 1^st reported case of splenic Listeria Monocytogenes and its clinical management. It is important to take a stepwise approach when treating patients with focal Listeria as little is known about its behavior and responsiveness to treatment. It also brings to light the gaps in our healthcare system that hinder patient’s ability to obtain care due to lack of nsurance coverage, as seen with our patients struggle to obtain home IV antibiotics.

THE CLOT BURDEN: A CASE OF RECURRENT THROMBOSIS IN CLASS V LUPUS NEPHRITIS

Connie Ha, Alejandra S. Chavez Carrera, Michael A. Thomashow. Internal Medicine, Hayward Wellness, Oakland, CA. (Control ID #4042097)

CASE: A 23-year-old man with limited health literacy, SLE complicated by biopsy-proven class V LN, presented with right-sided pleuritic chest pain. He was found to have multiple pulmonary emboli in the right lower lobe and a 24-hour urine protein of 12g. The likely etiology was a hypercoagulable state due to nephrotic syndrome from class V LN as he was negative for antiphospholipid antibodies and lupus anticoagulant. He was initiated on apixaban.

Three months later, he presented with left-sided pleuritic chest pain in the setting of several days of missed apixaban doses. At the time, he was taking four additional medications. He was found to have acute left upper lobe pulmonary infarcts. He was switched to rivaroxaban to improve medication adherence with once daily dosing.

One week later, he re-presented with persistent pleuritic chest pain and dyspnea and was found to have breakthrough pulmonary emboli on CT despite adherence to rivaroxaban. This represented direct oral anticoagulant failure and thus warfarin was started with a goal INR of 2-3. Repeat testing for antiphospholipid antibodies remained negative.

A few days later, he was readmitted with left upper quadrant abdominal pain and was found to have an arterial splenic infarct. He reported confusion regarding how to take his warfarin. The medication was dispensed as warfarin 5 mg tablets with instructions to take 2.5 tablets for a total of 12.5 mg a day. He took only 1.5 tablets (7.5 mg) and had several episodes of emesis from abdominal pain that resulted in a subtherapeutic INR of 1.6. In light of his arterial thrombosis, a multidisciplinary discussion with hematology and rheumatology led to the decision to increase his goal INR from 2.5-3.5. Prior to discharge, the hospital team emphasized the significance of medication adherence, reviewed the pill count for the correct warfarin dose, and arranged close follow up with rheumatology, hematology, anticoagulation clinic, and primary care.

IMPACT/DISCUSSION: Thrombosis is one of the most common causes of death in systemic lupus erythematosus (SLE). Herein we present a case of anticoagulation failure in a patient with SLE and Class V lupus nephritis (LN), with emphasis on the complexity of navigating medication management, and the importance of involving a multidisciplinary team.

CONCLUSION: This case demonstrates the complexity of navigating anticoagulation for a systemic disease with recurrent thrombosis. Our patient had SLE complicated by class V LN with nephrotic syndrome, which placed him at greater risk for thrombotic events. Medication management in SLE is complex as patients often require multiple immunosuppressants, anti-hypertensives, and bone health medications. Our case emphasizes the importance of delivering clear discharge instructions to avoid confusion and medication failure. Efforts should be made to choose the simplest regimen, use medication aids such as a weekly pill organizer, and arrange close multidisciplinary follow-up.

THE EMERGENCE OF LUPUS NEPHRITIS FOLLOWING THE M-RNA COVID-19 VACCINE: A NEW TRIGGER?

Sana Chaudhary¹; Rabia Malik¹; Asma Tameezud Din²; Kanza Ahmed¹; Yasir Ahmed¹. ¹Internal Medicine, UHS Wilson Medical Center, Johnson City, NY; ²Rawalpindi Medical University, Rawalpindi, Punjab, Pakistan. (Control ID #4065133)

CASE: A 60-year-old male with hypertension, rectal adenocarcinoma status post resection, was evaluated for generalized swelling. He reported unintentional weight gain, abdominal distension, and significant swelling in both lower extremities that started two months ago and had progressively worsened. He also noticed arthralgia, alopecia and photosensitive rash during this time. He was found to have nephrotic range proteinuria and microscopic hematuria two weeks prior to this presentation. The patient’s symptoms started two weeks after he received COVID vaccine. There was no history of smoking, drinking or substance use.

Initial laboratory work-up at admission showed a white blood cell count of 1.9 x 103/uL (4.0 – 10.5) hemoglobin 9.4 g/dL (13.0-18.0g/dL), albumin 1.9 mg/dL (3.5-5.0mg/dL), urinalysis showing red blood cells 14/HPF (<2/HPF) and urine protein 300 mg/dL (normal 0). Serology revealed high positive titers of antinuclear antibody (ANA) 1: 1280 and homogeneous pattern, high positive dsDNA titer 279 IU/ml (negative <30 IU/ml) and low C3 level at 58 mg/dL (90-180 mg/dL). Left kidney biopsy revealed diffuse immune complex glomerulonephritis with severe inflammatory activity and mild chronicity. There were areas of necrosis or segmental cellular crescent formation involving approximately one third of the glomeruli. The deposits stained in a "full house" pattern by a pair of fluorescence i.e., positive for Immunoglobulin (Ig)G, IgM, IgA, C3 and C1q. This constellation of findings is characteristic of lupus nephritis and the underlying disease was classified as systemic lupus nephritis (LN). Patient met the American College of Rheumatology criteria for SLE and the m-RNA COVID-19 vaccine was thought to be the inciting trigger as extensive history did not suggest any other etiology or trigger. Therapy with pulse dose steroids, mycophenolate, and hydroxychloroquine was initiated and the patient had a positive response with improvement in proteinuria, anti-ds DNA antibody and C3 levels

IMPACT/DISCUSSION: Literature review reveals only a handful of cases of new-onset LN following m-RNA COVID-19 vaccination and a few cases of flares have been reported as well. The immunological response elicited by the vaccine is thought to cause SLE in an immunologically predisposed individual. This signifies the importance of keeping a low threshold for diagnosis and close follow-up in case of new onset of symptoms following vaccinations, as early diagnosis can potentially improve outcomes.

CONCLUSION: In conclusion vaccinations can trigger immunological response leading to development of auotimmune diseases

Close follow up can help with timely intervention

THE FUNGUS AMONG US: A PUZZLING CASE OF PERSISTENT RIGHT UPPER LOBE CONSOLIDATION IN AN INDIVIDUAL WITH CROHN'S DISEASE ON UPADACITINIB

Robert A. Churchill¹; Dylan J. Goings²; Ioannis Kournoutas³; Lai Jiang⁵; Devika Das⁴; Michael Mueller⁶. ¹Alix School of Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Department of Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ³Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN; ⁴Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ⁵Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Minnesota, Rochester, MN; ⁶General Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4064014)

CASE: A 43-year-old male with history of Crohn’s disease treated with upadacitinib was admitted to an academic medical center in the midwest for evaluation of persistent right upper lobe consolidation. He had experienced 3 months of cough, respiratory symptoms, and chest tightness despite multiple courses of antibiotics in the outpatient setting. Prior to developing symptoms, he had spent several weeks camping, digging, and living on a houseboat in the midwest.

CT scan of the chest demonstrated a dense, multiloculated right upper lobe consolidation with mediastinal adenopathy and a right-sided pleural effusion. Upadacitinib was held and antibiotics were discontinued given low suspicion for bacterial infection. While blood cultures were negative, the Blastomycosis antibody returned positive.

The patient underwent bronchoalveolar lavage, with subsequent fungal PCR testing confirming the diagnosis of pulmonary blastomycosis; histoplasma, coccidiomycosis, legionella, and nocardia testing was negative. Following infectious diseases consultation, 1-week course of intravenous amphotericin B was initiated for presumed Blastomyces in the setting of immunosuppression. The patient was initiated on itraconazole 300 mg three times daily for 3 with transition to 200 mg twice daily while completing a week-long course of amphotericin B. He was discharged home with oral itraconazole and follow-up with infectious diseases and his primary gastroenterologist to discuss resuming upadacitinib.

IMPACT/DISCUSSION: Pulmonary blastomycosis is the most common manifestation of Blastomyces dermatitidis infection. It is acquired through inhalation of Blastomyces conida in its mold form, which is endemic to areas along the Mississippi, Ohio, and St. Lawrence rivers in the United States. Unlike other fungal infections, blastomycosis can occur in both immunocompetent and immunocompromised individuals, with the latter demonstrating higher risk of severe disease. Upadacitinib, a selective janus kinase inhibitor which modulates TNF-α levels, has been linked to disseminated fungal infections.

Radiographically, pulmonary blastomycosis often presents as alveolar infiltrates with pleural effusions, resembling community-acquired pneumonia. While fungal cultures are the gold standard for Blastomyces diagnosis, serum antibody testing can enable rapid identification. In immunocompromised individuals, intravenous amphotericin B is recommended, followed by a 12-month course of oral itraconazole once severe disease is ruled out.

CONCLUSION: Immunocompromised patients, including those taking upadacitinib, are at increased risk of severe blastomycosis. Intravenous amphotericin B is the drug of choice in these cases, with cross-titration to itraconazole monotherapy as an option once severe disease has been ruled out.

THE GREAT MIMICKER STRIKES AGAIN, A BEHAVIORAL CHANGE WORTH NOTING

Nirisha Commodore, Theresa Shirey, Weston F. Dicken, Joanna Bonsall. Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4060829)

CASE: A 58-year-old male with a history of hypertension and prediabetes was admitted to the hospital after a six-month history of falls and worsening behavioral changes (hyperverbal, agitation, and intermittent confusion). Per the patient’s family, a year ago, the patient had been independent with all activities of daily living with no agitation. During a recent admission, head imaging showed no acute abnormalities. His reported behavioral changes were attributed to early-onset dementia, and he was discharged. The patient returned to the hospital 24 hours later after being found wandering the streets. Apart from healing wounds from prior falls, his physical exam was normal. Labs, including thyroid function tests, vitamin B12, folic acid, urine drug screen, and HIV screen, were negative or normal. Repeat CT head was unremarkable. An RPR titer was obtained and was 1:128 (no historical titers were found). Subsequent lumbar puncture revealed lymphocytic pleocytosis (WBC 10 cells/microL), total protein 42 mg/dL, and a negative VLDR. The patient was started on IV Penicillin G for 14 days. Within three days of starting antibiotics, his intermittent hyperverbal episodes, agitation, and confusion resolved.

IMPACT/DISCUSSION: This case demonstrates the importance of considering neurosyphilis—the “great mimicker”—as part of the standard assessment of altered mental status and behavioral changes. The incidence of syphilis is rising in the United States, and the Southeast region had the second highest rate of reported syphilis as of 2021 (16.7 cases per 100,000; 26.5% increase from 2020). Syphilis is categorized into stages based on time since infection and/or clinical manifestations; however, neurosyphilis can occur at any point after infection.

There is no gold standard for the diagnosis of neurosyphilis. Generally, diagnosis is based on positive serum nontreponemal or treponemal tests and cerebral spinal fluid (CSF) abnormalities, including a combination of lymphocytic pleocytosis, an elevated protein concentration, or a reactive VDRL test.

Although the duration of infection in this patient was unknown, neurosyphilis can present similarly to other diseases of the nervous system; therefore, delayed and misdiagnosis can be common if not included in early evaluations.

CONCLUSION: Neurosyphilis is difficult to diagnose due to its variable time of onset and wide variety of clinical presentations.

Always consider neurosyphilis in the workup of behavioral changes, especially with increasing reported cases nationwide.

Prompt and accurate diagnosis can significantly improve patient outcomes.

THE HUNT IS ON! SEARCHING FOR AN ELUSIVE ECTOPIC ACTH-SECRETING TUMOR CAUSING REFRACTORY HYPERCORTISOLISM

Zach Rubnitz, Evan Gross, Meenu Singh. Internal medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4063017)

CASE: A 58-year-old male with MEN-1 syndrome presented for agitation and confusion. He was found to be persistently hypertensive and hypokalemic, and further endocrine work-up revealed a serum cortisol level of 27 ug/dL (6-18), 24-hour urine cortisol 886 ug/d (<60), and ACTH of 153 pg/mL (7-63) consistent with ACTH-dependent hypercortisolism. With his history of MEN-1 and a known pituitary mass, inferior petrosal sinus sampling (IPSS) was done but was consistent with ectopic ACTH production. A PET/CT showed multiple tumors throughout the pancreas, duodenum, stomach, and right adrenal gland. They were all resected (including right adrenalectomy), but biopsies were consistent with non-ACTH producing neuroendocrine tumors (NETs) and normal adrenal hyperplasia. All had negative ACTH stains. Despite removing all identifiable tumors and having required various combinations of etomidate, ketoconazole, and metyrapone, his hormone levels remained high: serum cortisol of 90, urine cortisol of 1530, and ACTH of 226. Because the search was unrevealing, he ultimately underwent left adrenal ablation resulting in improvement in symptoms and cortisol levels. He was then started on maintenance corticosteroid replacement therapy.

IMPACT/DISCUSSION: Our patient presented with signs and symptoms of hypercortisolism- psychosis, hypertension, nephrolithiasis, and hypokalemia. Other complications of hypercortisolism include myopathy and thromboses, both of which he developed, and increased risk of PJP and osteoporosis. Because his ACTH was elevated, his hypercortisolism was grouped into ACTH-dependent. In MEN-1 patients, the typical cause of hypercortisolism is a pituitary adenoma or less likely adrenal adenoma. However, tissue sampling ruled these out in our patient. Rarely thymic tumors in MEN-1 patients can secrete ACTH, but PET-CT was negative. Finally, any NET can be responsible, but despite full body PET, these tumors can be difficult to detect. In a retrospective series of 19 MEN-1 patients with hypercortisolism at one institution, etiology could not be found in 5 patients. The cyclical nature of hypercortisolism can also contribute to its elusiveness. Common pharmacologic treatment options include etomidate which blocks cortisol synthesis, as well as adrenal enzyme inhibitors e.g. ketoconazole and metyrapone, and corticotrope tumor targets e.g. cabergoline. However, surgery is often required for source control with bilateral adrenalectomy being the final option. Hormone screening allows for earlier diagnosis and improved morbidity/mortality, but unfortunately, hypercortisolism in MEN-1 carries a poor prognosis and is associated with an earlier death.

CONCLUSION: MEN-1 patients are predisposed to hypercortisolism through a variety of mechanisms. If ACTH is high, the source of ACTH should be searched for through imaging and tissue sampling. However, if the source cannot be obtained, definitive treatment is bilateral adrenal removal and subsequent corticosteroid replacement.

THE IMPORTANCE OF THE SOCIAL HISTORY IN DIAGNOSING LEPTOSPIROSIS

Erika S. Tsutsui²; David Bekhor¹; Erica Grabscheid². ¹Infectious disease, Mount Sinai Beth Israel Hospital, New York, NY; ²Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4014192)

CASE: A 78-year-old female with a past medical history of hypertension, hyperlipidemia, type 2 diabetes presented to the emergency department (ED) with 3 day history of bilateral calf pain. Patient denied any shortness of breath, chest pain, abdominal pain, dysuria or rashes. In the ED, BP 146/54, HR 139, RR 18, Temp 101.2F. Physical exam was within normal limits except noting bilateral calf edema. Initial labs were remarkable for a WBC of 16.4 K/uL with a left shift, a newly elevated creat of 2.49 mg/dl, abnormal LFT’s (AST 65 U/L, ALT 74 U/L, Total Bili 1.5 mg/dL, ALP 126 U/L and a GGT of 43 U/L), and a CPK of 569 U/L. VBG revealed a lactate of 2.6 mmol/L. Liver and kidney ultrasounds were without abnormalities. Deep venous thrombosis was excluded by ultrasound. The patient was admitted to medicine under a sepsis protocol and started empirically on cefepime and vancomycin. Hepatitis panel returned negative as well as acetaminophen/ salicylate levels, ANA, alpha 1 antitrypsin, ceruloplasmin, and EBV/ CMV titers. Blood cultures were negative. AST and ALT peaked at 198/ 182 U/L. Although the patient denied any animal bites, the team later learned there were rodent droppings/ urine in the patient’s apartment. The Leptospira IgM resulted positive. At the time of the leptospirosis diagnosis, she had received 7 days of cephalosporin treatment with complete resolution of symptoms.

IMPACT/DISCUSSION: Leptospirosis is a worldwide zoonotic infection but is most prevalent in tropical regions. In the United States, the incidence of leptospirosis is relatively low (approximately 100 to 150 cases are reported annually). Puerto Rico and Hawaii consistently report the most cases [1]. The patient in our case had not travelled to endemic areas, but resided in an overcrowded urban area in Northeast region and had exposure to rodent urine which act as the primary reservoir for Leptospira.

Health practitioners should ask broad questions to best understand their patient’s risk for animal exposure, not just limiting the conversation to animal bites; exposure to zoonotic pathogens may occur by being in a contaminated environment with the patient unaware of their own vulnerability. This case of leptospirosis originating in a New York City apartment exemplifies that simple questions regarding environmental cleanliness and hygiene could be helpful screening tools

CONCLUSION: Leptospirosis infection is not limited to tropical climates.

Exposure to zoonotic pathogens is not limited to animal bites. Risk may involve contact with animal stool, urine, or other bodily fluids. The patients themselves may be unaware of

the exposure. Asking the patient about their history of being in an unhygienic environment may be the only clue of a zoonotic transmission.

THE JOURNEY OF A CLOT: A CASE OF INFERIOR VENA CAVA (IVC) SYNDROME

Priya Sharma¹; Neelima Thati². ¹Medicine, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Wayne State University, Detroit, MI. (Control ID #4064493)

CASE: A 38-year-old African American male with a past medical history of stage IV colon cancer with liver metastasis/retroperitoneal lymphadenopathy and back spasms presented to the emergency department (ED) with a chief complaint of severe debilitating left groin pain. Upon further investigation, CT abdomen and pelvis revealed significant changes in the left hemipelvis with possible combination of deep vein thrombosis (DVT) extending throughout the left venous channels involving the common femoral, external iliac, common iliac, and IVC with mass effect on the left aspect of the urinary bladder. Cardiology was consulted, and the patient was suggested to have a venogram with possible thrombectomy.

Angiogram revealed 100% occlusion of the distal IVC, left common iliac, left common and external iliac, and left common femoral vein. The length of thrombosis was 13 cm. Thrombectomy was done and successfully removed all clots leaving 0% occlusion.

After the procedure, the patient switched from Heparin to Xarelto with initial dosing of 50 mg twice daily for 20 days followed by indefinite continuation of 20 mg once daily. Once home, he continued his home medications of Norco 10 every 4 hours as needed, lidocaine patches, and Flexeril. Compared to when he first came to the ED, patient noted significant improvement in his symptoms. He could ambulate comfortably again and tolerate his diet. He was scheduled for follow-up with his oncology and cardiology team.

IMPACT/DISCUSSION: Typically, when a male cancer patient presents with groin pain, differentials include renal stones, hematoma, or DVT. Especially in this patient with chronic malignancy and excruciating pain, his symptoms suggested possible metastasis or DVT. When the CT showed extreme clot burden of IVC, cardiology was consulted for a thrombectomy.

IVC syndrome accounts for about 1.5% of DVT cases with its incidence increasing 7-fold in cancer patients. Thus, IVC syndrome should be considered a differential especially when the patient has a malignancy near the IVC. Delayed treatment of IVC syndrome can lead to continued hypovolemic shock-like symptoms: tachycardia, hypotension, cold extremities; as well as ascites, lower extremity edema, and hypoxia. Without intervention, the decrease in blood can lead to altered mental status and death.

Due to limited reports of IVC syndrome related to malignancy and mass effects, treatments have not been extensively studied. Though in this case, performing a thrombectomy showed success. With 3 passes and heavy debulking of clot burden, final angiogram post-procedure showed complete resolution of clot. No intervention or stenting was required because flow was done and patent.

CONCLUSION: Since internists co-manage patients with blood clots alongside interventional cardiologists and oncologists, increased awareness of hypercoagulable states associated with malignancy should help with early recognition and successful treatment.

THE LIKELY ZEBRA AND THE UNLIKELY HORSE: A CASE OF PAINLESS JAUNDICE IN A CROHN’S DISEASE PATIENT

Sheel R. Vasavada, Juliana M. Mitchell, Hannah Duehren, Christine Tsai. Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4063701)

CASE: A 57 year old female with a history of metabolic dysfunction-associated fatty liver disease (MAFLD), Crohn's Disease (CD), colon cancer in remission, and cholecystectomy 9 years prior presented with painless jaundice, acholic stool, choluria, pruritus, decreased appetite, and elevated LFTs. Labs showed total bilirubin 9.8 mg/dL, direct bilirubin 9.82 mg/dL, alkaline phosphatase 880 U/L, AST 209 U/L, ALT 238 U/L, hemoglobin 13.9 mg/dL. Abdominal US had increased liver echogenicity consistent with MAFLD. MRCP revealed intrahepatic biliary ductal dilation without choledocholithiasis and alternating strictures and dilations of the CBD, pathognomonic for primary sclerosing cholangitis (PSC). Surprisingly, ERCP detected normal intrahepatic ducts, with two localized stenoses in the main bile and common hepatic ducts. Many cholelithiases were removed, and a stent was placed with subsequent improvements in the patient’s clinical picture.

IMPACT/DISCUSSION: PSC is rare, and typically not the cause of painless jaundice in the general population. Common causes of painless jaundice are viral hepatitis, alcohol-related, medication-induced, and biliary obstruction due to tumors or asymptomatic cholelithiasis. PSC is, however, the most common hepatobiliary manifestation of inflammatory bowel disease (IBD). As many as 70% of patients with PSC have underlying IBD. CD represents roughly 10% of IBD in PSC-IBD. Alternative diagnoses considered in this IBD patient with a history of colon cancer were autoimmune hepatitis, primary biliary cirrhosis, IgG4-associated cholangiopathy, granulomatous hepatitis, and cholangiocarcinoma.

Choledocholithiasis was lower on the differential, as the patient denied postprandial abdominal pain, her CBD was not significantly dilated, she had a remote cholecystectomy, and no cholelithiasis was detected with MRCP. Thus, it was a surprise that this common cause of jaundice was the final diagnosis in this patient. Recurrence of cholelithiasis after cholecystectomy occurs between 4-24% of patients, but typically in the first 2 years postoperatively.

CONCLUSION: Unique features of this case were the atypical presentation of choledocholithiasis without associated biliary colic and the delayed presentation after cholecystectomy. Additionally, given this patient's poorly controlled Crohn’s disease and MRCP imaging consistent with PSC, even the hepatologists put PSC higher on the differential despite its rarity in the population. This case required the gold standard diagnostic and therapeutic intervention for biliary obstruction, an ERCP, to accurately diagnose this patient with choledocholithiasis - the best possible diagnosis for the patient. All signs pointed to a zebra diagnosis of PSC, but instead, it was a horse, a common diagnosis of choledocholithiasis. However, even this horse had stripes, as the likelihood of developing choledocholithiasis nearly 10 years post-cholecystectomy has rarely been reported in the literature. Perhaps the horse was a bit of a zebra after all.

THE PERFECT STORM: A MULTIFACTORIAL PRESENTATION OF HYPO-CALCEMIC TETANY

Katherine L. Lee¹; Julia Aepfelbacher²; Tanya Nikiforova¹. ¹Internal Medicine, UPMC, Pittsburgh, PA; ²University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4061531)

CASE: A 50-year-old woman with GERD on omeprazole, obesity on subcutaneous semaglutide, and menorrhagia s/p hysterectomy 1 month ago, presented with progressive paresthesia and acute sustained tetany. Four months ago, she developed progressive intermittent numbness of her bilateral hands and feet. On the day of presentation, she had acute onset perioral and bilateral arm numbness, followed by severe bilateral upper and lower extremity cramping. Notably, she was started on semaglutide 4 months prior, up titrated to 2.4mg weekly. She was allowing herself 600-1200 calories/day on Weight Watchers. She also had poor appetite since her surgery 1 month ago. She lost 25 lbs. over 4 months. On presentation, vital signs revealed HR 120 and RR 40. Her BMI was 34. Upper and lower extremity strength was 4/5 in all muscle groups. She had carpopedal spasms bilaterally. Labs revealed K 3.3, Ca 7.8, ionized Ca 0.79, Mg 0.6, Phos 1.0, lactate 9.7, b-Hydroxy-Butyrate 2.19, VBG 7.51/19/53/15 with anion gap of 22, and CPK 1450. She had global electrolyte deficiencies, rhabdomyolysis, and starvation ketoacidosis with compensatory respiratory alkalosis. She was admitted to the ICU and electrolytes stabilized after aggressive repletion. Semaglutide and omeprazole were discontinued. The primary team, endocrinology and renal teams concluded that her presentation was a result of severe nutritional deficiency from semaglutide and PPI use.

IMPACT/DISCUSSION: GLP-1 receptor agonists are increasingly prescribed to patients with obesity. These medications are up titrated slowly, with dose changes typically occurring every 4 weeks to decrease the risk of side effects including nausea, diarrhea, and vomiting. In trials, 50% of individuals prescribed semaglutide achieved >15% body weight loss, with mean weight loss around 15kg. We describe a unique report of how rapid weight loss from semaglutide and calorie restriction resulted in severe starvation ketosis and electrolyte imbalance, particularly hypocalcemia. Chronic PPI use can also result in malabsorption of vitamins and minerals and can produce hypomagnesemia and hypocalcemia, which likely contributed to our patient’s presentation. Formal guidelines regarding routine laboratory testing with semaglutide use have not been established and may be indicated in populations with elevated risk for electrolyte abnormalities and significant weight loss.

The clinical features of starvation ketosis include elevated urine and serum ketones, metabolic acidosis (with or without compensatory respiratory alkalosis) and electrolyte abnormalities. Hypocalcemia can present with paresthesia, perioral numbness, tetany, and in severe cases, sustained tetany or muscle spasms causing rhabdomyolysis, as seen in this case report.

CONCLUSION: As semaglutide is increasingly prescribed for diabetes and weight management, monitoring electrolytes in at-risk populations may reduce risk of severe complications.

THE RARE TRIAD OF AUSTRIAN SYNDROME

Ramsha Abbas¹; Vishali Ramsaroop¹; Matthew Brown². ¹Medicine, Baystate Medical Center, Springfield, MA; ²Orthopedics, Connecticut Children's Medical Center, Hartford, CT. (Control ID #4062275)

CASE: 74-year-old female with Sick sinus syndrome and prior CVA presented with altered mental status after being found down. She had recurrent emesis, gaze deviation and diffuse rigidity prompting intubation for airway protection. Initial lab work was notable for neutrophilic predominant leukocytosis. Computed tomography (CT) of the chest was suspicious for bilateral aspiration consistent with pneumonia. CT of head revealed left parietal cortical and subcortical hypodensities suggestive of acute infarct. She was started on empiric antibiotics and anti-convulsants due to suspicion of scar seizures from prior known stroke and pneumonia. Infectious meningo-encephalitis was not excluded, prompting an LP, positive with >6k WBCs and gram (+) cocci on gram stain. Blood cultures grew Streptococcus pneumoniae (S. pneumoniae), while lower respiratory culture grew streptococcus Viridans. MRI brain was compatible with infectious ventriculitis and punctate restricted diffusion foci concerning for acute embolic infarcts. Findings of these infarcts in the setting of bacteremia prompted transesophageal echocardiogram (TEE), given the suspicion for left-sided endocarditis. Small fibrinous attachments on the coronary sinus leads of the patient’s right sided pacemaker were interpreted as likely vegetations; there did not appear to be an intra-cardiac shunt. She was extubated and discharged to rehab while completing a 6 week course of ceftriaxone.

IMPACT/DISCUSSION: Austrian Syndrome is a rare but life-threatening triad of pneumococcal pneumonia, meningitis and endocarditis. The increasing rarity of this condition is thought to be due to increasing use of penicillin and vaccination against pneumococcus. It has been described in case studies as respiratory symptoms consistent with pneumonia, then a sequelae of meningitis and endocardial involvement. Our patient presented with neurological symptoms concerning for CNS involvement, followed by respiratory failure and bacteremia. Our patient's CSF was consistent with infection. Other cases have described only clinical and radiographic features without confirmatory CSF findings. The likely right-sided lead associated vegetation with left-sided emboli remains a diagnostic paradox as TEE did not show evidence of an intra-cardiac shunt and could suggest two separate nidus of infection. The triad has been defined in literature as caused by S. pneumoniae. However, our patient grew streptococcus vestibularis on respiratory culture. This may suggest either an incidental polymicrobial co-infection or the possibility of a syndromic variant involving multiple streptococcus species.

CONCLUSION: It is important to recognize Austrian syndrome early, so it can be treated timely with appropriate coverage and durations of antimicrobials in addition to source control, if indicated. Though defined as a disseminated pneumococcal infection, there are limited studies given the rarity of the disease and has not yet been seen with two different species of streptococcus.

THERE IS A FUNGUS AMONG US: A HERPES ZOSTER MIMICKER

Krishna Suhagia^1,3; Marcella Christina Sousa Barreto^1,3; Jesus Javier Rubio Castillon^1,3; Muhammad Afzal²; Gabriel Brandeis^1,3. ¹Internal Medicine, New York City Health and Hospitals Corporation, New York, NY; ²St George's University, St George's, St George's, Grenada; ³Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4064747)

CASE: An 88-year-old woman with diabetes mellitus and dementia initially presented for symptomatic bradycardia with loss of consciousness. Her condition improved with administration of atropine and she was admitted for work-up of syncope. Her hospital course was extended while awaiting nursing home placement. On hospital day (HD) 18, the patient complained of burning back pain. Exam revealed an erythematous, confluent vesicular rash confined unilaterally to the T2-T4 dermatomes on her left back. A presumptive clinical diagnosis of herpes zoster was made and oral valacyclovir was initiated. Daily examination of the rash showed increasing number of vesicles on an erythematous base w/ crusting and scaling. On HD 24, there were new vesicles crossing the midline with involvement of bilateral axillae. A singular lesion was seen on the upper lip along with mucositis. Infectious disease (ID) and dermatology teams were consulted and upon evaluation agreed on the diagnosis of herpes zoster and treatment with oral valacyclovir. Varicella zoster PCR and IgM antibody were negative. On HD 28, a punch biopsy of the rash was performed. Due to clinical presentation concerning for dissemination and no improvement on oral valacyclovir, treatment was switched to intravenous valacyclovir. Tzanck smear was performed and did not reveal any multinucleated cells. The final dermatopathology results of the punch biopsy were tinea corporis. The patient was switched to topical ketoconazole with reduction in vesicular and crusting appearance of the rash without further spread and improved pain reported by the patient.

IMPACT/DISCUSSION: Tinea corporis is a fungal infection caused by dermatophytes that affects the skin of the trunk, neck, arms, and legs. Despite having a common presentation of an annular, erythematous, and pruritic rash, tinea corporis has been seen to appear as a mimic of other dermatoses. Factors that affect morphology of atypical tinea presentations include pathogenicity of the specific dermatophyte species and host factors such as immune status, underlying comorbidities, and mechanical insults. In our case, tinea corporis was initially diagnosed and treated as herpes zoster. The case emphasizes the importance of being mindful of anchoring and confirmation bias when treatment does not yield expected improvement. When considering alternative differential diagnoses of dermatoses in hospitalized patients, along with serological studies, it is important to do a skin scraping microscopy with KOH preparation and a skin biopsy, especially if initial less invasive diagnostic testing is negative.

CONCLUSION: Dermatophytosis can present in atypical form due to both patient and organism factors. In cases of presumed herpes zoster that do not improve with empiric treatment, it is imperative to consider tinea corporis in the differential and perform appropriate testing.

THE SILENT PATIENT: A PATIENT WHO WILL NOT ANSWER QUESTIONS

Brianna Mussman, Shana Zucker. Internal Medicine, Jackson Memorial Hospital, Miami, FL. (Control ID #4025729)

CASE: The patient is a 67-year-old white man with hypertension, type 2 diabetes, ischemic stroke with no residual deficit 1 year prior, brought by EMS from a wellness check after family had not heard from him in 4 days. He did not participate in the interview; chart review revealed home medications of folate, aspirin, rosuvastatin, metformin, and quetiapine. He drank a bottle of vodka every 3 days for over 10 years; after 4 months of abstinence, he resumed drinking wine. He is widowed, lives at home, works as a lawyer, and is guardian of his teenage granddaughter. He has strong social support.

Vital signs were within normal limits. He was disheveled, had masked facies, and was non-verbal apart from quietly responding “that’s fine” when asked if the team could perform an exam; he answered no further questions. Exam was limited as he did not follow instructions. He was noted to be visually tracking the examiner. He had bilateral vertical nystagmus with spontaneous eye movement. On auscultation, his heart rhythm was irregular. Grip strength was 3/5 bilaterally; he did not maintain lifted extremities to gravity.

Labs revealed mild leukocytosis. CMP, urinalysis, troponin, and VBG were unremarkable. CPK, lactate, vitamin B12, folate, and ammonia were normal. Urine drug screen, salicylates, and acetaminophen were undetectable. An ethanol level sample was lost. Chest radiograph was unremarkable. CT brain showed involutional and chronic microvascular ischemic changes and an old right thalamic lacunar infarct. MRI brain showed inferior colliculus enhancement with high T2 signal and restricted diffusion.

Neurology and psychiatry were consulted. He was diagnosed with akinetic mutism superimposed on Wernicke encephalopathy. He was treated with high dose IV thiamine, after which he rapidly became conversant and moved normally, but was nonsensical and confabulating; we concluded he persisted with Korsakoff syndrome. He was discharged to a skilled nursing facility.

IMPACT/DISCUSSION: Akinetic mutism is characterized by absent or significantly reduced spontaneous behavior and slowed responses, yet intense vigilance. Patients are observed visually tracking but are otherwise non-participatory. Whereas patients with catatonia demonstrate echolalia, echopraxia, or posturing, akinetic mutism has none of these features. The only report of akinetic mutism with Wernike’s encephalopathy was published in 1988.

We pursued a neurologic diagnosis rather than anchoring on a psychiatric one due in part to medical and social factors. Throughout the case we surmised the patient could not answer questions, not that he was "uncooperative." On reflection, we wonder if implicit bias protected this patient from being dismissed. How clinical and social factors frame a patient can lead to very different outcomes.

CONCLUSION: Akinetic mutism is characterized by minimal-to-absent spontaneous speech or behavior while visually tracking. It is important to consider neurologic diagnoses in patients who are awake but not speaking.

THE STUBBORN SPOOFER: PITFALLS OF AGGRESSIVE RATE CONTROL IN ATRIAL FLUTTER

Parmjyot Singh^1,2; Olivia Mann^1,2; Colleen M. Koller^3,4; Jessica A. Schumann^1,2; Adam Guss^3,4. ¹Internal Medicine, Jefferson Health - Northeast, Philadelphia, PA; ²Emergency Medicine, Jefferson Health - Northeast, Philadelphia, PA; ³Cardiology, Jefferson Health - Northeast, Philadelphia, PA; ⁴Cardiac Electrophysiology, Jefferson Health - Northeast, Philadelphia, PA. (Control ID #4064793)

CASE: A 72-year-old female with a history of sick sinus syndrome with a pacemaker (PPM) and paroxysmal atrial fibrillation (PAF) with prior ablation therapy presented for palpitations, dizziness, and thoracic muscle pain for two days. Her exam was reassuring except for a heart rate (HR) of 128 beats per minute (BPM). The underlying rhythm appeared to be sinus tachycardia (ST). Her workup was largely unrevealing, except for marginally elevated cardiac enzymes, so she was admitted to hospital medicine. Rate control was achieved with a diltiazem infusion. She developed hypervolemia necessitating diuresis, which resulted in recurrent tachycardia. Electrophysiology (EP) consultation and PPM interrogation noted undetected episodes of AFL. Upon reevaluating her initial electrocardiogram (EKG), the underlying rhythm was identified as AFL with variable conduction. She underwent successful cardioversion and began amiodarone for rhythm control. She was discharged on hospital day three, with EP follow-up for ablation.

IMPACT/DISCUSSION: Effective management of AFL, categorized as 'typical' and 'atypical,' requires discerning its subtypes. 'Typical' AFL involves a macroreentrant circuit around the cavotricuspid isthmus. The latter may originate in either atrium, but the left atrium is a more common source.

AFL with 2:1 conduction is often misdiagnosed as ST, highlighting the importance of scrupulous EKG analysis. The 'sawtooth' pattern in inferior leads signifies typical AFL, with vector polarity indicating circuit rotation. Atypical AFL may require EP consultation and circuit mapping. Similarly, AFL with ‘variable block' refers to irregular AV nodal conduction and is often misdiagnosed as PAF. The S-T segment often obscures analysis, especially in patients with conduction disease.

Treatment focuses on preventing embolic complications and acutely managing HR. Overt rate control will often cause hypotension in AFL prior to adequately slowing the AV node, while PAF can often achieve rate control with a lower medication burden. Defining AFL versus PAF changes treatment course, highlighting the interplay of cardiac parameters and prioritizing patient care over appealing HR values. In preexisting heart disease, PAF and AFL can present with bradycardia, suggesting significant conduction disease and should prompt PPM evaluation.

Clinicians must guard against anchoring bias, especially when transitioning from acute to inpatient care. As this case shows, an unclear atrial rhythm requires further investigation. The patient's ablation history, a source of atypical AFL, proved crucial with PPM interrogation.

CONCLUSION: Understand the hemodynamic limits of rate control strategies in AFL.

Recognize different AFL subtypes and imitating rhythms.

Avoid anchoring bias when the etiology is unclear.

THE TICK STRIKES AGAIN: ANAPLASMOSIS WITH RENAL FAILURE AND NEUROLOGICAL SYMPTOMS

Lilli Schussler, Jennifer A. Corbelli. Medicine, University of Pittsburgh Department of Medicine, Pittsburgh, PA. (Control ID #4064578)

CASE: A 59 year-old male presented with altered mental status, ataxia and respiratory distress, after 3 weeks of ongoing flu-like symptoms and hypersomnia. He later developed dysarthria, amnesia, and ataxia and his family called EMS after he was found on the floor with overt confusion and inability to ambulate.

Exam was notable for fever of 39.4, tachypnea and hypoxemia requiring 4L. He was altered and somnolent. Skin exam revealed no rash or tick bites. Labs were notable for a platelet count of 23, WBC count of 3, Cr 2.8, CPK 21,000 and ALT/AST 116/281. Urine studies showed proteinuria. Hgb was 13.5 and remained stable, and hemolysis labs were normal. Pan CT scans were normal. Peripheral blood smear showed rare schistocytes. Initial working diagnosis was sepsis due to CNS infection, with some concern for tick-borne illness given his recent flu-like symptoms, with possible contribution of ITP.

He was administered platelets and was treated empirically for meningitis with ceftriaxone and vancomycin. Additional work up included testing for ADAMTS-13, Ehrlichia, Lyme, Rickettsia, Babesia, Anaplasma, HIV, HBV, HCV. LP was eventually obtained later in the hospital course and was unremarkable. On hospital day 2 he was started on doxycycline for empiric tickborne coverage, and his encephalopathy resolved soon thereafter.

He was ultimately diagnosed with anaplasmosis via PCR and continued doxycycline for 1 month. His thrombocytopenia resolved on hospital day 6. His course was complicated by progressive renal failure, requiring iHD due to ATN from anaplasmosis and rhabdomyolysis. The patient later regained significant renal function and HD was stopped. His Cr on discharge was 3.0.

IMPACT/DISCUSSION: In this patient findings typical of anaplasmosis include subacute febrile illness, thrombocytopenia, relative leukopenia and transaminase elevation. However, he initially presented with fever and florid encephalopathy concerning for CNS infection which resulted in a broad workup and short-term delay of appropriate treatment. While neurologic manifestations such as AMS and meningoencephalitis are seen in up to 20 percent of ehrlichiosis cases, neurologic symptoms (aside from headache in 40 percent of patients) are rarely noted in anaplasmosis (<1 percent).

This case exemplifies the potential for multi-system involvement in anaplasmosis including renal and respiratory failure and non-focal neurologic findings. A positive PCR result confirms infection. Blood smear showing intracytoplasmic inclusions are highly specific and therefore when present, can provide rapid confirmation. While awaiting definitive diagnosis with PCR, the prompt resolution of his encephalopathy with doxycycline strongly supported the diagnosis.

CONCLUSION: Anaplasmosis is characterized by febrile illness, thrombocytopenia, leukopenia, and transaminase elevation and is diagnosed through PCR.

Complications include renal, respiratory, cardiac and neurologic sequelae.

Standard treatment is one month of doxycycline.

THE UNEXPECTED GUEST: NEISSERIA MENINGITIDIS BACTEREMIA IN AN IMMUNOCOMPETENT ADULT

Yuqing Wang, Rutul Shah, Saiyid S. Mahmood, Inae Park, Kristin A. Swedish, Alexander Kushnir. Medicine, Division of General Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4062209)

CASE: A 39-year-old man presented with 2 days of dysuria, and severe suprapubic pain radiating to bilateral flanks. He did not have urinary discharge, hematuria, urgency, or frequency. Additional symptoms included fever, chills, myalgias, and multiple non-bloody diarrheas and vomiting. On exam, he had suprapubic and right paraspinal lumbar tenderness. Initial biochemistry results showed leukocytosis. Urine analysis indicates moderate bacteria and leukocyte esterase. CT abdomen/pelvis with IV contrast revealed thick-walled loops of jejunum on the left upper quadrant. Suspecting sepsis secondary to UTI and gastroenteritis, he was treated empirically with Ceftriaxone and Metronidazole. Subsequent urine culture, taken after the first dose of antibiotic administration, yielded no growth. Over 24 hours, he developed headaches, arthralgia, mild knee pain, and back pain, with no rashes. WBC normalized the next day. 2 days after admission, blood culture obtained in the ED identified gram-negative cocci and the diagnosis of Meningococcal bacteremia was made. Infectious control was informed, and the patient’s family members received prophylaxis for N. meningitidis. Immunology workup revealed normal level of Complement CH50 and SC5b-9 Complement. The patient received 5 days of IV ceftriaxone and was discharged on oral ciprofloxacin. He remained afebrile throughout the admission, with no meningeal signs, rashes, or persistent suprapubic pain.

IMPACT/DISCUSSION: Patients with Invasive meningococcal disease (IMD) typically have a fever and hemorrhagic rash, leading to severe circulatory collapses. Early symptoms can be nonspecific, the disease may rapidly become severe and has a 10% fatality rate. IMD is usually seen in infants, adolescents, and elderly people; infections in adults, especially immunocompetent adults, are uncommon. Here we present a rare case of Neisseria bacteremia in an adult without a known history of immunodeficiency. Despite the absence of a definitive source, the patient's condition improved quickly after empirical treatments and blood culture later revealed the causative agent. Recent findings indicate that a novel non-groupable N. meningitidis in the United States can cause bacteremia with urethritis as initial symptoms, particularly in immunocompromised individuals. Another study from France indicates that gastroenteritis presentations of IMD are associated with hyperinvasive isolates of meningococci with a mortality rate of 24%. Our case contributes to the growing body of literature on IMD, particularly focusing on cases in immunocompetent individuals with atypical initial presentations.

CONCLUSION: This case underscores the importance of following sepsis management guidelines and the need for comprehensive differential diagnosis when approaching a sepsis case. Given the rarity yet high risk associated with bacteremia, clinicians should include N. meningitidis in the differential diagnosis of sepsis, even in patients without evident immunodeficiency.

THE VALUE OF REASSESSING WORKING DIAGNOSIS: A CASE OF PAINFUL DISCOLORED DIGITS

Celestine M. Christensen. Internal Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4064556)

CASE: A 67-year-old male with current tobacco use, profound unintentional weight loss (>100lbs), recent incidental pancreatic cysts, and chronic leukocytosis was admitted with painful discolored R 5th distal finger and R 5th toe.

He was discharged from an inpatient admission two weeks prior where he was found to have a non-ST segment myocardial infarction and underwent emergent cath. During that admission rheumatology was consulted due to concern for rheumatoid arthritis and he had a workup which included B2 glycoprotein and anticardiolipin ab which were both negative. While hospitalized he developed purple discoloration of his R 5th toe which was not worked up and he was discharged to SNF. Discoloration and pain progressed and involved an additional digit so he presented back to the emergency department.

CT on admission showed tiny wedge-shaped renal hypodensities bilaterally, likely acute infarcts. Pancreatic cystic lesions were stable. He was started on a heparin drip and vascular surgery was consulted and did not recommend surgical intervention. Hematology/oncology was consulted due to concern for a hypercoagulable state in the setting of underlying malignancy. His course was complicated by stroke and mesenteric ischemia while on anticoagulation. As more data came in, the etiology was still not clear and at that time immunologic studies were repeated and he was now found to have a positive anticardiolipin ab. He was treated for probable catastrophic antiphospholipid syndrome with high dose steroids, anticoagulation and plasmapheresis on hospital day 11. Ultimately he developed worsening abdominal pain and mental status with imaging showing hemoperitoneum and rectus hematoma. He was transitioned to comfort care and discharged to hospice.

IMPACT/DISCUSSION: This case meets criteria for probable catastrophic antiphospholipid syndrome per guidelines from the International Congress on aPL. This patient's atypical presentation made diagnosis challenging. Factors that complicated the diagnosis included reasonable alternative diagnoses. He had multiple risk factors for embolization including recent stenting, so initial concern was for cholesterol emboli. Hypercoagulable state was thought to be secondary to underlying malignancy and initial focus was on that workup. His atypical presentation took place over weeks, so on presentation he did not have three organ involvement and he did not meet diagnostic criteria. He also had a recent workup that refuted the ultimate diagnosis; recent anticardiolipin ab was negative. Given the recent negative testing, repeat studies were initially deferred which led to a delay in diagnosis.

CONCLUSION: As a clinician, being presented with a case with broad differentials can propose a challenge when trying to judicially decide which clinical tests to perform. As this case demonstrates, it is important to reassess a working diagnosis (particularly in cases that present atypically) and to revisit previous differentials when the diagnosis remains unclear.

THE WARBURG EFFECT: LACTIC ACIDOSIS FROM UNDERLYING MALIGNANCY

Jaeun Ahn¹; Phillip R. Ball²; Sami G. Tahhan¹. ¹Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA; ²Eastern Virginia Medical School, Norfolk, VA. (Control ID #4064339)

CASE: A 91-year-old male with a known history of benign prostatic hyperplasia (BPH), diastolic heart failure, pulmonary embolism, hypertension, and previous extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli) urinary tract infection (UTI) presented with encephalopathy. His breathing and heart rate were normal, but his bicarbonate was less than 8 with elevated lactic acid of 7.8mmol/l. He had leukocytosis, and the patient was started on meropenem and vancomycin in concern of sepsis from a UTI. Despite his improved mental status, resolution of leukocytosis, and normal hemodynamics, lactic acid was persistently elevated, ranging between 6 and 12 mmol/l. His hepatic function and liver imaging were normal. Urine culture grew pansensitive Enterococcus faecalis. A review of his prior-to-admission labs showed markedly elevated prostate-specific antigen (PSA) at 481ng/ml and multiple metastases of cancer in the bone scan. Follow-up thiamine and riboflavin levels did not show deficiencies. Type B lactic acidosis from prostate cancer was presumed, and degarelix was administered prior to discharge.

IMPACT/DISCUSSION: Lactic acidosis is the leading cause of metabolic acidosis in hospitalized patients. Three types of lactic acidosis exist: Type A lactic acidosis, linked to impaired tissue oxygenation; Type B lactic acidosis, without systemic hypoperfusion; and D-lactic acidosis, associated with short bowel syndrome, diabetic ketoacidosis, and rapid propylene glycol infusions.

Type B lactic acidosis is caused by impaired cellular metabolism and regional areas of tissue ischemia. Commonly associated conditions include thiamine or riboflavin deficiency, malignancy, alcoholism, toxic alcohol, and medications such as metformin, linezolid, propofol, and IV epinephrine. We believe that our patient had type B lactic acidosis due to his underlying malignancy. Type B lactic acidosis is more commonly reported in hematologic malignancies, while it is a rare finding in solid tumors without hepatic metastasis. Underperfusion of tumor clusters, hepatic metastases, and aerobic glycolysis in neoplastic cells (Warburg effect) are possible mechanisms. Although type B lactic acidosis is an uncommon metabolic complication in prostate cancer, it is a significant finding that indicates a poor prognosis. Regardless of the mechanism, treatment of the tumor, whether through chemotherapy, irradiation, or surgery, typically corrects the lactic acidosis. Lactic acidosis is commonly encountered in the context of sepsis, and this case underscores the importance of a comprehensive differential diagnosis for the various types of lactic acidosis to ensure appropriate treatment.

CONCLUSION: Although type B lactic acidosis is a rare finding in solid cancer, it indicates a significant tumor burden and poor prognosis. As we generally encounter lactic acidosis in the context of sepsis, identifying the underlying cause of lactic acidosis is important to deliver the appropriate treatment.

THE WEIGHT OF THE ANCHORING EFFECT ON DIAGNOSING LUPUS NEPHRITIS

Yunisse Gonzalez²; Samantha Chua¹; Ramya Radhakrishnan¹; Joseph Rencic¹. ¹Boston Medical Center, Boston, MA; ²Boston University Chobanian & Avedisian School of Medicine, Boston, MA. (Control ID #4015333)

CASE: A 38-year-old female with a history of treated latent tuberculosis, hemoglobin E anemia, risky alcohol use, and daily herbal tea ingestion, presented with five days of worsening abdominal distension and bilateral lower extremity edema. Her distension began suddenly 5 days ago and progressed rapidly despite over-the-counter diuretics. She had baseline dyspnea on exertion that worsened with her distension and a chronic, dry cough. She was tachycardic but otherwise afebrile and normotensive. Her abdomen was distended and tense but non-tender. She had 2+ pitting edema up to her upper thighs. Labs were notable for hypokalemia, hypoalbuminemia, and 3+ proteinuria. Her abdominal ultrasound showed a nodular liver with large-volume ascites, and diagnostic paracentesis revealed a SAAG >1.1. Her ultrasound and her moderate alcohol use first raised concern for decompensated cirrhosis with a differential including autoimmune hepatitis, drug-induced liver injury from herbal teas, or infection. However, her abdominal MRI showed no evidence of liver fibrosis or signs of portal hypertension, and her history did not explain her proteinuria. The protein-to-creatinine ratio was 19.76, and the 24-hour protein was 16.8 g/g, prompting evaluation for renal etiologies. Renal biopsy showed class V lupus membranous nephropathy.

IMPACT/DISCUSSION: An anchoring heuristic is the tendency to attribute disproportionately more weight to initial information, subsequently influencing decision-making. As a result, there is a failure to properly adjust diagnostic probabilities when additional clinical data is presented. Systemic lupus erythematosus (SLE) is an autoimmune disorder that can impact multiple organ systems. Lupus nephritis (LN) is the most common form of kidney injury in SLE and affects approximately 50% of patients. LN occurs when immune complexes accumulate in the glomeruli, with membranous lupus nephritis (MLN) defined as these complexes depositing in the glomerular subepithelial space. MLN clinically presents as a nephrotic syndrome, characterized by edema, hypoalbuminemia, and dyslipidemia. Creatinine is often normal. MLN can present with few extrarenal manifestations of SLE, and serologic markers for active SLE (anti-dsDNA, C3/C4) can be normal, although ANA would be positive. Lupus nephritis was not initially considered because the ultrasound showed nodularity of the liver, a sign considered to be accurate for diagnosing cirrhosis. However, cirrhosis is diagnosed by a combination of clinical, laboratory, and radiographic data. While this patient had ascites, she had no other laboratory or clinical history indicative of cirrhosis. Anchoring bias can help expedite the diagnostic process, but it can also lead to decisions that narrow the differential too soon.

CONCLUSION: Avoid anchoring bias by re-evaluating the history, laboratory data, and physical exam findings when new data is presented.

Membranous lupus nephritis can present as a nephrotic syndrome with few extrarenal manifestations.

THINK ABOUT THE KIDNEYS, PLEASE!

Abdul Arham³; Prasana Ramesh¹; Kirti Joshi². ¹Internal Medicine, Baystate Medical Center, Springfield, MA; ²Dept of Medicine, Baystate Health, Springfield, MA; ³Internal Medicine, Baystate Health, Springfield, MA. (Control ID #4062955)

CASE: A 69-year-old male underwent a robotic prostatectomy for carcinoma of the prostate and presented with septic shock in the setting of bladder wall anastomosis dehiscence. He was admitted to the medical ICU for further management. The patient was found to have Enterobacter Cloacae in the blood cultures. The infectious disease team recommended that the patient be on Cefepime and metronidazole for 4 weeks. He was eventually weaned off the pressor support and was discharged home on antibiotics with a PICC line. Within a week of discharge, the patient was readmitted with complaints of worsening abdominal distension and reduced output in his drains. During the hospitalization, the patient developed a sudden onset neurological decline. The patient was altered and minimally responsive to commands. A complete neurological workup was ordered including CT head, CT angio of the head and neck followed by MRI of the brain. Neuro was consulted and an EEG was performed with concerns for seizures and the patient was started on Keppra.

IMPACT/DISCUSSION: The patient was notably on 2g of IV cefepime three times a day. This was a very high dose given his renal functions. Therefore, cefepime toxicity was also suspected. The stroke workup was negative and there were no specific changes concerning seizures. Infectious disease was consulted and the patient was transitioned to levofloxacin and cefepime was stopped. Nephrology was consulted and recommended dialysis given further decline of renal function with cefepime administration. Over the next 48 hours, the patient had a stepwise improvement in his neurological status. He returned to his baseline mentation and was alert and oriented x4 responding to commands with meaningful comprehension. The patient's rest of the medical care was continued and the patient was discharged without further neurological dysfunction.

CONCLUSION: Cefepime needs to be dosed or in most cases should avoided in patients with compromise in renal functions.

Alternate antibiotics should be considered in such patients, especially given acute reversible neurocognitive decline with cefepime overdose/ adverse reaction.

THIS IS THE GIST OF IT: A CASE REPORT ON GASTROINTESTINAL STROMAL TUMORS

Amber Kuta²; Linda Youn¹; Noel Maldonado¹. ¹Internal Medicine Residency Program, St. Bernards Medical Center, Jonesboro, AR; ²Internal Medicine Residency Program, St Bernard's Medical Center, Jonesboro, AR. (Control ID #4057651)

CASE: A 54 year old male was seen for a 6 month history of fatigue, weight loss, and increasing abdominal girth. CT abdomen/pelvis showed extensive tumor encompassing the majority of the abdomen with tumor size greater than 30 cm in 2 dimensions and small bowel obstruction (SBO) with dilation of the proximal bowel, stomach, and distal esophagus. Surgery deemed mass was inoperable. In addition, SBO was not appropriate for surgical intervention and was treated conservatively. CT guided biopsy showed diffuse cell positivity for tyrosine kinase receptor KIT (CD117) antigen and discovered on GIST-1 (DOG-1) with rare mitotic figures. The final diagnosis was gastrointestinal stromal tumor, epithelioid type. PET scan showed no metastatic disease. Therefore, the plan was to begin treatment with imatinib, a tyrosine-kinase inhibitor. Initiation of imatinib was hindered by the patient's inability to tolerate oral medication secondary to complications of his bowel obstruction. Ultimately, the patient opted to pursue hospice care.

IMPACT/DISCUSSION: Although most patients with GIST are asymptomatic with an incidental finding of a tumor, the most common presentations are gastrointestinal bleeding, abdominal pain/discomfort, and acute abdomen. Average tumor size found by Jumniensuk, et al. was 8.78 cm. Metastatic disease is associated with large tumor size and non-spindle cell histology. Our patient did have a large tumor size but did not have histology consistent with non-spindle cell type. Pathology typically reveals presence of the CD117, differentiating GISTs from leiomyosarcomas, leiomyomas, and other spindle cell tumors. In addition, DOG-1 and protein-kinase C theta (PKC-theta) are two markers that are positive in GIST regardless of the presence of CD117. DOG-1 is now widely used as a diagnostic marker due to higher sensitivity compared to CD117 and increased detection of KIT-negative GIST and unusual subgroups. Presence of molecular alterations such as KIT and DOG-1 are associated with an aggressive phenotype and therefore worse prognosis.

Current approach to treatment is based on resectability. Surgical resection is the preferred first-line treatment in localized disease. For locally advanced tumors without distance metastasis Imatinib can be used to lessen the tumor burden, however has little impact on overall survival. In tumors with distant metastatic or unresectable disease, Imatinib becomes first line therapy. However, patients with PDGFRA D842V mutation imatinib is not used. Various TKIs are the other therapy options. Unfortunately, effective TKI’s for GIST only have an oral route of administration. This limitation may impede treatment, when complications such as bowel obstruction occur.

CONCLUSION: Overall, GIST tumors have a favorable outcome especially when surgery is an option. For those considered unresectable, TKIs are the mainstay of therapy. Further research into other targeted therapies as well as expansion of route of administration for currently existing therapies is needed.

THROMBOLYSIS IN THE CONTEXT OF CEREBRAL AMYLOID ANGIOPATHY

Emmanuel Oundo. Internal Medicine, University of Kansas - Wichita, Wichita, KS. (Control ID #4064048)

CASE: A 91-year-old male presented with right-sided weakness and speech difficulties concerning for an acute ischemic stroke. His past medical history included hypertension, hyperlipidemia, benign prostatic enlargement, hearing loss, nephrolithiasis, and a renal cyst. For the past three years he had experienced infrequent staring episodes during which he would not respond to his wife but would rapidly return to baseline.

His blood pressure was 119/73 mmHg; other vitals were unremarkable. He was awake but confused to year and place, with expressive aphasia, right-sided weakness and sensation loss, dysarthria, a Glascow coma scale of 14 and an initial NIH Stroke Severity score was 9. Clotting studies were unremarkable.

An initial head computed tomography (CT) showed a senescent brain with involutional changes. A head and neck CT angiogram showed no areas of hemodynamically significant stenosis or occlusion. He had no identifiable contraindications to thrombolysis, so intravenous Tenecteplase was administered.

Magnetic resonance imaging (MRI) of his brain 14 hours after thrombolysis revealed multiple intraparenchymal hematomas involving both cerebral hemispheres.

A subsequent review of his brain MRI from 2021 revealed evidence of prior microbleeds suggestive of CAA, though the original report made no mention of such.

Despite the hemorrhagic complication, his neurological symptoms continued to improve, and he was discharged home with outpatient physiotherapy and an NIHSS of 2.

IMPACT/DISCUSSION: Thrombolysis has long been accepted as part of the initial care of patients presenting with ischemic stroke. However, there remain challenges in select patient populations, including patients with undiagnosed CAA.

The definitive diagnosis of CAA requires postmortem tissue diagnosis. A high index of suspicion and use of the validated Boston criteria 2001 (revised to version 2.0, 2022) is required. In TIMI II, two of the five patients who had intracerebral bleeding were found to have CAA. Charidimou et al. showed that there was an association between cortical micro-bleeds and higher risk bleeding complications post thrombolysis, however the benefits of thrombolysis in these patients were not assessed.

CONCLUSION: This case reinforces the importance of maintaining an index of suspicion for CAA, especially in the elderly. Our patient had prodromal events over the preceding few years that may have heralded the onset of CAA. Furthermore, the case highlights the importance of reviewing prior images in potential thrombolysis candidates, even in the context of normal CT scans/MRI reports, to aid in the selection of patients for thrombolysis and to avoid potential hemorrhagic complications.

TICKED OFF: ENCEPHALITIS CAUSED BY BABESIA DUNCANI

Asma Mohammadi, Owen Schwartz. Internal Medicine, UPMC Mercy, Pittsburgh, PA. (Control ID #4016272)

CASE: This case report details an unusual case of a young male with no comorbidities, diagnosed with B. duncani encephalitis. The 22-year-old presented with fever, malaise, and joint pains, having recently traveled to Israel and stayed in rural Pennsylvania. He had no recollection of tick or mosquito bite. Labs were remarkable for leukopenia (WBC 3.1), low absolute neutrophil count (1.5 with 2 blast forms), elevated lactate dehydrogenase (393), and elevated ALT/AST levels. An EKG indicated first-degree heart block. Initially, he was treated for suspected Lyme disease with doxycycline, but the treatment was halted due to a headache and then he was treated with Amoxicillin and Rifampin for 2 days until the tick-borne panel returned negative. Given the persistent headache, Acyclovir was started for empiric Herpes encephalitis. Serology and cerebrospinal fluid (CSF) studies for cytomegalovirus (CMV), Epstein-Barr virus (EBV), varicella-zoster virus (VZV), herpes simplex virus (HSV), Anaplasma, Rickettsia, West Nile, cryptococcus, and parvovirus were negative. Brain MRI showed findings of subarachnoid space infection. CSF studies were unremarkable with normal glucose, a slightly elevated protein with a white count of 44, with 99% monocyte predominance. Serology testing for B. duncani returned positive. He was treated with azithromycin and atovaquone for 7 days.

IMPACT/DISCUSSION: Babesiosis, caused by apicomplexan parasites from the Babesia genus, is primarily transmitted by Ixodes scapularis ticks and occasionally through blood transfusion, organ transplantation, and congenital means. While over 100 species have been identified, including Babesia microti, Babesia divergens, Babeisa (B.) duncani, and the yet unnamed MO-1 strain, B. duncani is primarily found on the West Coast. However, its presence in the northeastern US is now emerging. Most cases occur during spring and summer, manifesting with fever, flu-like symptoms, joint and muscle pain, neck stiffness, dyspnea, photophobia, and weight loss.

CONCLUSION: Babesiosis occurrences are rare in Pennsylvania, and B. duncani cases are even rarer. The vague initial symptoms pose a diagnostic challenge. This case report underscores the significance of B. duncani testing for suspected tick-borne illnesses and highlights its emergence in the eastern US. The unique presentation involves a traveler with unexplained neutropenia, thrombocytopenia, and hemolytic anemia, initially unresponsive to doxycycline. Evidence suggests potential antibiotic resistance of B. duncani, complicating treatment with standard agents like atovaquone and azithromycin.

In conclusion, this case underscores the need for heightened awareness and testing for B. duncani in suspected tick-borne illnesses, especially in regions where its emergence is noted. The complex clinical presentation and potential antibiotic resistance underline the challenging nature of managing this pathogen.

TICK TALKS - IDENTIFYING THE CAUSE OF PERSIST FEVERS

Lauren A. Sachs. Internal Medicine Residency, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #4064685)

CASE: A 69yo male with HTN, HLD, and GERD presented to the ED for 3 weeks of fatigue and fever. He reported intermittent fevers with Tmax 105F, chills, diaphoresis, 12lb weight loss, generalized weakness, dyspnea on exertion, and headaches. No nausea, vomiting, diarrhea, rashes, chest pain, myalgias, arthralgias, or urinary changes. Work up at two other EDs a week prior had been negative per patient. No prior surgeries or new medications. Only medications were atorvastatin, lisinopril, and pantoprazole.

No recent travel. Only international travel was to Jamaica and Mexico, over 10 years prior. No sick contacts, blood transfusions, or illicit substance use. He was monogamous with his wife. He had two dogs, and regularly volunteered with rescue dogs, driving them cross-country to new homes and stopping to walk them on the way. Denied other pets or animal contacts, known bites or scratches, or known tick or mosquito bites. He had worked as a social worker with incarcerated clients.

He was afebrile with normal VS. No acute distress. Cardiac exam: RRR, 3/6 systolic murmur. Lymphatic exam: one <1cm lymph node in the subclavian region, soft and mobile. No rashes or petechiae. Normal lung, GI, and neurologic exams.

Initial work up notable for WBC 7.0, Hgb 11.6 (MCV 91.1), Plt 98, abs lymphocyte count 6100, AST 70, ALT 69. BMP and lactate within normal limits. LDH, ESR, and CRP were elevated. UA, blood cultures, and respiratory panel showed no evidence of infection. CT chest/abdomen/pelvis showed no apparent infectious loci.

Autoimmune, infectious, and hematologic work ups were pursued simultaneously. Autoimmune work up was unrevealing, and hematologic work up was discontinued due to positive infectious work up. Infectious work up included testing for tick-borne diseases, fungal etiologies, indolent viral etiologies, and endocarditis. Notable for positive ehrlichia PCR, with morula on blood smear. He was started on doxycycline and rapidly improved.

IMPACT/DISCUSSION: Human monocytic ehrlichiosis is endemic and increasingly common in the Midwest. Those affected may not even be aware of a tick bite. Presentation can be nonspecific with fever, malaise, myalgias, and headaches, but complications can include seizures, heart failure, or toxic shock-like illness. Lab findings include leukopenia, thrombocytopenia, anemia, elevated transaminases, elevated LDH, and elevated alkaline phosphatase. Lymphopenia will often be present early, followed by lymphocytosis. As testing often takes days to result, it can be important to start doxycycline empirically if suspecting ehrlichiosis or another tick-borne disease.

CONCLUSION: -Fever of unknown origin is defined as fever above 38.3C on several occasions over at least three weeks with sufficient work up

-Differential for FUO includes infectious, hematologic, autoimmune, drug induced, and thrombus induced etiologies

-Lab findings in ehrlichiosis can include leukopenia, thrombocytopenia, anemia, elevated transaminases, elevated LDH, and elevated alkaline phosphatase

TICK TOCK: DON’T LET THE ABSENCE OF MALTESE CROSSES DELAY AN IMPORTANT DIAGNOSIS

Lily Nguyen¹; Tarik Alagha¹; Yunjoo Hwang²; Benjamin Goodman¹. ¹Internal Medicine, Eastern Virginia Medical School, Norfolk, VA; ²Eastern Virginia Medical School, Norfolk, VA. (Control ID #4064484)

CASE: The patient was an 86-year-old male, with a history of hypothyroidism, presenting for a syncopal episode one week prior to admission. He reported no preceding symptoms but had experienced recent fatigue and weakness. He was admitted for inpatient management due to hypotension, pancytopenia, and transaminitis. CBC showed decreased hemoglobin of 9.2, hematocrit of 25.2, WBC of 3,200, and platelets of 114,000. Hepatic panel showed elevated AST of 63, ALT of 45, total bilirubin of 3.5, and direct bilirubin of 2.0. Initially, workup was focused on ruling out malignancy, and hematology was consulted. Test results were consistent with hemolysis due to elevated lactate dehydrogenase and reticulocyte count. Echocardiogram, carotid ultrasound, and morning cortisol were normal; blood cultures and tests for viral hepatitis and HIV were negative. He had normal orthostatic blood pressures and his hypotension responded appropriately to intravenous fluids and midodrine. Imaging was significant for liver cysts and portal hypertension. On day 4 of admission, the patient’s hemoglobin dropped to 6.6, and he was transfused with 1 unit of packed red blood cells.

Upon further history, the patient’s wife mentioned that he was often outdoors and had discovered an engorged tick on his shoulder about a month prior to admission. He estimated it was attached for 1-3 days. He removed the tick and did not send for testing or seek medical care. In addition, the patient reported joint pains and had developed asymptomatic microscopic hematuria. Testing for tick-borne illnesses was sent, including Babesia and Lyme. Infectious disease was also consulted, and he was started on empiric doxycycline. A blood smear revealed no Maltese crosses. Babesia PCR testing was positive; the test is more sensitive than microscopy and has a specificity of 100 percent. IgG and IgM antibodies to Lyme were also positive. A 10-day course of atovaquone and azithromycin was started in addition to continuing doxycycline; symptoms and cell lines improved over the next 48 hours. The patient went home, though was shortly readmitted for hemorrhagic shock secondary to hemolytic anemia. He was transfused appropriately and discharged with continued antibiotics.

IMPACT/DISCUSSION: This case emphasizes the importance of obtaining a thorough history and considering tick-borne illnesses in the differential diagnosis of patients with myriad symptoms, especially during active tick season. The number of babesiosis cases is thought to be underestimated due to asymptomatic infection, failure to report, and misdiagnosis. Babesiosis is not covered by empiric doxycycline; treatment is atovaquone and azithromycin for 7-10 days, or alternatively, clindamycin and a quinine.

CONCLUSION: A thorough history can reveal tick-borne illness exposure.

Babesiosis can present with low cell counts and hypotension; PCR testing is highly sensitive and specific. Antibiotic regimen should appropriately cover babesiosis.

TIP OF THE ICEBERG

Alexander Kaplan¹; Annie Massart². ¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4062113)

CASE: A 49-year-old woman with history of multiple meningiomas (status post resections complicated by intracranial abscess requiring craniectomy & prosthetic cranioplasty), a prior stroke with left-side weakness, & ventriculoperitoneal (VP) shunt placement for pseudomeningocele, presented with redness & swelling around her left eyebrow that started 8 hours prior. She had pain above her eyebrow but no headache, fever, chills, or recent trauma to the area. She had 1 episode of cellulitis in this area ~2 years prior. Family noted 2 weeks of intermittent confusion & viral upper respiratory infection (URI) symptoms.

On arrival, she was afebrile & pulse was 103; other vitals were normal. She had erythema over the left superior orbital rim & eyebrow with associated warmth & tenderness but no induration. Neurologic exam was normal aside from chronic left-side weakness. Labs revealed white blood cell count of 16 k/mcL. Xray of the VP shunt showed no discontinuity or kinking. Head CT showed no acute abnormalities, only chronic changes from previous surgeries.

She was started on clindamycin for cellulitis. Over the next day, fluctuance developed over the left supraorbital area. Brain MRI revealed an extra-axial abscess subjacent to the bifrontal cranioplasty ~3x7x5 cm. Signal abnormality suggested infected prosthetic hardware, with extension into the left forehead soft tissues with cellulitis & abscess. She underwent removal of cranioplasty & periocranial flap debridement. Endoscopy revealed no sinusitis. Antibiotics were changed to meropenem & vancomycin. Blood & epidural fluid cultures grew no organisms. She was discharged on 8 weeks of meropenem.

IMPACT/DISCUSSION: Intracranial epidural abscesses (IEAs) are usually caused by sinusitis but can occur after trauma or procedures. Symptoms can be subtle & may include fever, neck stiffness, & periorbital edema. MRI is preferred for characterizing IEAs compared to CT. Management includes drainage & antimicrobials (6-8 weeks). Because ≤10% of blood cultures are positive, antibiotic choice may be dependent on the likely source. If infection from sinusitis is suspected, starting metronidazole & ceftriaxone is appropriate. If bacteria could have been introduced from the skin, adding vancomycin is warranted. Imaging is recommended 4-6 weeks following initiation of antimicrobials/surgery or if clinical deterioration occurs.

CONCLUSION: IEAs may develop in patients with prior cranioplasties, even years after the surgery. Common manifestations include fever & neck stiffness. Duration of antibiotic therapy is usually 6-8 weeks. Clinicians should keep IEAs on their differential when caring for patients with soft tissue infections overlying cranial prosthetics & have a low threshold to pursue MRI imaging.

TREATMENT OF SEVERE THROMBOSIS EVENT IN A POST-CARDIOVASCULAR-INTERVENTION PATIENT EXACERBATED HEPARIN-INDUCED THROMBOCYTOPENIA

Trung Nguyen, Nikhil Seth, Shamis Khan. Internal Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4047619)

CASE: The patient is a 66-year-old man with congenital chest wall deformity, hypertension, hyperlipidemia, and peripheral vascular disease who presented for a robotic coronary artery bypass graft (CABG) surgery. 20,000 units of unfractionated heparin (UFH) were used for intraprocedural anticoagulation. The patient's platelet count was 132 K/μL on the day of CABG and 213 K/μL at discharge (6 days after CABG). Three days after discharge, the patient was readmitted due to left lower extremity pain and swelling. Venous ultrasound with Doppler of the left leg showed acute thrombosis and total obstruction of the common femoral, profunda femoral, femoral, popliteal, posterior tibial, and peroneal veins. His platelet count at that time (9 days after CABG) was 139 K/μL. The decision was made to start an UFH drip. That evening, the patient developed an acute pulmonary embolus (PE) in the left main pulmonary artery. The following day (10 days after CABG), his platelets count dropped to 71 K/μL. Hematology was then consulted for concern for heparin-induced thrombocytopenia (HIT) with a 4T score of 6 indicating high probability of HIT (~64%). UFH drip was discontinued, and the patient was started on a bivalirudin drip. Heparin antibody was strongly positive at 2.954 OD and confirmed with a serotonin release assay. The patient then underwent left femoral vein thrombectomy and an incision and drainage of a hematoma in the left femoral groin. He was bridged to warfarin at discharge.

IMPACT/DISCUSSION: Cardiovascular patients are at higher risk of HIT due to exposure to UFH during both procedure and post-procedural prophylaxis. The incidence of HIT following cardiac surgery is reported between 0.7 to 2% and is associated with higher incidence of thrombotic and embolic complications (Gurbuz et al, 2005). In our case, the timing of onset (9 days after procedure) and extent of thrombosis could point to the diagnosis of HIT occurring post-cardiovascular-intervention. The delay in diagnosis and the mistake of starting an UFH drip in a patient with high risk of HIT might have exacerbated the patient’s HIT complications, resulting in his subsequent acute PE. In a systematic review and meta-analysis involving 3068 patients with suspected HIT, the negative predictive value of a low 4T score (<4) was 99.8% (95% CI, 0.970-1.000) (Cuker et al, 2012). Therefore, given its ease of use and extremely high utility in excluding HIT, there should be a low threshold for providers to use the 4T score to guide their management for patients with high risks of HIT.

CONCLUSION: This case highlights the importance to keep HIT on the differential diagnoses in a patient with thrombosis who has recently been exposed to UFH. In such cases, extreme cautions must be used in the selection of anticoagulation as the choice of anticoagulant could further worsen the patient’s condition. Utilization of triaging tools such as the 4T score and prompt consultation with hematology can make a life-saving difference for patient care.

TREATMENT RESISTANT GASTROPARESIS WITH INTRACTABLE NAUSEA AND VOMITING MARKEDLY IMPROVED WITH IV FOSAPREPITANT

Casey E. Norlin²; Chelsea Hylton¹; Kanika Gupta²; Nam Nguyen¹; Brett Wilkinson². ¹Pharmacy, Xavier University of Louisiana, New Orleans, LA; ²Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4055045)

CASE: A male in his 40s with type 2 diabetes complicated by gastroparesis, blindness, and ESRD on hemodialysis, presented and re-presented for intractable nausea and vomiting. His symptoms could not be treated with metoclopramide, the first-line prokinetic agent for gastroparesis, as he had a history of tardive dyskinesia. On initial presentation, he was started on IV erythromycin with ondansetron PRN, resulting in initial resolution of symptoms. However, during repeat hospitalization for the same symptoms, QTc prolonged from 444 to 514, and both erythromycin and ondansetron were discontinued. At this time, the patient was barely tolerating a liquid diet. Gastroenterology, internal medicine and inpatient pharmacy teams collaborated to trial the patient on 150 mg IV fosaprepitant, a medication typically used to treat nausea and vomiting associated with chemotherapy. The patient experienced remarkable symptomatic improvement by the next morning. After three doses of IV fosaprepitant, he was successfully transitioned to oral aprepitant, and discharged on oral aprepitant 80 mg twice weekly.

IMPACT/DISCUSSION: Metoclopramide, a dopamine antagonist, is the only medication approved by the US FDA for treatment of gastroparesis. However, metoclopramide can cause extrapyramidal symptoms. Patients who have experienced these symptoms can try off-label use of other prokinetic agents such as erythromycin, an antibiotic thought to activate motilin receptors. However, erythromycin can prolong the QTc, and furthermore is not a long-term solution past four weeks as tachyphylaxis can occur. Another off-label treatment option is prucalopride, a 5-HT4 agonist. Unfortunately, prucalopride is renally excreted and thus not recommended in patients with end stage renal disease. Given that patients with gastroparesis secondary to diabetes often have poorly controlled, advanced diabetic disease, this patient population commonly has chronic kidney disease or end-stage renal disease as well, thus limiting their treatment options.

A study with 126 patients with gastroparesis or gastroparesis-like symptoms showed mixed results with oral aprepitant. Three prior case studies demonstrated utility of oral aprepitant in gastroparesis. No cases have been published on the use of IV fosaprepitant in gastroparesis.

IV fosaprepitant, a neurokinin-1 receptor antagonist, and its oral form, aprepitant, while normally used to treat nausea and vomiting associated with chemotherapy, were trialed as a novel alternate treatment option in this case, with profound success.

CONCLUSION: Our clinical vignette demonstrates the potential utility of both IV fosaprepitant and oral aprepitant in gastroparesis, particularly in patients who are unable to be prescribed other motility agents such as metoclopramide, prucalopride, and erythromycin.

TREMORS AND DYSTONIA: ATYPICAL NEUROLOGIC PRESENTATION OF SINGLE MASS TOXOPLASMIC ENCEPHALITIS IN AN AIDS PATIENT

Ainanshe Jama¹; Veronica Muyolema-Arce¹; Jai Bhatt¹; ASHKAN EIGHAEI SEDEH². ¹Internal Medicine, Capital Health, Trenton, NJ; ²TRANSITIONAL YEAR, Capital Health, Trenton, NJ. (Control ID #4064253)

CASE: A 51-year-old male with a medical history significant for HIV and medication non-compliance presented with a progressive decline in his mental status, reduced speech, coarse left-hand resting tremors, occasional left arm jerking movements, and focal dystonia of the left arm and hand. Laboratory results exhibited a low CD4 count of 42 cells/μL and a high HIV viral load of 209,000 copies. Serology was positive for Toxoplasma, with elevated serum IgG titers. On initial MR imaging, a single enhancing mass was noted within the right thalamic-capsular region, extending into the gangliocapsular region, corona radiata, midbrain pons, and right middle cerebellar peduncle, accompanied by vasogenic edema. The analysis of the cerebrospinal fluid (CSF) indicated the presence of lymphocytic pleocytosis and elevated protein levels (>300 mg/dl). CSF Meningo/encephalitis panel, along with CSF culture, were negative, and CSF cytology did not identify malignant cells. Additionally, electroencephalography was unremarkable for epileptiform discharges. The patient was initiated on empiric intravenous antibiotic therapy with Trimethoprim-Sulfamethoxazole, which substantially reduced the size of the primary mass and resolved the surrounding edema. The patient began to show signs of clinical improvement with resolving tremors and dystonia of the left arm and gradual improvement in mental status, which continued throughout the course of hospitalization.

IMPACT/DISCUSSION: Toxoplasmic encephalitis (TE) is a potentially fatal infection caused by the intracellular protozoan parasite Toxoplasma gondii (T. gondii). It most commonly affects immunocompromised patients, such as transplant patients and those infected with human immunodeficiency virus (HIV) who have a CD4 count below 100 cells/microL. Patients with TE typically experience symptoms such as headaches, confusion, and fever, as well as focal neurological deficits or seizures; however, despite T. gondii predisposition for the basal ganglia, movement disorders, such as tremors and dystonia, are extremely rare. In addition, imaging classically reveals multifocal intracranial ring-enhancing lesions, while solitary brain lesions only account for 30% of cases.

CONCLUSION: Although headaches, seizures, fever, focal neurological deficit, and behavioral changes are common findings in patients with TE, other clinical findings such as tremors and dystonia, as seen in this case, can be rarely encountered. This case emphasizes that even if initial findings deviate from the norm, the possibility of AIDS-related toxoplasmosis should not be excluded. Moreover, the radiographic finding of a solitary enhancing mass and not multifocal ring-enhancing lesions, which are pathognomonic of the disease, further complicated this case. If left untreated, TE can lead to severe and ultimately irreversible neurological injury; thus, timely diagnosis and management are pertinent to improving patient outcomes.

TRIPLE POSITIVE ANTI-PHOSPHOLIPID SYNDROME: A CURIOUS CASE OF CUTANEOUS NECROSIS

Areeba Nayyer¹; Frank Cassavell¹; Rayan Elhag¹; Aparna Iyer¹; Desiree R. Brower³; Fausto G. Lisung^1,2; Stephanie Rosales¹; Coral Parikh¹. ¹Internal Medicine, Englewood Hospital and Medical Center, Englewood, NJ; ²Hackensack Meridian Hackensack University Medical Center, Hackensack, NJ; ³Medical School, Rowan University, Glassboro, NJ. (Control ID #4063045)

CASE: A 50-year-old female with known hypothyroidism and chronic venous insufficiency presented with altered mental status to our hospital. Exam was significant for lethargy, bilateral lower extremity edema, and necrotic weeping wounds with purulent discharge. She was admitted for toxic metabolic encephalopathy secondary to severe sepsis, evident by leukocytosis (26.47K/UL), lactic acidosis (3.5MMOL/L), hypotension (68/47mmHG), and tachycardia (110bpm). The infection, initially presumed to be cellulitis related to bilateral lower extremity wounds, prompted initiation of empirical antibiotic therapy. Subsequent deterioration required transfer to the ICU for hemodynamic support.

Despite improvement in mental status with antibiotics, the lower extremity wounds continued to deteriorate, expanding to her upper thighs with worsening necrosis. She became thrombocytopenic (nadir of 52 K/UL) which prompted further testing. DIC workup was negative, CT scan of the lower extremities was normal and no deep vein thrombosis (DVT) was seen on doppler. Blood cultures remained negative. She eventually tested positive for beta-2 glycoprotein, anti-cardiolipin antibodies, and lupus anticoagulant. Skin punch biopsy of the lesions confirmed cutaneous infarction with underlying vascular thrombosis. This, along with APS antibodies clinched our diagnosis.

Treatment with high-dose steroids and therapeutic anticoagulation was initiated. Consequently, the patient was considered stable for discharge with ongoing wound care and potential surgical intervention. Confirmation of her APS diagnosis will be done at the 12-week mark.

IMPACT/DISCUSSION: APS is a rare autoimmune disease with an annual incidence of 1 to 2 per 100,000. It presents with a wide array of cutaneous findings such as livedo reticularis and ulcers, with disseminated cutaneous necrosis being the rarest. Therefore it is not considered in common differentials when patients present with diffuse cutaneous findings. This can have devastating consequences as therapy is delayed.

In our case, it was even harder to diagnose since our patient lacked the common risk factors of multiple pregnancy losses and previous history of DVT. Cutaneous findings must be addressed early on since there is a significant morbidity rate (60% need surgery for debridement or amputation) and highly associated with catastrophic APS (CAPS), with risk of progression to other vital organs. Since no other organs were affected in our case, CAPS criteria was not met.

Although there is no established criteria for managing cutaneous necrosis in APS, our patient responded to therapeutic anticoagulation and high-dose steroids with surgical debridement scheduled.

CONCLUSION: Disseminated cutaneous necrosis is a rare presentation of APS, associated with significant morbidity and severe complications. Early recognition and treatment are essential for improved outcomes. This case aims to add to the very limited articles reporting extensive cutaneous necrosis as the presenting sign of primary APS.

TWISTS AND TURNS: A REMARKABLE UNVEILING OF ASCITES CAUSED BY OVARIAN TORSION

Shivangini Duggal¹; Lakshmi Prasanna Vaishnavi Kattamuri¹; Sparsha Reddy Duvvuru¹; Swati Mahapatra²; Angelica Lehker¹. ¹Internal medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX; ²Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX. (Control ID #4064124)

CASE: 25-year-old healthy female presented with complaints of abdominal pain for two days. She had insidious onset abdominal distension progressing over 7 months. She denied a history of extensive alcohol use, low grade fevers or night sweats or recent travel. She reported a significant weight loss over the last year. Abdominal paracentesis revealed low serum ascites albumin gradient (SAAG) and high protein with features suggestive of bacterial peritonitis (BP). She was started on ceftriaxone for treatment of BP. Her CTAP showed liver etiology concerning cirrhosis however peritoneal fluid analysis was inconsistent with portal hypertension and thus other causes of ascites were sought for. Due to high suspicions of ovarian malignancy she underwent a pelvic ultrasound which was negative for any ovarian mass and the right ovary was poorly visualized. Repeat ascitic fluid analysis was consistent with BP with slight improvement in polymorphonuclear neutrophils with low SAAG and high protein. An echocardiogram was obtained to rule out heart failure, and it was normal. A CT enterography revealed a large ovarian mass which had decreased in size as per the radiology, implying accidental aspiration of the fluid from the ovarian mass during initial paracentesis. Magnetic resonance imaging was then obtained to further characterize the lesion and it revealed a large complex cystic and partially enhancing hemorrhagic mass likely benign. Patient followed up outpatient with gynecology for an exploratory laparotomy.

IMPACT/DISCUSSION: Common potential causes for a low SAAG in young individuals include tuberculosis, peritoneal carcinomatosis, as well as pancreatic and biliary issues. Minimal ascites is a common finding found with ovarian torsion (73%), however gross ascites with chronic adnexal torsion is limited to case reports. Ovarian torsion causes circulatory stasis, initially reducing lymphatic drainage and leading to ovarian enlargement. Venous obstruction and hemorrhagic infarction may follow, ultimately compromising the arterial blood supply and potentially causing complications like gangrene, peritonitis, and ascites. Acute ovarian torsion is usually symptomatic and receives medical attention and prompt surgical intervention. However, subacute or chronic torsion can imitate malignancy, making diagnosis challenging. While torsion may affect the normal ovary, it typically arises secondary to a preexisting adnexal mass like a teratoma. Swift surgical intervention is crucial to prevent irreversible adnexal damage aiming to preserve ovarian function.

CONCLUSION: Pelvic ultrasound (US), is a common diagnostic test with 97% specificity for ovarian anatomy. However, reliance on the US alone may be misleading due to poor sonographic window in the background of gross ascites. Clinicians should maintain a high index of suspicion for unusual presentations and consider advanced imaging when necessary.

TWO DOGS, ONE MAN, AND A BROKEN HEART: A CASE OF CAPNOCYTOPHAGA AND CARDIAC ARREST

Rachel A. Rubel, David Goldmeier, Bibek Koirala. Department of Medicine, Stamford Hospital, Stamford, CT. (Control ID #4064007)

CASE: A 62-year-old-male with history of chronic lymphocytic leukemia (CLL) and two distant allogenic bone marrow transplants, no longer on immunosuppression, presented with one hour of fever and chills. Notable exposures included close contact with his two large dogs. He denied recent dog bites.

He was febrile (38.5 C), tachycardic (115 bpm), hypertensive (162/104 mmHg), tachypneic (22 bpm), and saturating 97% on room air. On physical examination he had a small scratch on his mid-back. His initial white blood cell count was 9.3, sharply increasing to 23.0 the following day. His lactic acid was mildly elevated to 2.4. A CT of the chest showed bilateral atelectasis. Blood cultures were drawn and empiric antibiotics initiated for presumed community acquired pneumonia.

On hospital day one, he became acutely unresponsive. Telemetry demonstrated pulseless junctional escape rhythm culminating in asystole and pulseless cardiac arrest. Cardiopulmonary resuscitation efforts commenced until return of spontaneous circulation was achieved.

Two days later he developed sudden, unprovoked pallor of his right upper extremity, extending from fingertips to mid-forearm. A CT angiogram was inconclusive. A heparin drip was initiated, and his upper extremity quickly regained its normal appearance and function. A necrotic-appearing macule developed on the dorsal right forearm.

After close to two weeks of incubation, blood cultures finally grew gram negative rods, speciating to Capnocytophaga. Antibiotics were narrowed from piperacillin-tazobactam to amoxicillin-clavulanic acid according to culture sensitivities and the patient recovered remarkably well. He was discharged to a rehabilitation facility.

IMPACT/DISCUSSION: Capnocytophaga is a gram-negative, facultative anaerobic bacteria found in the oral cavity of dogs, cats, and humans. Infection is rare and most commonly transmitted via dog bite, but cases after dog scratch or mere exposure to dogs or cats have been reported. Patients with history of alcohol use or immunocompromise are most susceptible. Male sex, history of stem cell transplant, and history of hematologic malignancy have also been found to be associated. Prior cases have described septic shock, rapid multiorgan failure, endocarditis, meningitis, and septic arthritis secondary to capnocytophaga, usually in the setting of immunocompromise. However cardiac arrest in the setting of capnocytophaga has yet to be described.

CONCLUSION: Cardiac arrest as the presenting feature of capnocytophaga is unique. While the patient did not have any dog bites, he did have close contact with his two dogs. Transient ischemia of his right hand is also characteristic of the micoremboli described in capnocytophaga. Prognosis is typically good if supportive care and broad spectrum antibiotics are promptly initiated.

UNCHARTED TERRITORY IN MYCOBACTERIAL WORLD: THE SECOND REPORTED CASE OF MYCOBACTERIUM SHIMOIDEI IN THE UNITED STATES

Aung Sitt Naing²; Erin K. Bartholomew²; Nadeem Inayet¹. ¹Pulmonary and Critical Care, Sentara Healthcare Inc, Norfolk, VA; ²Internal Medicine, Eastern Virginia Medical School, Norfolk, VA. (Control ID #4031325)

CASE: A 68-year-old male with a history of cigarette smoking and COPD presented with a six months of cough, night sweats, weight loss, and malaise. He was treated with multiple courses of azithromycin for community-acquired pneumonia without improvement. He did not travel outside of the US and had no known exposure to TB. CT chest revealed a complex left upper lobe cavitary lesion with surrounding consolidation in the left upper lobe with background emphysematous changes. Sputum was positive for acid-fast-bacilli. He underwent bronchoscopy and bronchoalveolar lavage cultures later grew M. shimoidei, identified based on gene sequence analysis. He was started on clarithromycin, rifabutin, and ethambutol. He had mild side effects of treatment, including nausea, fatigue, hair loss, and dry skin, but he managed to continue therapy. Cultures showed sensitivity to ethambutol and rifabutin but resistance to clarithromycin. On 6-month follow-up, he continued to have persistent low-grade fever and cough with purulent sputum speckled with black particulate matter. COPD symptoms had worsened, causing persistent wheezing and shortness of breath. Repeat CT of the chest showed progression in the size of the cavitary lesion with surrounding ground glass opacities. It was deemed that the antibiotic treatment had failed. After multidisciplinary discussion with pulmonary, infectious disease and cardiothoracic surgery teams, a decision was made to proceed with left upper lobectomy. The patient's recovery was without any complications, and his symptoms improved significantly. Pathology of the resected specimen showed non-caseating granulomatous inflammation. On follow-up visits over the next 5 years, he remained symptom-free, and repeat sputum AFB tests continued to be negative. CT scans of the chest showed no recurrence of disease.

IMPACT/DISCUSSION: Mycobacterium shimoidei is a rare, slow-growing nontuberculous mycobacterium, first isolated in Japan in 1968. Only one case was reported in the United States, out of a total of fifteen cases reported worldwide. Due to its rarity, current understanding of pathogenicity, risk factors and treatment is limited. Presentation is similar to TB, and it predominantly causes pulmonary disease. There is no current consensus on established therapy, but the triple-drug regimen, including clarithromycin, rifabutin, and ethambutol, has been effective in most cases. There is limited experience with cases of macrolide resistance and therapeutic failure. There have never been any case reports requiring surgical resection which might be a potentially curative option for appropriately screened patients.

CONCLUSION: There are limited guidelines for treating M. shimoidei infection with drug resistance. Due to their extreme rarity, our knowledge is limited on surgical options for such cases with antibiotic failure. Our case highlights that surgical resection might be a curative option after a careful joint decision-making process among patients and multidisciplinary teams.

UNCONTROLLED HYPERTENSION? GIVE ENAC CHANNEL BLOCKERS A TRY

Alejandro E. Segarra Concepción. Internal Medicine, Boston Medical Center, Boston, MA. (Control ID #4019897)

CASE: 32 year-old male with history of uncontrolled hypertension (previously on 6 medications + loop diuretic) complicated by prior hypertensive emergencies, HFrEF, CKD 3b who presented to the emergency department with severe headache, nausea and vomiting found to be in hypertensive emergency with BP 232/167 in the context of medication non-adherence over the past several months. On admission, K 2.9 and bicarbonate 25. As outpatient K+ as low as 2.7 and CO2 as high as 32. Prior outpatient work-up of common secondary causes of hypertension, such as primary hyperaldosteronism, renal artery stenosis, pheochromocytoma, Cushing's Syndrome, aortic coarctation and thyroid disorders had been unremarkable. Additionally, the patient had a strong family history of resistant hypertension.

During admission, BP remained elevated (170/110) despite carvedilol 50 mg twice daily, hydralazine 75 mg three times daily, nifedipine 60 mg once daily along with spot doses of labetalol 20 mg IV. Given patient’s hypokalemia and prior metabolic alkalosis but no response to spironolactone, Liddle syndrome was suspected at this time. Patient was subsequently started on amiloride 5 mg daily. After a single dose, his blood pressure improved from 180s/110s to 130s/80s and in the subsequent days, hypokalemia resolved. Patient was eventually discharged on amiloride 20 once daily, nifedipine 60 once daily and carvedilol 50 twice daily with BP 120s/80s.

IMPACT/DISCUSSION: Here we present a young male with resistant hypertension of unknown etiology. Given his strong family history, young age at presentation, prior hypertensive emergencies and hypokalemia, primary hyperaldosteronism was the leading differential diagnosis. However, renin/aldosterone levels were low/normal and the patient's BP did not adequately respond to mineralocorticoid receptor antagonists (MRA) however did improve dramatically upon the initiation of an ENaC channel blocker which made us consider Liddle syndrome (LS) as a possible cause of the patient’s resistant hypertension. LS is gain-of-function mutation of ENaC channel in the collecting tubule of the nephron which causes sodium retention, hypertension, hypokalemia and metabolic alkalosis which is independent of renin-aldosterone. Therefore presents like primary hyperaldosteronism but without elevation in renin-aldosterone.

At the time of this writing, the patient's diagnosis has not been confirmed by genetic testing. However, given the impressive response to amiloride and resolution of hypokalemia, as well as his strong family history of uncontrolled hypertension, Liddle syndrome is currently the leading differential diagnosis.

CONCLUSION: In patients with severe uncontrolled hypertension, trial of a ENaC channel blocker as a 4th or 5th line medication appears to be a reasonable option given its potent anti-hypertensive properties and potential to suggest Liddle Syndrome in patients whom primary hyperaldosteronism has been ruled out.

UNCOVERING THE CAUSE OF SUPERIMPOSED ACUTE KIDNEY INJURY ON CHRONIC KIDNEY INJURY: HYDRALAZINE INDUCED VASCULITIS.

Paulina Kuzmin, Tomy Marco, Vanessa Adams, Numaan Mahmood, Aaron Bertolo, Denis Ruzdija, Chelsea Takamatsu. Internal Medicine, Banner - University Medical Center Tucson, Tucson, AZ. (Control ID #4064113)

CASE: We present a 72-year-old female with a past medical history significant for hypertension, diabetes, CKD of unclear etiology, heart failure, chronic PE, and thrombocytopenia who was admitted for acute hemoptysis and acute kidney injury. Given her initial constellation of AKI, hematuria, HTN, upper respiratory symptoms, and hemoptysis, granulomatosis with polyangiitis vasculitis (ANCA, cryo), antiphospholipid syndrome or drug-induced (chronically used hydralazine) were considered as possible etiologies. Her initial UA, which was a clean catch, demonstrated >50 RBC/HPF, proteinuria 1 mg/g with microalbumin/creatinine 193. Renal ultrasound demonstrated normal anatomy with nonobstructive stone. Bronchoscope with bronchoalveolar lavage was performed with no malignancy identified. Further into her hospital course, immune serologies were obtained and the patient was found to have ANA positive (1:320), P-Anca positive, negative dsDNA, positive anti-Histone Ab, and hypocomplementemia. Renal biopsy was performed and demonstrated advanced diabetic nephropathy, 60-70% tubo-interstitial fibrosis, and early crescent formation involving 3 glomeruli. She was found to have pauci-immune crescentic glomerulonephritis. Given her positive serologies and presentation, her diagnosis was determined to be drug-induced ANCA glomerulonephritis, likely from hydralazine. Due to her development of cytopenias, she was treated with rituximab and glucocorticoids. She was stable enough to be discharged to a skilled nursing facility.

IMPACT/DISCUSSION: Hydralazine is a commonly used antihypertensive, especially in the inpatient setting. There has been a well established association with hydralazine and drug-induced lupus as well as ANCA-associated vasculitis. There should be strong consideration to ordering rheumatologic serologies in a patient that presents similarly at the onset of presentation to help expedite treatment. The choice to proceed with rituximab versus cyclophosphamide was made due to her past medical history and her development of cytopenias during her hospital stay. The RAVE study indicated rituximab therapy as non-inferior to daily cyclophosphamide in the treatment of ANCA-associated vasculitis. This case demonstrates the effective use of Rituximab with glucocorticoids in a critically ill patient requiring hemodialysis.

CONCLUSION: Although rare, hydralazine-induced ANCA vasculitis is a known side effect and should be considered on presentation. Positive serology (p and c ANCA, ANA, etc) is an early clinical clue that a vasculitis may be of drug-induced etiology, even before the lab and biopsy results come back to confirm the diagnosis. Additionally, important landmark trials have occurred since the RAVE trial exploring maintenance with rituximab as a non-inferior option to standard of care or placebo.

UNCOVERING THE LINK BETWEEN TRAFFIC INJURY AND ILEOCECAL VALVE LESION

Yuma Takeda¹; Takaaki Kobayashi²; Hiroki Matsushita¹; Akihito Yoshida¹. ¹General Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan; ²Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #4055696)

CASE: A 68-year-old man with a history of type 2 diabetes presented to the emergency room following a traffic injury. He lost consciousness while driving a truck and collided with a guardrail, leading to his transfer to the emergency department (ED). Upon physical examination, a substantial contusion was identified on his right knee. As he presented with a mild fever and elevated inflammatory markers, two sets of blood cultures were collected before his discharge. The following day, he returned to the hospital for trauma and fever follow-up. Vital signs were unremarkable including normal temperature. Contrast-enhanced computed tomography of the chest and abdomen revealed multiple liver lesions indicative of an abscess. Brain magnetic resonance imaging showed two small old infarcts. Electrocardiogram and transthoracic echocardiogram were unremarkable. Blood culture results from the initial ED visit subsequently identified Streptococcus constellatus. A dental and oral examination did not reveal a bacterial entry site, but colonoscopy identified an inflammatory lesion on the ileocecal valve, considered to be the source of bacteremia. The liver abscess was successfully treated with ampicillin/sulbactam, followed by oral amoxicillin/clavulanate for a total of 3 months.

IMPACT/DISCUSSION: Liver abscesses stand as the most prevalent form of visceral abscesses, commonly attributed to organisms like Escherichia coli, Klebsiella pneumoniae, Enterococcus faecalis, Streptococci, and anaerobes. As part of the Streptococcus anginosus group (SAG), S. constellatus constitutes normal flora in the oropharynx, gastrointestinal, and reproductive tracts. Members of SAG have been associated with infections at a wide variety of sites including skin/soft tissue, oropharynx, abdomen, and brain. While colonoscopy is recommended for S. gallolyticus bacteremia due to its strong association with colonic neoplasms, it is not routinely recommended for other streptococcus species. However, in this case, colonoscopy played a pivotal role in identifying the bacterial entry point. Similar reports have highlighted the utility of colonoscopy in cases of SAG bacteremia complicated by liver abscess. The patient's traffic injury, resulting from loss of consciousness (LOC) was attributed to sepsis. On the evaluation at the initial ED visit, the patient only had mild fever without any other symptoms suggestive of sepsis, but a further examination led to the underlying cause of the LOC. This case underscores the importance of investigating internal causes in patients with trauma, even in the absence of apparent sepsis symptoms.

CONCLUSION: S. constellatus is an important causative agent of liver abscess. Colonoscopy may need to be considered in cases of S. constellatus bacteremia when the entry point is unclear.

UNDERDIAGNOSED CULPRIT: AL AMYLOIDOSIS AS A FREQUENTLY MISSED CAUSE OF RECURRENT PLEURAL EFFUSION.

Kristina Pradhan¹; Yogesh Yadav¹; Jillian Senner¹; Lavanya Kodali². ¹Department of Medicine, Cayuga Medical Center, Ithaca, NY; ²Department of Pulmonary/Critical Care, Cayuga Medical Associates, Ithaca, NY. (Control ID #4064574)

CASE: A 73-year-old female presented with a one-year history of dyspnea and light-headedness. Initially diagnosed with lower extremity edema, she was prescribed diuretics. Upon presentation to the Emergency Department, she complained of flank pain radiating to the back. Imaging revealed a possible renal infarct and a large left-sided pleural effusion. Renal function was normal, and tests for microalbuminuria were negative. The pleural effusion, identified as exudative, showed negative cytology and birefringence for amyloid.

Further investigations revealed an out-of-proportion left ventricular hypertrophy compared to EKG voltage on echocardiogram. The patient displayed RV pseudo infarct. Concerns for amyloidosis prompted additional tests, including Serum Protein Electrophoresis (SPEP) and Free Light Chain (FLC) serum assays, which indicated Kappa FLC of 37.8 and Lambda FLC of 0.93 with an MG/DL ratio of 46. A fat-pad biopsy, performed approximately a year after symptom onset, confirmed AL amyloidosis, specifically [Kappa]-type amyloid. Subsequently, the patient initiated chemotherapy and underwent indwelling pleural catheter placement on the right side.

IMPACT/DISCUSSION: Recurrent pleural effusions present a diagnostic challenge, often leading to the oversight of AL amyloidosis due to its nonspecific clinical presentation. This case underscores the imperative for clinicians to maintain a vigilant approach when encountering cases of recurrent pleural effusion. The cardiac involvement, as indicated by echocardiographic findings, raised suspicion for amyloidosis, prompting further investigations.

The diagnostic process involved SPEP, FLC serum assays, and a fat-pad biopsy, eventually confirming AL amyloidosis. The case highlights the critical importance of considering rare and atypical etiologies, such as amyloidosis, in the differential diagnosis of recurrent pleural effusions. Timely diagnosis is crucial for initiating appropriate management strategies, as demonstrated in this case where chemotherapy and pleural catheter placement were employed.

CONCLUSION: This case emphasizes the need for heightened clinical awareness in cases of recurrent pleural effusion. AL amyloidosis, despite its nonspecific presentation, can frequently go unnoticed, leading to delayed diagnosis and management. Clinicians should consider rare and atypical etiologies to ensure prompt diagnosis and effective management of AL amyloidosis. This case serves as a reminder of the importance of a comprehensive diagnostic approach in addressing recurrent pleural effusions, ultimately contributing to improved patient outcomes.

UNDERSTANDING GASTRIC ANTRAL VASCULAR ECTASIA (GAVE): A CONTRIBUTOR TO SEVERE TRANSFUSION-DEPENDENT ANEMIA IN CIRRHOSIS AND HEPATOCELLULAR CARCINOMA

Sparsha Reddy Duvvuru¹; Shivangini Duggal¹; Lakshmi Prasanna Vaishnavi Kattamuri¹; Swati Mahapatra²; Brian P. Edwards¹. ¹Internal medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX; ²Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX. (Control ID #4064865)

CASE: A 60-year-old female with a past medical history of cirrhosis secondary to nonalcoholic fatty liver disease, hepatocellular cancer on chemotherapy, and type 2 diabetes presented to the hospital with complaints of melena, progressive fatigue, and weakness for the past 3 days. She had an endoscopy 1 month ago that revealed esophageal varices, underwent sclerotherapy, and is currently on propranolol. She followed up with hematology-oncology for hepatocellular carcinoma and received 6 cycles of chemotherapy. At admission, she was found to be hypotensive, with a hemoglobin of 6g/dl. She was subsequently transferred to an intensive care unit for pressor and transfusion support. She required packed red blood cell transfusions every other day to maintain Hb >7g/dl. After 5 days, upper gastrointestinal endoscopy (EGD) showed no endoscopic evidence of varices or active bleeding in the gastric fundus. However, it revealed GAVE with actively bleeding spots in the gastric antrum. The hemostatic spray was applied. The patient symptomatically responded to the treatment. The patient was then to undergo a repeat EGD with argon plasma coagulation or radiofrequency ablation in 2 weeks for retreatment as an outpatient.

IMPACT/DISCUSSION: GAVE syndrome, also known as watermelon stomach, is a rare but significant cause of severe acute or chronic gastrointestinal blood loss in the elderly. It is associated with cirrhosis and is seen in 30% of cases. Its association with hepatocellular carcinoma (HCC) is rarely reported. The initial presentation could be severe acute GI bleed, severe transfusion-dependent iron-deficiency anemia similar to our case, or nondescript abdominal pain and gastric outlet obstruction. While patients with cirrhosis and GAVE can be female as in our case, male patients make up 75% of the cases.GI bleeding due to GAVE is often overlooked in patients with cirrhosis and HCC and attributed to more common causes such as bleeding varices and portal gastropathy. When identified, treatment should be initiated early to avoid repeated blood transfusions. Endoscopic argon plasma coagulation is emerging as the preferred treatment.

CONCLUSION: GAVE is often overlooked as a cause of GI bleeding in patients with cirrhosis and HCC

Clinicians should acknowledge that GAVE can be associated with hepatocellular carcinoma and not just cirrhosis.

Timely recognition and intervention are pivotal in mitigating recurrent blood transfusions, with endoscopic argon plasma coagulation emerging as a promising therapeutic approach.

UNEXPECTED DIAGNOSIS OF SYPHILITIC AORTITIS IN A PATIENT WITH PERSISTENT SYMPTOMS DESPITE APPROPRIATE ANTIBIOTIC THERAPY

Quinn T. Seau¹; Evan J. Czulada¹; Danny Rayes²; Tyler Geshay³; Trevor Wyand²; Ethan J. Fraser²; Justin Beckett²; Ronald M. Beaulieu². ¹Internal Medicine, Georgetown University School of Medicine, Washington, DC; ²Internal Medicine, MedStar Georgetown University Hospital, Washington, DC; ³Department of Radiology, MedStar Georgetown University Hospital, Washington, DC. (Control ID #4063712)

CASE: An 89-year-old man with a history of chronic lower extremity lymphedema, deep vein thrombosis, and peripheral artery disease presented with one week of erythema and swelling of the right lower extremity. CT scan of the right lower extremity demonstrated soft tissue infection consistent with cellulitis, and he was started on vancomycin. Despite this empiric coverage, the patient developed sepsis; his antibiotic regimen was broadened to vancomycin and piperacillin-tazobactam while additional workup was completed to search for an alternative source of infection. Contrast-enhanced cross-sectional imaging was obtained and this identified circumferential soft tissue infiltration of the ascending aorta, aortic arch, and branching vessels, which was concerning for aortitis versus possible intramural hematoma. MR angiography confirmed a diagnosis of active aortitis. Rheumatology was consulted and had low suspicion for autoimmune disease. IgG and IgG4 were within normal limits, and antinuclear antibodies were negative. Chemiluminescence immunoassay was performed and was reactive; RPR was positive with a titer of 1:4. A lumbar puncture was performed. Cerebral spinal fluid returned negative for VDRL; however, FTA-ABS returned positive. It was elected to treat the patient for presumed neurosyphilis and therefore he received a course of intravenous penicillin G.

IMPACT/DISCUSSION: Large-vessel vasculitides are the leading causes of aortitis. With the advent of antibiotics and public health campaigns syphilitic aortitis (SA) has become an exceptionally rare diagnosis. Importantly, cardiovascular complications of SA include aortic aneurysm, valvular disease, and coronary involvement. These complications typically emerge 15-30 years post-primary infection, commonly presenting in the 4th and 5th decades of life. The literature on SA is sparse, comprising mainly case reports and series. We present a case of tertiary syphilis characterized by uncomplicated aortitis involving the ascending aorta, arch, and branching vessels. This case is distinctive due to the patient’s lack of localizing symptoms. Furthermore, the soft tissue infiltration around the ascending aorta posed a diagnostic challenge, as its resemblance to an intramural hematoma on CT complicated the diagnosis. This case emphasizes the importance of considering SA in the evaluation of large vessel vasculitis and contributes to a broader understanding of the radiologic features of uncomplicated SA.

CONCLUSION: Despite its rarity, syphilis should still be considered in the differential diagnosis of aortitis and can be asymptomatic.

The CT findings of luetic aortitis may resemble alternate pathology such as intramural hematoma. In these cases, MRA can help to clarify diagnosis.

UNEXPECTED NEED FOR INTERVENTION IN THE SETTING OF NORMAL LACTATE AND NON-TENDER ABDOMEN

Xiaomei Meng¹; Gina Ma². ¹Hospital Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4063219)

CASE: A 52-year-old male with hypertension, sleep apnea, and polycythemia presented to an outside hospital for abdominal bloating with pain for 2 weeks with leukocytosis, mild transaminitis, and total bilirubin of 2.8 mg/dl with normal lipase and lactate levels. Initial CT showed concern for enteritis, ileus, or partial obstruction. With his symptoms persisting, repeat CT found extensive portal venous thrombosis (PVT) extending to segmental branches and the superior mesenteric vein (SMV). Abdominal pain mostly resolved after broad antibiotics, heparin drip, and bowel decompression. Upon transfer to our hospital, surgery recommended conservative management, given his persistently normal lactate and benign exam. He remained stable with persistent bloating until 5 days later when he developed acute fever, with leukocyte count and total bilirubin rising to 37K/l and 7mg/dl, respectively, despite a benign abdominal exam and unremarkable lactate. Repeat CT angiogram remained unchanged. Due to clinical deterioration, he underwent a laparoscopic procedure converted to open after encountering dusky bowel with hemorrhagic exudate in the peritoneal cavity. Findings included 50cm of ischemic small bowel with hyperemic, thrombosed mesentery and a frankly necrotic 15cm segment which was resected. Pathology showed acute ischemic enteritis with transmural necrosis. After the surgery, bilirubin, transaminase, leukocyte count, and abdominal distention improved. He tolerated a regular diet at discharge and on outpatient follow-up, recovered with regular bowel movements and resolution of pain.

IMPACT/DISCUSSION: This report describes an unusual presentation of significant bowel necrosis, with persistently normal lactate levels, bloating, and benign physical examination. Given his benign presentation, surgical intervention was delayed for nearly 10 days in the setting of a life-threatening condition. Although lactate typically increases in ischemia, in late presentations after necrosis, levels may have already risen and fallen to normal levels when dry gangrene has developed. Additionally, his persistently normal lactate levels could stem from venous thrombosis, as arterial thrombosis usually has more rapid and higher lactate increases. Per literature review, portomesenteric system thrombosis is often initially misdiagnosed as more benign condition due to milder manifestations when compared to acute artery bowel ischemia. The bowel infarction and necrosis process in venous thrombosis is also slower, consistent with our surgeon’s report that his necrosis appeared subacute over the course of weeks. This gradual nature can slow elevations in lactate, which may remain normal for a prolonged period.

CONCLUSION: Normal lactate with persistently mild symptoms in a patient with portal or mesenteric venous thrombosis does not rule out bowel necrosis. Furthermore, in patients with prolonged ischemia, late-stage necrosis may present with normal lactate.

UNLIKELY BUT NOT FORGOTTEN: A CASE OF ACUTE HEPATITIS B INFECTION

Philip Chang¹; Kantiya Jindachomthong²; Divyaam Satija³. ¹General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²The Ohio State University Wexner Medical Center, Columbus, OH; ³The Ohio State University College of Medicine, Columbus, OH. (Control ID #4018743)

CASE: We present the case of a 39-year-old female with pertinent past medical history of intravenous drug use (opioid and methamphetamine) and hepatitis C (reported previous documented clearance) who was admitted with edema, joint pain, and jaundice. Recently, the patient had been discharged from a drug rehabilitation facility, with reported relapse prior to admission. On presentation, she endorsed insidious onset of joint pain and generalized edema which progressively worsened over time. Shortly thereafter, she developed jaundice. Initial presentation was concerning for significant elevation of her liver enzymes and inflammatory markers, coagulopathy, and somnolence. Due to concern for worsening liver injury without etiology, she was admitted to general medicine. During her stay, hepatology was consulted and was initially concerned for ischemic liver injury. A broad workup was undertaken after no improvement with initial care. Given her history, viral hepatitis panels were ordered. Hepatitis C antibody was positive, but PCR was negative. However, hepatitis B antigen testing was positive, and her hepatitis B PCR returned elevated. Initial treatment with tenofovir led to clinical improvement. Interestingly, due to her initial presentation, rheumatologic testing was undertaken and showed several positive autoimmune markers, in addition to significant elevation of ferritin and decreased complement level. Rheumatology was consulted and had concern for reactive arthritis, as well as a potential development of hemophagocytic lymphohistiocytosis. She unfortunately left against medical advice before further evaluations could be completed.

IMPACT/DISCUSSION: This case highlights the diagnostic uncertainty of acute hepatitis B infection. Significant inflammation in the acute phase can come with several rheumatologic sequelae and mimics, and can potentially be a harbinger to rarer immunologic illness. Collaboration with specialists is important to the diagnosis of this rarer disease in the United States. Hepatitis B remains a significant concern worldwide, and though the rates of disease are lower in this country, it has become a growing problem in some populations, including those with a history of injection drug use and newly immigrated patients. These patients can be four times more likely to contract hepatitis B than the general population. Coupled with a decrease in hepatitis B immunity in young adults, as well as new antiviral therapies for hepatitis B on the horizon, it is important for internists to recognize at-risk populations, screen, and vaccinate against hepatitis B.

CONCLUSION: -Hepatitis B can present comorbidly with other inflammatory diseases

-Prompt identification of acute hepatitis B is critical to successful antiviral treatment and improved outcomes

-Community immunity is decreasing, emphasizing the importance of screening high-risk individuals and vaccinating appropriately

UNLOCKING RELIEF: APPROACH TO ALLEVIATING MEDIAN ARCUATE LIGAMENT SYNDROME

Amanda Rigdon²; Daniela Carralero-Somoza²; Vivian Loveday-Laghi¹. ¹Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; ²Internal Medicine Residency, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4064869)

CASE: Median Arcuate Ligament Syndrome (MALS) is a rare condition with no diagnostic criteria established, resulting in alternative causes of abdominal pain to be excluded. We report a case of a 42-year-old female with a history of bariatric surgery presented with several hospital admissions for debilitating, intractable abdominal pain requiring narcotics and celiac plexus nerve block, giving transient relief. She represented screaming in agony with 10/10 sharp, diffuse pain now poorly controlled after gradual return, triggering hypertensive urgency and tachycardia. Despite extensive workup including esophagogastroduodenoscopy (EGD), pain clinic management, antidepressants, proton pump inhibitors and dietary changes, her episodic flares culminating in vomiting and inability to eat recurred. After finally attaining comfort with extensive opioid medications, her undulating postprandial flares unrelieved with outpatient regulation indicates potential vascular etiology. Though rare, median arcuate ligament syndrome entering differential for post-bariatric surgery abdominal pain refractory to gastrointestinal evaluation warrants consideration. Determining underlying compression could direct more tailored therapy for this debilitating pain.

IMPACT/DISCUSSION: It's hypothesized that rapid weight loss after bariatric surgery leads to loss of the fat pad around vessels. This reduces protection for the celiac artery, making it more susceptible to compression by the median arcuate ligament. Patients coming with excruciating abdominal pain that seems somehow unexplained by imaging with recent abdominal surgery should bring suspicion for MALS. Delays in diagnosis lead to undercare of patients. Accurate identification will lead to tailored treatment strategies. Making surgical interventions more successful than conservative measures. In a similar case report, Cunha et al., 2022, suggests this may bridge patients to surgical interventions which consist of celiac artery decompression, with possible resection or ablation of the celiac ganglion to relieve neuropathic pain. This case offers insights into the nuanced challenges MALS presents and arising concern and light to this usually missed diagnosis.

CONCLUSION: Though rare, MALS warrants inclusion in differential diagnoses of chronic or postprandial abdominal pain after common etiologies are excluded. Increased awareness of MALS can prompt vascular imaging, enabling earlier detection and relief for this often overlooked cause of abdominal pain. Celiac plexus ablation can provide substantial temporary pain relief in median arcuate ligament syndrome by using injected anesthetic agents to block signals from the celiac ganglion. Though not curative and with pain often recurring in months, it establishes diagnosis. More research on durability is needed to determine the utility of plexus ablation alongside decompression surgery in a multimodal approach targeting the abdominal pain of median arcuate ligament syndrome.

UNLOCKING THE FLOODGATES: PEMBROLIZUMAB-INDUCED PERICARDITIS, TAMPONADE, AND ARRHYTHMIAS

Misa Ito¹; Melissa J. Miller²; Talal Alnabelsi²; Amit Arbune²; Hirotaka Kato³. ¹Internal Medicine and Pediatrics, University of Kentucky, Lexington, KY; ²Cardiovascular Medicine, University of Kentucky, Lexington, KY; ³Hospital Medicine, University of Kentucky, Lexington, KY. (Control ID #4063347)

CASE: A 58-year-old male with metastatic non-small cell lung cancer (NSCLC) on Pemetrexed and Pembrolizumab for two years presented with a one-day history of acute substernal sharp chest pain. Initial vital signs and serum troponins were unremarkable while inflammatory markers were elevated: WBC 14,110 /uL, ESR >111 mm/h, and CRP 167 mg/L. CT demonstrated progression of lung cancer which was initially believed to be the culprit. However, serial EKGs in the first 24 hours showed dynamic ST segment changes including diffuse ST elevation as well as atrial fibrillation. Echocardiography noted small pericardial effusion, suggesting a diagnosis of acute pericarditis. Given his reduced renal function, colchicine 0.6 mg daily and prednisone 50 mg daily were initiated and subsequently tapered as outpatient. In a month after discharge, the patient developed dyspnea on exertion and anasarca. Echocardiography showed large pericardial effusion with cardiac tamponade. The patient underwent emergent pericardiocentesis with drainage of 1.1L of bloody fluid. The patient responded to diuresis and increased prednisone back to 40 mg daily with subsequent slow taper, and colchicine was continued.

IMPACT/DISCUSSION: Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy by enhancing immune responses against tumor cells. Pembrolizumab disrupts the interaction between T-lymphocytes and PD-L1 on tumor cells, facilitating immune activation against tumors. While widely employed in metastatic NSCLC, ICI use has been linked to a risk of immune-related adverse events (irAE) among cancer patients. Cardiovascular irAE (CV-irAE) are rare but carry a high mortality in certain instances. T-lymphocyte-mediated inflammation is implicated in the pathogenesis of CV-irAE such as myocarditis, pericarditis, cardiomyopathies, and arrhythmias. In addition to standard treatment for pericarditis, high-dose corticosteroids should be considered for high-grade cardiotoxicities which require hospital admissions. Gradual tapering over 4 to 6 weeks is recommended if initiated. Our case highlights the emerging challenges in diagnosis and management of CV-irAE due to unique factors: a late onset after 2 years on ICI, dynamic EKG changes obscuring classic pericarditis findings, and occurrence of cardiac tamponade despite the initial treatment with prednisone.

CONCLUSION: Our case underscores the emergence of various CV-irAE associated with ICI use such as pericarditis and arrhythmias. These patients likely present to primary care clinics or emergency rooms with chest pain or arrhythmias, therefore, general internists must be fully aware of these adverse events and management strategies. This report contributes to the growing body of evidence about variations in CV-irAE from ICIs, emphasizing the importance of close monitoring and prompt intervention to optimize patient outcomes.

UNMASKING RAPIDLY PROGRESSIVE COGNITIVE DECLINE IN THE CONTEXT OF EXTENSIVE SUBSTANCE USE HISTORY AND LONG-TERM METHADONE THERAPY

Nicole Hao¹; Shobi Mathew¹; Karthik Sridasyam¹; Mohamed Elbathani²; Tamara Mabrouk²; Anza B. Memon³; Kareem Bazzy³; Naveed Shaikh³. ¹Student, Wayne State University School of Medicine, Detroit, MI; ²Detroit Medical Center, Detroit, MI; ³John D Dingell VA Medical Center, Detroit, MI. (Control ID #4060029)

CASE: The patient is a 60-year-old black male with a medical history including hypertension, diabetes, polysubstance use (cocaine and heroin), and extensive methadone use, who presented with 4-month history of subacute, rapidly progressive dementia to our VA medical center. Before that, he presented to outside hospitals, and a diagnosis of possible frontotemporal dementia was suspected. He had a brain MRI at an outside hospital, which was normal. Spinal fluid analysis was sent, which showed elevated CSF protein at 188 with normal cell count, glucose, gram stain, and culture. On physical exam, the patient was alert and oriented to place only. The patient followed simple commands but had difficulty following complex commands. He was confused, selectively mute, and uncooperative. The patient had an exaggerated startle response. A repeat brain MRI at our hospital showed severe generalized brain atrophy when compared to the last brain MRI that was completed 3 months ago. The patient had a repeat spinal tap, which continued to show elevated CSF protein. CSF viral PCRs, VDRL, gram stain, and cultures were negative for infections. Other metabolic, infectious, and paraneoplastic work was also negative. CT chest, abdomen, and pelvis were negative for malignancy. The patient had negative RT-QuIC for CJD with mildly elevated CSF 14-3-3 protein. The autoimmune encephalopathy panel was positive for high anti-GAD antibody. The patient received 2 g/kg IVIG followed by IVMP 1 g x 5 days, resulting in improvement of his startle response and verbal output.

IMPACT/DISCUSSION: This case highlights the diagnostic and treatment complexities of autoimmune encephalitis (AE), especially in the presence of multiple comorbidities and a remote history of substance use. Misdiagnosis is common in AE, as symptoms often overlap with other neurological conditions. However, this misdiagnosis was particularly harmful given that AE was successfully treated with immunotherapy. The patient's documented polysubstance use history potentially introduced bias, limiting a comprehensive differential. The 20-year history of methadone raised concerns for overdose or withdrawal at the outside hospitals, leading to a delay in AE evaluation. Treatment with immunotherapies like IVIG and methylprednisolone showed varying efficacy, consistent with existing literature on AE management.

CONCLUSION: This case emphasizes the importance of considering AE in differential diagnoses of rapidly progressive neuropsychiatric disorders. The case illustrates the need for healthcare professionals to avoid biases, especially regarding substance use history, to ensure timely and accurate diagnosis and treatment, especially in cases where overlooking alternative explanations can have profound consequences for patient outcomes.

UNMASKING THE HIDDEN RISK: OVER-THE-COUNTER MEDICATION LINKED TO IATROGENIC CUSHING’S SYNDROME

Ebunoluwa Oshinuga-Atere¹; Aman Rajpal²; Xaviera Ortiz-Soto¹. ¹Internal Medicine, Alameda Health System, Oakland, CA; ²Medicine/Endocrinology, Alameda Health System, Oakland, CA. (Control ID #4025596)

CASE: More than 10 million people in the United States (US) are exposed to glucocorticoids each year. Iatrogenic Cushing's symptoms arise from chronic exposure to glucocorticoids. Most over-the-counter (OTC) glucocorticoids available in the US are either topical or inhaled forms at lower doses. Many immigrant patients using either prescribed or OTC medications not common in the US, can unknowingly be exposed to medications with serious adverse effects. Medication reconciliations, especially for our immigrant patients, are imperative to ensure patients are not unknowingly exposed to potentially dangerous medications. We present a case of a Hispanic female, who was diagnosed with iatrogenic Cushing's syndrome (ICS) after being exposed to an OTC medication from her home country, called as Ardoson, which contains Betamethasone.

A 50-year-old immigrant woman from Mexico with HTN and osteoarthritis presents with chronic progressive bilateral knee pain, fatigue, weight gain (reported 50-60 pounds over 1 year), facial hair growth, red stretch marks on her abdomen, and absence of menses for 7 months (though previously with regular monthly cycles). The patient stated that due to her chronic bilateral knee pain, she started taking an oral over-the-counter (OTC) medication, from Mexico, four times a day called Ardoson. On review, it was found that Ardoson contains 25mg of indomethacin, 0.75mg of betamethasone, and 215mg of methocarbamol per capsule. Additionally, she had been getting glucocorticoid injections in her bilateral knees for worsening osteoarthritis. Physical exam was notable for cushingoid features (dorsocervical fat pad, round facies, and purple striae on the abdomen), in addition to secondary amenorrhea. Given her history, and physical exam findings, she was diagnosed with ICS, and instructed to stop taking the medication. She was told to follow up on obtaining endogenous labs given concern patient would develop secondary adrenal insufficiency, and was then started on physiologic hydrocortisone supplementation. 3 months after cessation of Ardoson, the patient reported an improvement in her symptoms (including weight loss of 20 pounds, and better blood pressure control).

IMPACT/DISCUSSION: High dose glucocorticoids can lead to ICS, along with secondary adrenal insufficiency (due to hypothalamic- pituitary- adrenal axis suppression). Endogenous hormone studies (ie DHEA, ACTH, cortisol) should be obtained frequently to ensure the HPA axis is recovering appropriately. The duration of treatment with endogenous hormones (ie hydrocortisone) is based on the type of glucocorticoid that the patient was taking and for how long they had been taking the medication.

CONCLUSION: 1. It is imperative for clinicians to routinely screen medication lists to catch potential harmful medications.

2. Patients benefit from clinicians providing education on all supplements, to ensure they are taking them appropriately, and that the supplement is warranted at any given time.

UNPROVOKED OR ANATOMICALLY-PROVOKED? AN UNCOMMON CAUSE OF DEEP VENOUS THROMBOSIS

Steven Gadd¹; Isaac Stevens¹; Michelle Solik¹; Megan Easley². ¹Internal Medicine, Ascension St Vincent, Indianapolis, IN; ²College of Osteopathic Medicine, Marian University College of Osteopathic Medicine, Indianapolis, IN. (Control ID #4063880)

CASE: A 62-year-old gentleman presented to the hospital with three days of worsening left lower extremity pain, swelling, and erythema. Doppler ultrasonography of the left lower extremity showed extensive deep venous thrombosis (DVT) extending into the left iliac vein. He was started on a heparin drip and Interventional Radiology was consulted for consideration of thrombolytic intervention. Venous computed tomography (CTV) of the abdomen and pelvis was ordered to further evaluate clot burden, which showed extensive thrombus extending from the left greater saphenous vein into the distal left common iliac vein. Significant compression of the left iliac vein between the spine and right common iliac artery was also seen, confirming the diagnosis of May-Thurner Syndrome. Lytic therapy was performed by Interventional Radiology and a left common iliac vein stent was placed. Following completion of successful catheter-directed thrombolysis therapy he was transitioned to Eliquis and was discharged home the following day in good condition.

IMPACT/DISCUSSION: May-Thurner Syndrome accounts for less than five percent of all cases of DVT and is most commonly found in females between the ages of 25-50. The proposed mechanism is that chronic pulsating pressure from the overlying iliac artery compressing the iliac vein against the spine leads to a venous intraluminal fibrous band (commonly referred to as a “spur”) and subsequent anterior-posterior narrowing of the vein. The significant narrowing of the left common iliac vein over time leads to venous stasis which significantly increases the risk of thrombus formation.

Ultrasonography is the preferred method for identifying DVT, however significant limitations exist in visualizing the Inferior Vena Cava and Iliac Vein. In patients with thrombosis extending superiorly into the iliac vein, further venous imaging with CTV should be performed to determine both clot burden as well as identify any anatomical abnormalities such as iliac vein compression as seen in May-Thurner Syndrome.

CONCLUSION: Patients diagnosed with deep venous thrombosis should be evaluated to determine if thrombosis development was provoked or unprovoked. May-Thurner Syndrome is an uncommon and anatomically-provoked cause of DVT and requires both intravascular stent placement and chronic anticoagulation therapy.

UNPROVOKED VENOUS THROMBOEMBOLISM; COULD IT BE WORSE?

Alina Sehar¹; Ali Hachem³; Jesse Faulk¹; Hassoun Ali²; Aesha Patel¹. ¹Internal Medicine, The University of Alabama at Birmingham, Huntsville, AL; ²Allabama Infectious Disease Centre, Huntsville, AL; ³Southern Cancer Center, Huntsville, AL. (Control ID #4045811)

CASE: A 36-year-old male with no medical history presented with fatigue, chills, fever, bilateral calf pain, and redness for 1 week. Vital signs were normal. Physical examination revealed mild tenderness in the epigastrium along with bilateral leg swelling and erythema. Laboratory studies revealed a WBC count of 119.55 x10^3/mcL with a blast count of 50.1%, elevated ANC count of 31, lymphocyte count of 13, and mild monocytosis of 1.8. Mild metamyelocytes and atypical lymphocytes were seen. Hemoglobin was normal and the platelet count was 130 x10^3/mcL. PT, PTT, and fibrinogen were essentially unremarkable. The patient had a normal CBC six months prior. Ultrasound showed deep venous thrombosis in the right and left popliteal vein, and CTA chest showed CT of the abdomen and pelvis revealed an occlusive thrombus within the SMV and a nonocclusive thrombus in the main portal vein without intestinal ischemia. The patient was started on Lovenox. Flow cytometry showed 56% blast cells expressing lymphoid markers CD19 and minimal coexpression of CD10, findings most consistent with B-acute lymphoblastic leukemia/lymphoma.

IMPACT/DISCUSSION: Acute lymphoblastic leukemia (ALL) is relatively uncommon in adults; it comprises less than 20% of cases in adults. Although patients with ALL may present with severe thrombocytopenia, thromboembolic events can still be seen. Unprovoked thrombotic events in an otherwise healthy individual could be an initial presentation of undiagnosed malignancy.

The pathophysiology of the prothrombotic state in ALL is multifactorial. Our patient's case involves occlusion of the mesenteric vein along with diffuse venous thromboembolism. SMV thromboembolism typically occurs due to inflammation like pancreatitis, congested flow like cirrhosis, or compression by abdominal malignancies. Since the patient had no such pertinent findings, the clinical scenario supported new-onset ALL as the cause of hypercoagulability. VTE is considered rare to occur at the initial stages of the disease with an incidence of vascular thrombosis as low as 1.4%, but its incidence is increased to up to 10.6% while receiving chemotherapy. Induction chemotherapy enhances the risk of coagulopathy by activating endothelium and platelet. Additionally, L-asparaginase, an essential chemotherapeutic drug in ALL, is known to cause thrombotic events by decreasing levels of protein C, S and antithrombin. Yet, profound pancytopenia and thrombocytopenia are common side effects of ALL treatments. This presents a challenging situation when deciding on the safety of anticoagulation therapy and the choice of induction chemotherapy regimen.

CONCLUSION: Acute VTE, including SMV thrombosis as an initial presentation in ALL is quite uncommon, but a potentially life-threatening event. It requires a high level of suspicion in an otherwise healthy individual with unusual symptoms. Balancing the risk of bleeding versus worsening thrombosis when initiating anticoagulants and induction chemotherapy is crucial for a good outcome.

UNRAVELING AMYLOID SPELLS: EXPLORING SYNCOPE IN THE REALM OF CEREBRAL AMYLOID ANGIOPATHY-RELATED INFLAMMATION FOR INTERNISTS

Yogesh Yadav¹; Kristina Pradhan¹; Jillian Senner¹; James Gaffney². ¹Department of Medicine, Cayuga Medical Center, Ithaca, NY; ²Department of Neurology, Cayuga Medical Associates, Ithaca, NY. (Control ID #4064534)

CASE: A 73-year-old female with a past medical history of hypertension, third-degree AV block s/p pacemaker placement, and progressive dementia suggestive of probable Alzheimer's disease (AD) presented to the emergency room multiple times with altered mental status. The initial visit revealed syncope related to third-degree AV block, leading to the placement of a dual-chamber permanent pacemaker. Subsequent visits included falls without tongue bite but with facial trauma, leading to the interrogation of the implanted cardiac device and an MRI that identified Cerebral Amyloid Angiopathy (CAA)-related vasogenic edema. EEG findings indicated occasional right centroparietal sharp waves, suggesting increased epileptic potential. A subsequent visit with syncope and increased left-sided weakness led to the initiation of Valproic acid for potential seizures. The patient met diagnostic criteria for probable Cerebral Amyloid Angiopathy-related inflammation (CAA-ri), received IV solumedrol for three days, and was discharged on oral tapering steroids with improved physical strength. A referral to a dementia clinic for further workup and diagnosis was made.

IMPACT/DISCUSSION: CAA-ri is an uncommon autoimmune disorder with associations to CAA and Alzheimer's disease, often diagnosed late or under recognized. The clinical presentation includes altered awareness episodes known as amyloid spells, potentially leading to misdiagnosis as seizures or cardiovascular events. The pathophysiology, possibly involving cortical spreading depression, remains unsettled. This case underscores the importance of considering CAA-ri in progressively dementing patients with altered awareness and highlights the potential treatability of this autoimmune disorder through immunosuppressive therapy. The recognition of amyloid spells in the differential diagnosis emphasizes the need for non-neurological specialists to be aware of CAA and its potential treatment options.

CONCLUSION: This case emphasizes the significance of recognizing CAA-ri in the differential diagnosis of altered awareness in progressively dementing patients. The clinical presentation, including amyloid spells, should prompt consideration of CAA, and the potential treatability with immunosuppressive therapy underscores the importance of early recognition. Non-neurological specialists should be vigilant in considering CAA-ri when faced with episodes of unresponsiveness in their patients and collaborate closely with neurology for appropriate diagnosis and management.

UNUSUAL INVASION OF ENTEROCOCCUS FAECALIS INTO PERICARDIAL SPACE IN AN IMMUNOCOMPROMISED PATIENT

Julia Y. Lu. Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA. (Control ID #4032490)

CASE: A 51-year-old male with past medical history of stage IV nasopharyngeal carcinoma status post tracheostomy and PEG placement, who presented with shortness of breath and increased airway secretions. On arrival, the patient was afebrile, blood pressure 83/67, heart rate 90, oxygen saturation of 80% on 10L trach mask, and RR 26. VBG was notable for a pH of 7.26, pCO2 of 66. He had a leukocytosis of 14.2 K/mm3 with 90% neutrophil, and lactate 2.2mmol/L. Chest x-ray showed bilateral pleural effusions status post thoracentesis. He was initially placed on ceftriaxone but was broadened to meropenem after pleural fluid grew gram negative rods. A bedside cardiac ultrasound demonstrated tamponade. Cardiology performed immediate pericardiocentesis with removal of 660mL and his blood pressure and oxygen improved. He was again noted to have tamponade 2 weeks later, and removed another 650mL. Initial culture of the pericardial fluid grew pan-sensitive Enterococcus faecalis, which the patient had been treated with ampicillin-sulbactam. However, the patient continued to deteriorate with multiorgan failure in setting of his active stage IV cancer until he passed away.

IMPACT/DISCUSSION: Purulent pericarditis is defined as an infection in the pericardial space that produces macro and microscopically purulent fluid. Patients often present with high fever, tachycardia, and chest pain. However, this patient’s only presentation was tachycardia and worsened hypoxia. His lack of inflammatory response could be partly due to his severely immunocompromised state, which made diagnosis of cardiac tamponade in him difficult. Because purulent pericarditis can present with vague symptoms, it has a high mortality rate due to delay in diagnosis. Often, it gets identified at autopsy or after tamponade developed.

The most common entry into pericardial space is through extension from a primary lung source. Often, management of purulent pericarditis includes prolonged, aggressive antibiotic along with surgical drainage of the pericardial fluid.

Enterococcus faecalis is a gram-positive, gamma-hemolytic anaerobic cocci that grows in chains. Commonly, this organism occupies the GI or GU tract, and is categorized as an opportunistic pathogen, and is known to cause endocarditis. However, this microbe had very rarely been known to cause tamponade. Although he did have pleural effusion positive for gram negative rods, this still would not explain the growth of Enterococcus faecalis in his pericardial space. Nevertheless, the patient presented with what is very likely malignant pericardial and pleural effusion, and that this microbe may have translocated from the GI tract and seeded in this space. The source of his Enterococcus faecalis remains obscure.

CONCLUSION: Enterococcus faecalis is known to cause endocarditis, but less so pericarditis. Prompt identification of cardiac tamponade in unexplained clinical deterioration should always be considered in patients who are immunocompromised to allow for timely interventions.

UNVEILING A RARE CASE OF ACUTE EOSINOPHILIC PNEUMONITIS

Noor Qaddour¹; Suyashi Singh¹; Yoonho Park¹; Frances Boly². ¹Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL; ²Infectious Diseases, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #4065104)

CASE: We present the case of a 54-year-old male with a history of methicillin-resistant Staphylococcus aureus-bacteremia secondary to epidural and bilateral psoas abscesses, status post laminectomy and drainage. The patient, discharged on long-term intravenous (IV) daptomycin, presented with a three-day history of cough, shortness of breath, and fevers. Initial evaluation revealed tachycardia, hypoxemia, and radiological findings indicative of multifocal pneumonia and pleural effusions. A computed tomography (CT) angiogram of the chest ruled out pulmonary emboli but identified new pulmonary nodular densities with ground glass opacities and bilateral pleural effusions that were not present previously. Daptomycin was promptly discontinued after a total exposure of 1-month due to suspicion of eosinophilic pneumonitis, and the patient was initiated on IV Vancomycin. Bronchoalveolar lavage two days later revealed eosinophilic pneumonitis with 31% eosinophils. Patient was started on Prednisone 40 mg daily and continued the IV Vancomycin. He demonstrated significant clinical improvement after discontinuation of daptomycin. He reported resolution of his shortness of breath and was weaned off supplemental oxygen to room air. He was eventually discharged with a peripherally inserted central catheter (PICC) line, planned for a total of 6 weeks of the IV Vancomycin and a Prednisone steroid taper.

IMPACT/DISCUSSION: Daptomycin-induced acute eosinophilic pneumonia (AEP) is a severe adverse effect associated with daptomycin use, potentially leading to respiratory failure and increased morbidity/mortality if not promptly recognized. This phenomenon, characterized by bronchial alveolar lavage eosinophilia, typically exhibits rapid clinical improvement upon steroid administration and cessation of the offending antibiotic. While the underlying mechanism remains poorly understood, one proposed theory involves daptomycin binding to pulmonary surfactant, resulting in elevated drug concentrations and subsequent epithelial injury. Antigen detection by alveolar macrophages is hypothesized to trigger T-helper 2 lymphocyte recruitment, interleukin-5 release, and subsequent eosinophilic infiltration into the lungs.

CONCLUSION: This case underscores the necessity of considering daptomycin-induced AEP in patients receiving the drug. Although there is no clear dose-related or consistent temporal relationship between Daptomycin and the development of AEP, timely recognition and intervention are crucial in preventing potentially fatal outcomes–including severe respiratory failure and acute respiratory distress syndrome. In conclusion, our case adds to the limited body of literature on daptomycin-induced AEP, providing valuable insights into its clinical features and management. While rare, the potential severity of this adverse event underscores the need for a proactive approach to diagnosis and management. Furthermore, the variability in its presentation emphasizes the importance of individualized patient care.

UNVEILING THE ENIGMA A VANCOMYCIN INDUCED DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS

Rayan Elhag¹; Hassan Alkhatatneh¹; Joseph Fleischer¹; Natasha Rastogi². ¹Internal Medicine, Englewood Hospital and Medical Center, Englewood, NJ; ²Internal Medicine, Englewood Health, Englewood, NJ. (Control ID #4060756)

CASE: A 54-year-old woman with a history of knee replacement surgery complicated by joint infection requiring prosthesis removal, vancomycin and cefepime one month prior. She presented with an acute generalized rash one week after initiation of antibiotics. Despite stopping Cefepime and taking antihistamines, the rash progressed to cover her entire body and was accompanied by fever, vomiting and diarrhea. On exam, she was febrile, tachycardic, and had a generalized morbilliform rash, prominently on her neck and chest. Labs revealed a normal leukocyte count at 8.4 K/uL with eosinophilia of 13%, normal ESR, elevated ferritin of 358.3 and transaminitis with ALT 164 and AST 109. Vancomycin was stopped, and she was started on Daptomycin along with Methylprednisolone. Her condition improved within 2 days, and was discharged home on Prednisone 20mg, Famotidine, and Cetirizine. Patient was readmitted the following day with persistent fever and a generalized erythematous rash covering most of her chest, back and upper and lower extremities, accompanied by a burning sensation with new facial and periorbital swelling. Repeat labs revealed a new leukocytosis of 25 K/ul. She was restarted on Methylprednisolone. A skin biopsy showed superficial and deep perivascular and interstitial dermatitis with eosinophils, and large lymphocytes compatible with DRESS syndrome. Her symptoms improved with the resolution of the rash, and she was discharged on Prednisone 70mg daily.

IMPACT/DISCUSSION: Drug reaction with eosinophilia and systemic symptoms (DRESS) is an idiosyncratic drug reaction characterized by widespread rash, visceral organ involvement, eosinophilia and atypical lymphocytosis. It is a rare syndrome with an occurrence of 0.9 to 2 per 100,000 patients per year and a mortality rate of ~10%.

Most causes of DRESS syndrome include anticonvulsants and Allopurinol. Here we describe a case that has been caused by an uncommon trigger, Vancomycin. Our patient met the diagnostic criteria for DRESS syndrome by the RegiSCAR score and was started on systemic corticosteroids, the gold standard treatment for symptoms during the acute phase. The rapid onset of symptoms within 1 week of the triggering event was also unusual given the typical latency phase of 2-8 weeks for DRESS syndrome. While in the past clinicians may not consider the diagnosis of DRESS syndrome if the onset of symptoms was less than 15 days after drug exposure, recent studies reveal the timing of onset is dependent on the medication involved. After the initial improvement in symptoms, our patient relapsed with worsening rash and new leukocytosis. This was attributed to rapid tapering of corticosteroids, indicating that gradual tapering over 6 to 8 weeks is essential for complete resolution.

CONCLUSION: Vancomycin must be recognized as a cause of rapid-onset DRESS syndrome. Early diagnosis is essential as timely discontinuation of antibiotics and the initiation of corticosteroids improves the prognosis and decreases mortality rates.

USE OF TICAGRELOR FOR DAPT RESULTING IN CATASTROPHIC BLEED DUE TO ACQUIRED HEMOPHILIA A

Jayne Nguyen, Sophie Sohval, Christopher Walsh. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4063678)

CASE: A 68 year-old man receiving aspirin and ticagrelor (DAPT) after coronary stenting 3 weeks prior presented to the hospital for right groin pain from a large retroperitoneal hematoma.

Labs demonstrated anemia (Hgb 5.4) with prolonged APTT, normal prothrombin time, and normal platelet count. Mixing studies showed no normalization of the prolonged APTT after incubation, severe factor VIII deficiency (FVIII, <1%), and elevated FVIII inhibitor levels, confirming the diagnosis of acquired hemophilia A (AHA). Ticagrelor was held and switched to clopidogrel given recent stent. He began treatment with NovoSeven (recombinant factor VIIa); however, the retroperitoneal hematoma worsened, and the patient developed hemorrhagic shock requiring vasopressors. All antiplatelet therapy was then held. Embolization of the hemorrhage was deferred given high risk of fatal intraoperative bleed. Labs continued to show prolonged APTT despite AHA therapy. Treatment was switched to FEIBA (FVIII Inhibitor Bypass Activity) without clinical improvement. He was planned to start Obizur (recombinant porcine FVIII) and ultimately begin Rituximab when stable; however, the patient expired from severe hemorrhagic shock before Obizur could be given.

IMPACT/DISCUSSION: AHA is a rare bleeding disorder in which one develops antibodies to clotting factor VIII (FVIII). Bleeding is usually mucocutaneous or soft tissue, and is often severe. Treatment involves controlling the bleed through factor replacement, eradicating the inhibitor via immunosuppressants, and treating the underlying cause. FVIII concentrates often do not correct the coagulopathy given the presence of FVIII inhibitor. Management therefore requires recombinant coagulation factors (e.g. NovoSeven) that bypass the inhibitor.

AHA can be triggered by other autoimmune diseases, malignancy, or pregnancy, though cases can be spontaneous as well. There have been reports of AHA caused by medications, including antiplatelet therapies such as ticagrelor. The Naranjo scale estimates the probability of adverse drug reactions. In this case, the score for ticagrelor indicates “probable” causality in the development of AHA based on the adverse event occurring after medication initiation, prior reports of similar events, and lack of more probable causes.

Our patient was not only at risk of life-threatening bleed from AHA, but also at risk for stent thrombosis from early cessation of DAPT. The presence of hemorrhagic shock was therefore weighed against risk of ischemia and infarct. Given the rapid progression of shock, DAPT was ultimately discontinued in an effort to best control the bleed.

CONCLUSION: AHA is a rare but potentially life-threatening coagulopathy that can be drug-induced, in this case requiring the early cessation of ticagrelor (DAPT) after recent coronary stenting despite the risk of stent thrombosis. The treatment of AHA often necessitates immunosuppression and specific bypassing agents, therefore requiring a prompt diagnosis and awareness of possible triggers.

UTILIZATION OF PLASMA EXCHANGE AS BRIDGE TO TOTAL THYROIDECTOMY IN PATIENT WITH REFRACTORY TYPE 2 AMIODARONE-INDUCED THYROTOXICOSIS

Vannessa Adams¹; Tom Marco¹; Numaan S. Mahmood¹; Aaron Bertolo²; Andrew Barr¹; Chelsea Takamatsu¹; Kendal Flegenheimer¹; Paulina Kuzmin³. ¹Internal Medicine, Banner - University Medical Center Tucson, Tucson, AZ; ²Internal Medicine, Banner University Medical Center Tucson, Tucson, AZ; ³Banner - University Medical Center Tucson, Tucson, AZ. (Control ID #4063973)

CASE: We present the case of a 67-year-old male with medical history significant for venous thromboembolism and atrial fibrillation presented to the emergency department (ED) with a 3-week history of worsening confusion. The patient denied recent fall, fever, headache, chest pain, shortness of breath, abdominal pain, nausea, vomiting, pain with urination, and blood in urine or stool. It was discovered that the patient was instructed to stop taking amiodarone two months prior to his admission for concern of drug-induced hyperthyroidism, however his pharmacy records indicated that he had recently refilled it. Patient was tachycardic (HR 100 bpm) and tremulous on physical exam, but otherwise hemodynamically stable. CMP was notable for creatinine 2.31, lactic acid 2.5, TSH less than 0.01, and T4 greater than 7.77. EKG was consistent with prior strips and demonstrated atrial fibrillation with T wave inversions in lead III. Chest X-Ray was unremarkable. Ultrasound of the neck demonstrated thyromegaly with heterogeneous hyperemic gland consistent with thyroiditis. He was diagnosed with amiodarone-induced thyrotoxicosis (AIT). Patient was treated with methimazole, hydrocortisone, beta blockade, and cholestyramine. Despite 9-days of maximal medical treatment, the patient's free T4 did not decrease. The endocrinology service suggested plasma exchange (PLEX) therapy in order to decrease T4 as a bridge to thyroidectomy. The patient received 4-sessions of plasmapheresis which decreased T4 levels to 3.62 within 48 hours. He was able to successfully undergo total thyroidectomy and was discharged home 4 days later.

IMPACT/DISCUSSION: Amiodarone causes a direct toxic effect to the thyroid gland due to its high iodine content. In the USA, 3-5% of all patients treated with amiodarone will become hyperthyroid, typically months to years after starting therapy. Furthermore, the half-life of amiodarone is ~100 days, so immediate discontinuation of the drug will do little to stop the adverse effect in the short term. This case demonstrates how challenging it can be to treat thyrotoxicosis. Despite optimized medical treatment and removal of the offending agent, our patient did not have improvement of his laboratory results or symptoms. This case re-iterates the utility of plasma exchange as a tool to acutely manage severe thyrotoxicosis as a bridge to thyroidectomy

CONCLUSION: Patients on amiodarone therapy are at high-risk of experiencing thyroid dysfunction. AIT may take years of therapy to manifest. In cases of severe thyrotoxicosis or thyroid storm, thyroidectomy may be necessary. Plasma exchange should be considered for patients with severe hyperthyroidism refractory to medical management in order to bridge them to surgical intervention.

VARICELLA MENINGOENCEPHALITIS IN PATIENTS WITH END-STAGE RENAL DISEASE ON HEMODIALYSIS FOLLOWING SHINGLES IN THE CHEST

Eunbee Cho¹; Fatimah O. Bello¹; Seokwon Choi²; Shreel Patel¹; Jessica Daza¹. ¹internal medicine, The University of Texas Rio Grande Valley School of Medicine, Edinburg, TX; ²School of Medicine, Kyung Hee University, Seoul, Korea (the Republic of). (Control ID #4032801)

CASE: A 63-year-old male with End-Stage Renal Disease(ESRD) on hemodialysis(HD) presented to the emergency department with altered mental status for 2 days. He had a recent flare of Shingles in the right chest region and was started on oral acyclovir before admission. On initial evaluation, the patient had a Glasgow Coma Scale(GCS) score of 8 with nuchal rigidity and was afebrile. Multiple vesicular rashes were observed involving the right upper chest and arm on dermatome C4-5. CT head on admission showed chronic findings of prior stroke without acute abnormalities. An electroencephalogram showed no report of seizure. MRI of the brain showed hyperintensities in the temporal lobes on T2/FLARE view. On day 3, the patient was intubated for aggravation of mental status with a GCS score of 3. Given the clinical suspicion of CNS involvement of Varicella-Zoster virus(VZV), a lumbar puncture was performed with fluid analysis revealing WBC 15/mm3 with 88% lymphocytes, protein elevated at 77.8 mg/dL, and a positive polymerase chain reaction (PCR) test for VZV, confirming the diagnosis of varicella meningoencephalitis(ME). IV acyclovir therapy that was started on admission was continued at a dose adjusted for renal function. Although the patient had an improvement in skin lesions over time, his mental status remained at a GCS score of 3 for 2 weeks until the patient’s family decided on hospice care, shortly after which the patient expired.

IMPACT/DISCUSSION: Varicella ME is a rare but potentially life-threatening complication of VZV infection, particularly in immunocompromised individuals. Although ESRD is known to cause immune dysfunctions of T-lymphocyte and antigen-presenting cells by diverse routes including uremia, the possibility of VZV dissemination in ESRD patients tends to be easily overlooked due to the rarity of cases that are reported. Also, the presence of multiple comorbidities that can contribute to acute encephalopathy made it harder to consider VZV ME in this case. Only when the initial HIV screening test came out falsely positive, the possibility of VZV dissemination was discussed. However, the confirmatory HIV test came out negative. Through this case, we suggest that ESRD patients on HD should be regarded as a high-risk population for VZV dissemination. For optimal patient outcome, VZV ME should be considered early when acute encephalopathy develops in patients with recent Shingles flare, and when the diagnosis is confirmed, renally-dosed acyclovir should be promptly initiated.

CONCLUSION: We present a rare case of a 63-year-old male with ESRD on HD, who developed acute encephalopathy due to VZV meningoencephalitis following a recent flare of Shingles in the right chest. We highlight the importance of considering CNS involvement of VZV in patients with immune dysfunctions such as patients with ESRD on HD for timely diagnosis and treatment.

VINTAGE VICTORY: WARFARIN OUTSHINES MODERN MARVEL ELIQUIS IN THE ANTIPHOSPHOLIPID ARENA

Michael Sabina, Zein Barakat, Bernardo Costa Guerra, Zoya khan, Andrew Lurie. Internal Medicine - GME, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4014589)

CASE: A 41-year-old female with a medical history significant for Sjögren's syndrome, hypertension, pre-eclampsia with resultant postpartum ESRD on dialysis via a temporary tunneled catheter to her right chest wall, and a known history of DVT and PE while on Eliquis, presented to the hospital for notable swelling and pain to her right arm, face and neck. The impetus for her presentation was a recommendation from her nephrologist due to occlusions of her bilateral brachiocephalic veins. Initial management included discontinuation of Eliquis and initiation of a heparin drip. Interventional radiology attempted a venogram, but faced complications owing to multiple obstructions in the brachiocephalic vein. Given the peculiar presentation of clot formation with failure of outpatient anticoagulation therapy, a hypercoagulability workup was initiated, which revealed a positive test for antiphospholipid syndrome. As a result, her anticoagulation regimen was modified, transitioning her to warfarin. The patient was ultimately optimized on warfarin with a target INR of 2.0-3.0 upon discharge.

IMPACT/DISCUSSION: Antiphospholipid syndrome (APS) is an autoimmune disorder causing recurrent thrombosis with elevated antiphospholipid antibodies. Management requires long-term anticoagulation. The American Society of Hematology (ASH) and the International Society on Thrombosis and Haemostasis (ISTH) recommend vitamin K antagonists as first-line treatment, advising caution with Direct Oral Anticoagulants (DOACs) in high-risk profiles. Modern oral anticoagulants such as Apixaban and Rivaroxaban provide a convenient alternative to Warfarin, eliminating routine monitoring and dietary restrictions. Their rapid onset, predictable pharmacokinetics, and fewer drug interactions have made them preferred for various indications. While Rivaroxaban’s efficacy has been explored, data remains conflicting. The RAPS trial indicated an increase in thrombin potential in APS patients treated with rivaroxaban compared to warfarin, though clinical thrombosis frequency was not the primary outcome. Larger trials have failed to demonstrate non-inferiority to Warfarin. Comparative efficacy between Apixaban and Warfarin in APS patients remains under-researched, with small trials suggesting Apixaban’s inferiority. Long-term Warfarin use also has its challenges, necessitating further exploration.

CONCLUSION: Management of antiphospholipid syndrome (APS) typically necessitates lifelong anticoagulation, with stratification into high and low-risk phenotypes guiding treatment decisions. While warfarin is the recommended anticoagulant for high-risk APS patients, the use of direct oral anticoagulants (DOACs) like rivaroxaban and apixaban is still under investigation. This case contributes valuable insights to the ongoing research and discussion on the efficacy and safety of apixaban compared to warfarin in managing APS, a topic that currently lacks robust investigations.

VITAMIN A SAVES LIVES; APML DETECTED BY PRESENTATION OF RECURRENT EPISTAXIS

Cole E. Hansell¹; Jonathan Zawadzki¹; Matthew Gorgone³; Rosaleen Petroccione². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Hematology-Oncology, UPMC, Pittsburgh, PA; ³Pulmonary & Critical Care, UPMC, Pittsburgh, PA. (Control ID #4059993)

CASE: A 22-year-old male with a past medical history of autism presented with sub-acute, recurrent, epistaxis. He was diagnosed with immune thrombocytopenia in the weeks prior and started on steroids without improvement. He was being considered for cauterization when he was found to have pancytopenia and transferred to our hospital for further evaluation.

Vitals on arrival were unremarkable with physical exam significant for left nare packing saturated with blood, and petechia on chest and upper extremities. Laboratory results include white blood cells (WBC) 1.7 x 10^3/mcL, with 19% neutrophils and 17% blasts, hemoglobin 7.9 g/dL, platelets 18 x 10^3/mcL, lactate dehydrogenase 292 U/L, international normalized ratio 1.7, partial thromboplastin time (PTT) 24 seconds, and fibrinogen 65 mg/dL.

Blast cell presence, coagulopathic labs, and active bleeding raised suspicions of APML, which can present with disseminated intravascular coagulation (DIC). Despite lack of promyelocytes on initial blood smear, All-Trans-Retinoic Acid (ATRA) was initiated while awaiting Fluoresence in situ hybridization (FISH) and peripheral blood flow cytometry. Coagulopathy was addressed with transfusions targeting goals of fibrinogen >150 mg/dL, hemoglobin >8.0 g/dL, and platelets >50 x 10^3/mcL.

Subsequently, FISH t (15;17) PML-RARA mutation was identified with confirmatory peripheral blood flow analysis demonstrating 45% promyelocyte. Further bone marrow examination revealed hypercellular marrow with 70% blasts, all consistent with an APML diagnosis.

The patient experienced resolution of epistaxis with replacement of platelets, cryoglobulin, and fresh frozen plasma. Once the diagnosis was confirmed, Arsenic Trioxide (ATO) was added to ATRA based on his intermediate risk profile. The patient demonstrated morphologic remission by discharge after a multiweek inpatient stay.

IMPACT/DISCUSSION: Acute leukemia should be in the differential diagnosis of any patient with pancytopenia, particularly if blasts are present in the WBC differential. Common complications of leukemia include infection, due to functional or absolute neutropenia, and tumor lysis syndrome. While bleeding may occur due to thrombocytopenia, any patient with bleeding in whom a diagnosis of acute leukemia is being considered, warrants empiric treatment for APML. Aggressive hematologic support and early administration of ATRA, which does not have significant side effects, is critical to reduce mortality in AMPL. Our patient did not have classic DIC, as his PTT was not prolonged, but his bleeding justified empiric ATRA.

CONCLUSION: - Suspicion for acute leukemia plus bleeding or coagulopathy warrants consideration of APML

- Early treatment with ATRA in patients with suspected APML is lifesaving, with minimal risks

VOCAL CORD ASTHMA

Muna Osman¹; Mai Hamaad¹; Mahmoud Elmahi¹; Mahmoud Elbadrawy²; Mazin Saadaldin³. ¹Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX; ²Internal medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ³internal medicine, TTUHSC, Amarillo, Texas, Amarillo, TX. (Control ID #4063974)

CASE:

Introduction:

Vocal cord dysfunction (VCD) or paradoxical vocal-fold motion (PVFM) is a functional disorder of the vocal cords characterized by episodic adduction of vocal cords, leading to significant inspiratory airflow limitation. Nearly 80% of VCD episodes are wrongly diagnosed as asthma, especially asthma caused by exercise.

Case presentation:

A 31-year-old nursing student presented to the ER via EMS with sudden onset increased shortness of breath and chest tightness that started when she was about to begin her exam. She was gasping for air when her friend called EMS, unrelieved by multiple albuterol inhaler doses. Upon arrival at the ED, she was de-sating to 70, and despite breathing treatments, steroids, magnesium, and oxygen therapy, she didn't improve and was intubated at the ED. Vital signs were remarkable for HR 123 bpm, BP130/85, ventilator sitting of PEEP 5 RR12 TV 400 FIO2 40%, with 100% o2 saturation. She was a febrile. Aside from tachycardia, no remarkable physical exam findings were found. Her medical history was significant for depression, anxiety, HIV, and asthma. She had similar presentations last year, which necessitated 16 intubations.

A broad workup included CBC, BMP, BNP high-sensitivity troponin, PT/PTT/INR, TSH, magnesium, urine toxicology, and CXR were within normal limits. The patient was extubated the following day, and a bedside laryngoscopy was attempted, which showed an abnormal vocal cord adduction on inspiration.

IMPACT/DISCUSSION: Vocal cord dysfunction (VCD) occurs when the vocal cords do not open correctly. Women experience vocal cord dysfunction more often than men. This abnormal adduction is considered primary (psychological) in 70% of cases. The remaining 30% may be secondary to disorders causing laryngeal hypersensitivity or other neurologic diseases. Diagnosing vocal cord dysfunction is problematic because it resembles asthma. Pulmonary function testing is beneficial in differentiating vocal cord dysfunction from asthma.

Flexible laryngoscopy is considered the diagnostic standard. Direct observation of abnormal vocal cord movement toward the midline during inspiration or expiration confirms the diagnosis. Patients with vocal cord dysfunction may present with acute respiratory distress in the emergency department or outpatient setting. Reassurance and breathing instruction may resolve an acute episode. Avoiding known triggers and treating underlying conditions, including anxiety, depression, and gastroesophageal reflux disease, is considered long-term management. Referral for speech therapy is indicated in patients with unresolved symptoms. Long-term tracheostomy may be appropriate in severe, resistant cases.

CONCLUSION: Nearly 80 percent of VCD cases are misdiagnosed as asthma. Although the two may have similar triggers and symptoms, the treatment approach for VCD is very different from the treatments used to manage and control asthma. This makes proper diagnosis essential.

WEAKNESS IN A PATIENT WITH SPINAL CORD INJURY: A BROAD DIFFERENTIAL IS KEY

Arti Vaishnav¹; Jessica Zimmer¹; Jodi M. Grandominico-Bradford². ¹College of Medicine, The Ohio State University, Columbus, OH; ²Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4063589)

CASE: A 70-year-old female with past medical history of T4 paraplegia presented with subacute onset of pruritic rash and acute shoulder and orofacial weakness. The rash began on her shoulders and spread diffusely; an initial outpatient trial of oral and topical steroids did not improve symptoms. Two weeks after the rash onset, the patient noted proximal shoulder weakness described as 30% of her baseline strength. Notably, the patient’s husband passed away two weeks prior to presentation. Review of systems was positive for diminished appetite, fatigue, chills, abdominal distension, constipation, weakness, and rash. On physical exam, the patient had numerous violaceous papules and plaques noted on extremities, chest, back, and head. Skin biopsy showed dermatomyositis. Steroids were started and rheumatology workup was significant for positive antinuclear antibody and elevated creatinine kinase. CT abdomen/pelvis showed enhancing omental nodularity, concerning for carcinomatosis. Tumor markers were notable for elevated CA-125. Omental biopsy revealed metastatic adenocarcinoma of Mullerian origin. Upon discharge, the patient was diagnosed with paraneoplastic dermatomyositis secondary to ovarian cancer with oncology follow-up and steroid therapy for dermatomyositis.

IMPACT/DISCUSSION: It is critical to keep a broad differential diagnosis in patients presenting with a chief complaint of weakness, particularly in those with SCI in which new onset weakness may be difficult to assess. Dermatomyositis and Polymyositis are crucial diagnoses to consider, particularly when the weakness is symmetric and proximal. Patients with SCI may not note these hallmark symptoms, so one must utilize the full physical exam. Classic dermatomyositis skin findings can clue the examiner into the potential diagnosis even in the absence of assessable weakness. In adult-onset disease, the risk is approximately 20%–32% for an associated internal malignancy, making it imperative to make a diagnosis to ensure prompt oncologic workup.

This case also highlights the importance of acknowledging social and behavioral influences on health. Studies have shown associations between bereavement and increased risk of developing adverse health outcomes. Up to 25.9% of adults experience health impacts after bereavement resulting in increased self-reported health problems and healthcare utilization. Weakness, or “flu-like symptoms”, is a commonly noted symptom of bereavement, which may lead providers to attribute similar symptoms to somatic complaints when social history aligns. Our case illustrates the importance of maintaining a broad differential and the importance of not anchoring on social history when evaluating a subjective chief complaint similar to weakness.

CONCLUSION: Patients with SCI represent a unique subset of patients in whom weakness is difficult to elicit and examine. This can make misdiagnosis likely and without thorough examination and broad differential, signs and symptoms may be attributed to psychosocial factors.

WEIGHT LOSS AND LYMPHADENOPATHY: A DIAGNOSTIC DILEMMA

Manasa Bhatta¹; Cary Blum². ¹Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4057526)

CASE: A 73-year-old female with no known past medical history presents to clinic for a new patient appointment after moving from the Dominican Republic. She reports that she has had diffuse pain for years, worst in the belt area, and a 20-pound weight loss over several months. She reports occasional headaches, eye pain and blurry vision but denies cough and shortness of breath. On physical exam, the patient was noted to have bulky left supraclavicular lymphadenopathy. ESR was 66 and CRP was 9.1. Age-appropriate cancer screening was notable for a breast mammogram/ultrasound with multiple enlarged axillary lymph nodes. CT neck, chest, abdomen, and pelvis revealed infraclavicular and subpectoral lymphadenopathy and a mosaic pattern throughout the lungs. Eye exam revealed no active inflammation. Axillary lymph node biopsy showed noncaseating granulomas with large histiocytes. AFB, fungal, and carcinoma stains were negative. Laboratory analysis revealed ANA 1:40, negative ANCA screen, negative rheumatoid factor, and negative Sjogren’s and anti-CCP antibodies. The patient was seen by a sarcoidosis specialist and a rheumatologist and started on prednisone 20mg daily with significant improvement of headaches, visual symptoms, lymphadenopathy, and joint pain.

IMPACT/DISCUSSION: Initially, the patient’s presentation was highly concerning for cancer given lymphadenopathy and weight loss, prompting an expedited workup. Despite the classic association between noncaseating granulomas and sarcoidosis, the clinical picture did not fit this diagnosis, which commonly causes bilateral hilar lymphadenopathy and pulmonary symptoms. The patient also did not demonstrate the most common extrapulmonary manifestations of sarcoidosis, including skin involvement, uveitis, or hypercalcemia. In addition to sarcoidosis, noncaseating granulomas can be seen in a variety of infectious, malignant, and autoimmune diseases, including vasculitis. The patient’s constellation of symptoms, including headache, vision change, axial joint pain, weight loss, and noncaseating granulomatous inflammation best fit a diagnosis of polymyalgia rheumatica (PMR) with giant cell arteritis (GCA). These diagnoses are linked and are almost exclusively seen in elderly patients. Lung parenchymal involvement in PMR has been reported, but the mosaic attenuation seen on our patient’s CT is nonspecific and of unclear significance in this patient with no clinical correlation. As is classic for PMR/GCA, the patient’s condition was extremely steroid-responsive, with improvement of lymphadenopathy, joint pain, and headache after initiating corticosteroids.

CONCLUSION: 1. The differential diagnosis of noncaseating granulomas includes vasculitis, sarcoid, lymphoma, and mycobacterial infection.

2. While lymphadenopathy and weight loss in an elderly patient must prompt a thorough evaluation for malignancy, infectious and autoimmune diseases must also be considered.

WEIGH YOUR OPTIONS OF UPPER EXTREMITY SWELLING CAUSES

John Flickinger, Nicole Curtis, Anna Kaiser, Kristian Feterik. Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4063538)

CASE: A previously healthy 45-year-old woman with no past medical history presented to the emergency department with right supraclavicular area pain and fullness for 3 days. Right upper extremity doppler ultrasound revealed acute axillary and subclavian deep vein thrombosis (DVT). Four months prior, she started daily weightlifting training resulting in increased muscle mass of arms and shoulders. There was no history of malignancy, blood clots, excessive bruising, or bleeding. She had no family history of hypercoagulability. She was up to date on age-appropriate cancer screenings. Home medications included cefuroxime; started 4 days prior to admission for acute bacterial cystitis. Musculoskeletal exam of the right arm revealed asymmetric 2+ edema extending from shoulder to hand with associated rubor, and prominent palpable proximal axillary vein. Initial labs, including a hypercoagulable panel, were unremarkable. Contrast-enhanced computed tomography scan showed occlusive thrombus of the right subclavian, axillary and basilic veins, and a left lower lobe segmental pulmonary embolism. The patient improved with unfractionated heparin infusion within 24 hours. Vascular surgery performed a right axillary and subclavian vein thrombolysis and pharmacomechanical thrombectomy with angioplasty of stenotic segments. She was discharged on apixaban with follow up plans for thoracic outlet decompression.

IMPACT/DISCUSSION: Effort thrombosis (Paget-Schroetter syndrome) results from strenuous upper extremity activity, causing axillary-subclavian vein thrombosis. Thoracic outlet anatomical abnormalities and repetitive trauma to the subclavian vein endothelium are key confounders. Due to its relatively infrequent occurrence and unique presentation, diagnosis can be challenging, highlighting the importance of a broad differential. While physicians typically encounter upper extremity DVTs associated with indwelling hardware, malignancy and thrombophilias, effort thrombosis accounts for 10-20% of cases. Early recognition, timely thrombolysis, and prompt referral for thoracic outlet decompression are essential. Our patient’s most obvious exam findings were right supraclavicular fullness and pain with palpation. History of weightlifting and evidence of axillary and subclavian DVT established the diagnosis. Although venography is not necessary for diagnosis, it is part of multimodal treatment strategy to deliver catheter-directed thrombolysis and plan thoracic outlet decompression surgery.

CONCLUSION: Effort thrombosis is a complex and relatively infrequent disorder with distinct pathogenesis. Prompt recognition and treatment are paramount to prevent residual symptoms, disability, and recurrent thrombosis. Local catheter-directed thrombolysis followed by thoracic outlet decompression is superior to upper extremity elevation and systemic anticoagulation.

WHAT CONNECTS LEG PAIN, BLEEDING, AND RENAL FAILURE?

Jaspreet Sian^1,2; Blake Lackey¹; Jenny L. Weon³; Stephanie Torres Rodriguez². ¹Internal Medicine, The University of Texas Southwestern Medical Center Department of Internal Medicine, Dallas, TX; ²Nephrology, The University of Texas Southwestern Medical Center Department of Internal Medicine, Dallas, TX; ³Pathology, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4064819)

CASE: A 68-year-old female presented with one month of bilateral foot and ankle pain that was tingling in sensation, for which she was taking naproxen. Vitals showed blood pressure of 157/103 mmHg and a heart rate of 105 beats per minute. Physical exam was benign. Labs showed leukocytosis with a white blood cell count of 17.46 X10^9/L, anemia with hemoglobin of 11.4 g/dL, and acute kidney injury with a creatinine of 2.7 mg/dL. Urine analysis showed microscopic hematuria and urine protein to creatinine ratio was 1g. Urine sediment analysis showed multiple muddy brown casts, suggesting acute tubular necrosis. A serologic workup was completed, which showed positive p-ANCA, ANA, rheumatoid factor, and MPO AB. A kidney biopsy was recommended, but the night before the procedure, the patient experienced an acute drop in hemoglobin and back pain. A CT scan revealed mixed right subcapsular and perinephric hematomas involving the right kidney. Coil embolization was completed on multiple right lower pole pseudoaneurysms. Due to bilateral renal pseudoaneurysms, a kidney biopsy was prohibitive. Since the clinical picture was highly concerning for MPA, she was treated with high-dose steroids and rituximab. The patient was started on dialysis due to oliguria and worsening renal function. After receiving two doses of rituximab, her urine output increased, and she began to experience renal recovery.

IMPACT/DISCUSSION: MPA is a type of vasculitis characterized by abdominal pain, bleeding, necrotizing glomerulonephritis, alveolar hemorrhage, pulmonary infiltrate, petechiae, ulcers, mononeuritis multiplex, and distal symmetric polyneuropathy. Diagnosis is made through serological testing, which reveals positive ANCAs, ANAs, and MPO AB. However, if possible, a biopsy is preferred for confirmation. MPA usually affects small vessels, but in rare cases, it has been associated with medium vessel involvement. Treatment includes high-dose steroids (either oral or IV) and rituximab (preferred) or cyclophosphamide. Once remission is achieved, patients can be on maintenance therapy with rituximab, methotrexate, or azathioprine. In cases of renal failure requiring hemodialysis, plasma exchange is an option.

CONCLUSION: Systemic vasculitides are characterized by inflammation of the blood vessel wall and can present with features involving the pulmonary, musculoskeletal, skin, nervous system, eyes, blood, and kidneys. Small vessel involvement is seen in ANCA-associated vasculitis which includes microscopic polyangiitis (MPA). Polyarteritis nodosa (PAN) involves medium-sized vessels. Sometimes overlapping features require a high level of clinical suspicion to obtain the most probable diagnosis and treatment. This is a case about a patient who presented with leg pain and was found to have kidney failure and intrarenal pseudoaneurysms, leading to a diagnosis of MPA.

WHAT’S IN THAT SUPPLEMENT? A CASE OF HYPERKALEMIA

Mansi Shah²; Mytra Haerizadeh¹. ¹Medicine, Columbia University Irving Medical Center, New York, NY; ²Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY. (Control ID #4064764)

CASE: An 84-year-old woman with a past medical history of diabetes, hypertension, and macular degeneration presented with generalized weakness. Two days ago, she began taking an ophthalmic supplement called Preservevision AREDS2 and has since had several soft bowel movements. One day ago, she had an episode of non-bloody, non-bilious vomiting. Her vital signs were checked at home and her heart rate was 34 with a blood pressure of 76/50 so EMS was activated. In addition the new supplement, her other relevant medications include hydrochlorothiazide, lisinopril, metoprolol, nifedipine, and carteolol eye drops. In the ED, she was afebrile, but persistently bradycardic and hypotensive. Her physical exam revealed a slow heart rate with a regular rhythm. Labs revealed a potassium of 7.4 and creatinine of 1.5 from a baseline of 0.9. Her EKG revealed a junctional bradycardia at 30 bpm and peaked T waves. The patient was started on transcutaneous pacing. She was treated emergently for hyperkalemia and acute kidney injury with improvement in her bradycardia and shock. She was admitted to medicine for further management and was discharged home after an uncomplicated hospital stay.

IMPACT/DISCUSSION: This 84-year-old woman presented with generalized weakness and vomiting in the setting of a new ophthalmic supplement use, found to have severe hyperkalemia, acute kidney injury, and bradycardia with shock requiring transcutaneous pacing. This case highlights the generalist’s role in risk-stratifying for life-threatening side effects of polypharmacy. The PreserveVision supplement consists of large doses of vitamins C, E, and A, zinc, and cupric oxide. It is not approved by the Food and Drug Administration but has been extensively studied via large, randomized controlled trials, which demonstrate a 25% decreased risk of developing advanced macular degeneration after five years of supplement use (AREDS, 2008). Common side effects, however, include nausea, vomiting, and diarrhea. These side effects likely led to volume depletion, leading to acute kidney injury with concomitant use of the ACE inhibitor lisinopril. This was likely the cause of the patient’s hyperkalemia and unstable bradycardia.

Another drug-drug interaction at play may have been the combination of the calcium channel blocker nifedipine, the beta blocker metoprolol, and the eyedrop carteolol. An 84-year-old woman with a similar medication regimen as the patient presented here was found to have bradycardia and shock in the setting of carteolol use. Since carteolol is absorbed systemically, it can potentiate beta blockade (Arai et al., 2021).

CONCLUSION: This case challenges the internist to 1) identify the clinical features of hyperkalemia and 2) engage in conversations about supplement use and polypharmacy with patients.

WHEN AGEP MET DRESS: A UNIQUE OVERLAP OF SEVERE CUTANEOUS ADVERSE REACTIONS

Sanjana Rao²; Alexis Malecki²; Kristopher A. Mosier¹; Adam Ladzinski¹; Julio Pinto Corrales¹; Yoshio T. Wagner³. ¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Wayne State University School of Medicine, Detroit, MI; ³Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4057698)

CASE: The patient underwent excisional biopsy of left breast lobular carcinoma in situ lesion and received intravenous vancomycin (1,250mg). Post-operative day (POD) 2, she developed a pruritic rash on her trunk, extremities, and face. Her surgeon prescribed oral methylprednisolone 4 mg POD 5. After no improvement, she presented to dermatology clinic on POD 8 where she was diagnosed with Acute Generalized Exanthematous Pustulosis (AGEP) secondary to vancomycin without biopsy as patient declined. Despite oral prednisone (40 mg daily), the rash worsened.

She presented to emergency department POD 12 with elevated C-Reactive Protein (2.4 mg/dL), white blood cell count (22.3 K/uL), and absolute eosinophil count (3.1 K/uL). She had transaminitis with aspartate transaminase (AST) of 28 IU/L and alanine aminotransferase (ALT) of 74 IU/L. Facial edema, patchy erythema with pustules, and scattered purpuric patches were noted. Dermatology confirmed diagnosis of AGEP with overlapping Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome. Diagnosis was made with clinical/lab findings (no biopsy).

She was admitted on POD 13 for worsening of above findings. IV methylprednisolone (1 mg/kg daily) was initiated. On POD 14, cyclosporine (175mg twice a day) was added in an effort to taper steroids due to patient’s hesitancy with systemic corticosteroid use. On POD 19, her eosinophilia, rash and transaminitis all resolved or improved. Follow-up visits with allergy/immunology and dermatology showed no reactivation concerns.

IMPACT/DISCUSSION: Compared to other medications, vancomycin is a rare but possible cause of severe cutaneous adverse reactions (SCARs). The presentation of AGEP is very rare with an estimated incidence of 1-5 cases per million per year. DRESS syndrome is also rare with an incidence of 1 in 1,000 to 1 in 10,000 per drug exposure. One study showed vancomycin to be responsible for a third of DRESS cases. Vancomycin-induced AGEP is highly uncommon; a 2015 report reveals only two previously reported cases in the literature.

It is important to recognize the presentation of SCARs because of the potentially fatal outcomes and significant morbidity. Studies have shown DRESS syndrome to have a mortality rate of approximately 10%. In comparison, AGEP has a mortality rate of less than 5%.

To the author’s knowledge, this is the first reported case of AGEP and DRESS syndrome overlap due to vancomycin. In addition, the use of cyclosporine as an adjunct immunosuppressant contributes to this unique clinical course. Prompt, aggressive treatment with systemic steroids prevents morbid outcomes of systemic involvement and progression of these SCARs.

CONCLUSION: - While rare, SCARs can present simultaneously. Distinguishing their presentations can prevent morbidity and mortality from commonly-used medications.

- Organ involvement distinguishes DRESS syndrome from AGEP and warrants aggressive immunosuppressive treatment.

WHEN A UBIQUITOUS GENE GOES AWRY: A RARE CAUSE OF HYPOCALCEMIA

Marisa Echaniz¹; Rebecca Unterborn². ¹Medicine, University of Colorado - Denver Health, Denver, CO; ²Internal Medicine, University of Colorado, Denver, CO. (Control ID #4023365)

CASE: A 23-year-old patient with PMH: Trevor syndrome & shoulder surgery, was admitted from neuro clinic, for an episode of flexion of bilateral elbows, adduction of the right shoulder, and variable flexion/extension of bilateral lower extremities. He’d been referred to neurology for a year of paroxysmal tonic posturing in extremities that lasted a few seconds at a time, no post-ictal state or seizure like activity. He'd been prescribed Baclofen and levetiracetam. Labs: calcium: 5.7 mg/dL, ionized calcium: 0.74 with a (+) Chvostek sign, phosphorus: 5.9 mg/dL, PTH: 288.6, 25-hydroxy vitamin D: 21.7ng/mL and 1,25 dihydroxy vitamin D: 24.3 The paroxysmal episodes were deemed tetany from hypocalcemia. His calcium was repleted aggressively; high dose vitamin D repletion was started. On further chart review, he had seen a geneticist at an outside hospital and was found to have truncating GNAS variant c.565_568del p.Asp189Metfs*14. Given this patient’s prior shoulder surgery at a young age (likely due to ossification of the shoulder joint), correlating genetic variant, and his current presentation of hypocalcemia, he was diagnosed with progressive osseous hyperplasia (POH) – his diagnosis of Trevor syndrome was incorrect and removed from the chart. In support of POH, as his calcium level continued to improve, he had no further tetany episodes in the hospital.

IMPACT/DISCUSSION: This is a case of symptomatic hypocalcemia, caused by pseudohypoparathyroidism in the setting of POH. POH is the abnormal ossification of tissues caused by a genetic alteration in the GNAS gene complex¹, which is important for signaling of parathyroid hormone’s (PTH) target organs², and therefore calcium homeostasis. Given the GNAS gene alteration in POH, pseudohypoparathyroidism has been described with this syndrome. Oral calcium and vitamin repletion remains mainstay of treatment. This case uncovered many challenges in diagnosis and management of patients with this rare disease.

CONCLUSION: This case highlights the importance of proper diagnosis of genetic conditions as they are often syndromic. This patient’s diagnosis was delayed one year, and he was given centrally acting medications unnecessarily in the process. Providers should be aware of POH and monitor these patients closely, as they are at high risk for developing hypocalcemia via pseudohypoparathyroidism.

WHEN BREAD AND BUTTER TURN INTO MOLD: A CASE OF “RECURRENT COPD EXACERBATION” MASKING ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS.

Justin Q. Wang¹; Anna K. Donovan². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4063560)

CASE: A 68-year-old female with a history of chronic obstructive pulmonary disease (COPD) on 3 liters of home oxygen presented with 2 days of persistent shortness of breath, cough, and wheezing. She had five admissions this year alone attributed to COPD exacerbations. The admitting medicine team initiated standard COPD treatment with azithromycin, nebulizers, inhaler optimization, and increased prednisone to 60mg per day. The patient’s wheezing worsened prompting a new medicine team who took over the service to broaden their evaluation; respiratory viral panel, sputum culture, AFB, blastomycosis, and histoplasma antigen were negative. Repeat high resolution CT showed worsening bronchiectasis and bronchial thickening with new centrilobular and endobronchial opacities and migratory nodularity. Further studies showed elevated IgE (3136 KU/L), Aspergillus IgE (22.3 kUA/L) and IgG (3.3) which met Rosenberg-Patterson criteria for Allergic Bronchopulmonary Aspergillosis (ABPA). The patient improved on a prolonged steroid course.

IMPACT/DISCUSSION: While COPD is a common cause for hospital admissions, the patient’s lack of response to multiple inpatient courses of treatment warranted additional investigation. ABPA classically presents in patients with asthma and cystic fibrosis with recurrent wheezing despite optimal therapy. The patient met the Rosenberg-Patterson criteria for ABPA with the following: patchy fleeting pulmonary infiltrates, bronchiectasis, positive Aspergillosis IgM and G, and repeated exacerbations despite appropriate respiratory therapy. Initial treatment for ABPA is with corticosteroids and then antifungals if steroid resistant. Given the patient’s known COPD and prior exacerbations, framing bias from the previous teams influenced initial diagnostic reasoning. After transition of care with a new physician team, they re-examined etiologies given the discordant data of prior CTs with migratory nodularity, new peripheral eosinophilia, and failure to improve on traditional COPD exacerbation therapy. This patient likely developed adult-onset asthma that placed her at higher risk for ABPA and created an asthma-COPD overlap syndrome that complicated her recurrent admissions for exacerbations.

CONCLUSION: Adult patients with longstanding COPD may develop new onset asthma as part of the Asthma-COPD overlap which places them at higher risk for ABPA infections, which may be confused for bread-and-butter COPD exacerbations. During inpatient transitions of care, it is important to assess framing bias in diagnostic reasoning.

WHEN CEFEPIME TURNS TOXIC: A CASE REPORT OF ENCEPHALOPATHY IN A RENAL TRANSPLANT PATIENT WITH SEPSIS

Joseph Burzynski¹; Kenneth Ralto². ¹Office of Undergraduate Medical Education, University of Massachusetts Chan Medical School, Worcester, MA; ²Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4023412)

CASE: An 84-year-old female with a past medical history significant for stage IIIb chronic kidney disease status-post renal transplant in 2011 on tacrolimus was brought to the emergency department after being found wandering the street. She had been living alone for the past month, and her neighbors reported that she appeared to have poor oral intake days prior to this event. In the emergency department, she was oriented to self and place only and was confused as to why she was in the hospital. There was suspicion for sepsis, and she was treated with renally dosed cefepime and metronidazole. Her encephalopathy workup was unremarkable including normal vitamin B12 and TSH, and an unreactive RPR. Her encephalopathy improved with the clinical improvement of her sepsis. On hospital day 5, she awoke with global aphasia, stupor, and inability to follow simple commands. Cefepime was discontinued due to suspicion of Cefepime Induced Neurotoxicity (CIN). Repeat head imaging showed no acute abnormalities. Continuous EEG noted severe encephalopathy with triphasic waves, but no evidence of non-convulsive status epilepticus. On the second day following discontinuation of cefepime, the patient’s mental status rapidly improved. 3 days post discontinuation, she had returned to her baseline mental status.

IMPACT/DISCUSSION: This case illustrates a common presentation of a rare, under-recognized cause of acute metabolic encephalopathy, despite dosing of cefepime based off creatinine. Evidence of CIN has been growing with a recent RCT finding cefepime resulted in significantly more neurological dysfunction than piperacillin-tazobactam, and CIN remains an important consideration in the workup of acute metabolic encephalopathy. The most important risk factor is high doses of cefepime in the setting of reduced renal function. In one review of patients with CIN, median reported creatinine was 3 mg/dL, and median cefepime dose per 24 hours was 4 grams. Notably, our patient lacked these risk factors. However, in the frail elderly, serum creatinine often overestimates true GFR and other markers like cystatin C are more accurate. CIN is a diagnosis of exclusion, and our patient had multiple potential causes of her encephalopathy including poor nutrition, sepsis, suspected cognitive impairment and hospital admission. However, given the acute onset of encephalopathy within a few days of the initiation of cefepime and the lack of significant changes in any other potential causes, CIN was suspected. CIN was ultimately confirmed with resolution of symptoms 2 days after cessation of cefepime treatment.

CONCLUSION: This case highlights the need for inclusion of cefepime as potential cause of encephalopathy even in the setting of appropriate dosing and relatively preserved renal function

WHEN SYMPTOMS CONVERGE: GASTROPARESIS AND THE UNANTICIPATED TWIST OF FOCAL NODULAR HYPERPLASIA

Pranav Chalasani, Javaria Asif, Alaa Taha, Palpasa Bhui, Zain Kulairi. Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4062809)

CASE: A 35 year old female with a history of uncontrolled type 1 diabetes mellitus and previous hospitalizations for diabetic ketoacidosis(DKA), on combined oral contraceptives pills (OCPs) for birth control initially presented with abdominal pain associated with distention,nausea and vomiting. Initial lab work was significant for elevated glucose and high anion gap. She was treated for diabetic ketoacidosis. Her symptoms improved but the abdominal pain and nausea persisted. Abdominal CT was insignificant for any hepatic abnormalities. She was discharged after symptom improvement with metoclopramide. Gastric emptying study confirmed the diagnosis of gastroparesis and the patient was continued on metoclopramide, partially resolving her symptoms. One week later, the patient represented with similar complaints as initial presentation but with more of right upper quadrant pain. She was afebrile and hemodynamically stable. Physical exam showed right upper quadrant and epigastric tenderness, with negative Murphy’s sign. Normal bowel sounds were heard throughout the abdomen without signs of peritonitis. Labs were within normal limits, including normal liver function tests. Upper endoscopy was performed and ruled out gastric outlet obstruction. Given her persistent symptoms, repeat abdominal CT was performed and showed at least four well-circumscribed liver lesions with the largest measuring 4.8 cm in segment VII with diminished enhancement relative to normal hepatic parenchyma. Abdominal MRI confirmed CT findings as well as demonstrating a small central scar in the largest lesion. These findings were consistent with focal nodular hyperplasia (FNH). She was advised to discontinue her OCPs, and was discharged with no further intervention.

IMPACT/DISCUSSION: Focal nodular hyperplasia (FNH) is a well-defined benign hepatic angioma with minimal symptoms but new, rapidly progressing FNH (lesions > 4cm) can present as abdominal pain and nausea. However, reports linking abdominal pain to FNH often lack rigorous efforts to rule out alternative causes. Clinicians should exercise caution when associating symptoms with FNH, as the precise physiological mechanisms of pain related to this lesion remain unidentified. Given the history of uncontrolled diabetes in this patient, her presentation can often be confused by newly diagnosed gastroparesis. Currently, there is no evidence that shows OCPs can cause FNH. However, women who are on a daily oral contraceptive regimen display larger nodules that women who are not taking oral estrogen-based contraception. In the case of refractory nausea and pain in gastroparesis, it may be prudent to consider further CT or MRI imaging to rule out FNH in a young woman.

CONCLUSION: The identification of new liver masses accompanied by vague abdominal symptoms, featuring central scarring on MRI, is adequate for diagnosing FNH, eliminating the need for biopsy or resection. Longitudinal studies are essential for gaining a deeper understanding of FNH's natural progression.

WHEN THE DRESS DOES NOT FIT: A CASE OF PIPERACILLIN-TAZOBACTAM INDUCED ATYPICAL DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS) SYNDROME WITHOUT A RASH

Katherine L. Lee¹; Andy Wu². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Gastroenterology, Hepatology and Nutrition, UPMC, Pittsburgh, PA. (Control ID #4061521)

CASE: A 30-year-old man with recent admissions for appendicitis complicated by abscess formation presented with several days of fevers, abdominal pain, nausea, vomiting and diarrhea. Prior to presenting, his appendicitis was managed with an appendectomy, drainage and a four-week course of piperacillin-tazobactam. Vitals on arrival were: T 38.5°C, BP 121/64, HR 130, RR 26. Labs revealed eosinophilia of 1700 eosinophils/mL, atypical lymphocytes. AST 860, ALT 1335, alkaline phosphatase 110, total bilirubin 2.6. CT showed abdominal abscess resolution, mild splenomegaly and enlarged portal caval lymph nodes. A liver biopsy was then pursued which revealed widespread inflammation with many eosinophils, most consistent with drug-induced liver injury. Autoimmune hepatitis was also on the differential based on the histomorphology, but less likely given serologic tests including ANA, ASMA, AMA and Anti ds-DNA were negative. Viral hepatitis studies were also negative. We concluded that he had DRESS induced by piperacillin-tazobactam, which was atypical as he did not have a rash. Hepatitis, eosinophilia and fevers resolved with a prednisone taper.

IMPACT/DISCUSSION: DRESS is a rare, potentially fatal adverse drug reaction with variable presentation. RegiSCAR, a multinational registry of severe cutaneous adverse reactions (SCAR), created a scoring system to identify potential DRESS cases as definite, probable, possible or no case. Points are assigned based on the presence or absence of fever, enlarged lymph nodes, atypical lymphocytes, as well as the degree of eosinophilia, organ involvement, and skin involvement with rash or biopsy suggestive of DRESS. The diagnostic validation score also grants points based on time course (resolution occurring in ≥15 days), and evaluation of other potential causes, including blood cultures and serologic tests for ANA and viral hepatitis. A final score >5 indicates a definite case; 4-5, a probable case; 2-3, a possible case; and <2, no case. The final score for our patient was 6 indicating a definite case, and liver involvement was a notable feature. DRESS rarely presents without a rash. There have been several case reports of piperacillin-tazobactam induced DRESS in the literature. To our knowledge, this case of piperacillin-tazobactam induced DRESS is the first one documented without cutaneous involvement.

CONCLUSION: Piperacillin-tazobactam induced DRESS is a rare adverse drug reaction, and can have an atypical presentation without a rash.

WHEN TWO WORLDS COLLIDE: A CHALLENGING CASE OF GYNECOLOGICAL ABNORMALITIES FOR THE INTERNIST

Sameer Khan¹; Nathan Douthit²; William S. Kutsche³. ¹Internal Medicine Residency Program, East Alabama Medical Center, Opelika, AL; ²Internal Medicine Residency, East Alabama Medical Center, Opelika, AL; ³Internal Medicine Residency Program, Thomas Hospital, Fairhope, AL. (Control ID #4060470)

CASE: A 25-year-old female G1P0010 with LMP two weeks prior to admission was admitted for a right pleural effusion. She states that six months prior to admission, she had 6L of bloody fluid drained and three months prior, 2.5L of bloody fluid drained from her abdomen at an outside facility; however, she states that physicians were unable to provide her with a diagnosis. Her menstrual cycle is regular and without pain or increased bleeding. She is adopted and is not aware of her family’s medical history. Vitals on admission were a temperature of 98.3°F, HR 77bpm, BP 113/72mmHg, RR 16, and O2 saturation 97%. Physical exam was significant for decreased breath sounds on the right. Labs on admission were significant for a hemoglobin/hematocrit of 10.3gm/dL/33.4%. CA 125 level was elevated at 189U/mL (normal 0-35U/mL). Chest x-ray revealed right pleural effusion. Thoracentesis done on the second day of admission yielded 1200mL of bloody fluid. Pelvic ultrasound and CT angiogram of the chest were negative for any acute processes. Gynecology was consulted for evaluation of endometriosis, and a diagnostic laparoscopy revealed stage IV endometriosis. Gynecology felt further evaluation for endometriosis in the pleural space was unnecessary as the patient likely had lesions given her presentation and laparoscopy findings. Our patient did admit to us that she experiences dysmenorrhea and menometrorrhagia. She was discharged home and follows with gynecology with her endometriosis controlled on medroxyprogesterone acetate injections with no recurrence of her effusions.

IMPACT/DISCUSSION: Thoracic endometriosis syndrome (TES), endometrial tissue in or around the lung, is an underdiagnosed and rare condition. The difficulty in diagnosis is usually multifold. Symptoms do not present in a temporal relationship with menses, and often presents as a pneumothorax in approximately 73% of cases and hemothorax in just 14% of cases, such as ours. TES is a clinical diagnosis, and although histopathology is not needed, it can help with further confirmation. Other diagnoses that were considered due to the bloody pleural effusion and abdominal fluid was Meigs syndrome, however CT imaging and pelvic ultrasound ruled out malignancy and the elevated CA-125 level was due to her endometriosis and effusion. First line treatment for TES is hormonal suppression, while refractory cases may benefit from pleurectomy and pleurodesis, alternative hormonal agents, or even hysterectomy with bilateral salpingo-oopherectomy. Our patient is currently stable on hormonal therapy. This case highlights the importance of understanding gynecological abnormalities in internal medicine to develop broader differentials when treating patients.

CONCLUSION: 1. Consider gynecologic abnormalities in female patients when developing differential diagnoses.

2. TES is a rare diagnosis and should be considered in female patients who present with cyclic or unexplained bloody effusions.

3. Hormonal suppression is the mainstay of treatment for TES

WHEN YOU THINK YOU HAVE THE ANSWER AND DON’T: AN ATYPICAL PRESENTATION OF SEPTIC ARTHRITIS WITH SPOROTHRIX SCHENKII

Christopher Viamontes, Kristina Collins, Shivani Desai. General Internal Medicine, UT Southwestern, Dallas, TX. (Control ID #4063606)

CASE: A 46-year-old Hispanic male with untreated HIV and 6 months of chronic right knee pain presented with a one-week history of chills, worsening right knee swelling, and pain. Vitals noted BP 130/84, T 37.4, HR 82, RR 16, and SPO2 100. He had a yellow penile discharge, a non-erythematous swollen and tender right knee with a partially limited range of motion, and labs significant for WBC 11.01, CRP 3.3, neutrophil predominant (80%) cloudy red synovial fluid, and negative gram stain thought to be due to traumatic tap rather than infectious etiology. X-ray revealed diffuse soft tissue swelling with large knee joint effusion. He was sent home with a follow-up in the HIV clinic for further evaluation. He presented again two days later with fever, a painful red, immobile right knee, and axillary lymphadenopathy with interval labs notable for WBC 13.50, CRP 12.5, ESR 79, and no change in joint fluid analysis. In light of the prior penile discharge and new axillary lymphadenopathy, gonococcal species and TB infection were considered, and he was started on ceftriaxone and vancomycin. Initial fungal cultures were positive for yeast, and micafungin was added. Final cultures were only positive for sporothrix schenkii. He transitioned to amphotericin B for 2 weeks and was discharged on itraconazole for a 12-month course.

IMPACT/DISCUSSION: Septic arthritis (SA) is an orthopedic emergency that accounts for ~ 20,000 ED visits per year nationally. Infectious sources include hematogenous spread, contiguous spread from surrounding bone, or direct inoculation. Each patient’s risk profile differs based on factors such as age, premorbid conditions, immune status, among others. Common organisms in an immunocompetent adult include staphylococcus aureus, streptococcal species, and neisseria gonorrhea. In immunocompromised patients such as this one, indolent presentations of septic arthritis are not uncommon, and atypical organisms such as mycobacterial, spirochete, and fungal species (including candida, aspergillus, and histoplasmosis) must be considered. In fungal SA, routine synovial fluid and laboratory investigations may initially suggest non-infectious arthritis. In this case, TB was considered and eventually ruled out, with final synovial fungal cultures growing sporothrix species. Though the source of the sporothrix is unclear in this case, obtaining a proper social history is essential as sporothrix species can be found in the soil or plants such as sphagnum moss, rose bushes, or hay.

CONCLUSION: It is imperative to develop a diagnostic approach to SA in the immunocompromised host with early synovial fluid sampling and initiation of appropriate antimicrobial therapy to mitigate potential complications such as septic shock, debility, and mortality.

WHY DOES EVERYONE KEEP TAPPING ON MY FACE? A RARE CASE OF SEVERE SYMPTOMATIC HYPOCALCEMIA DUE TO PSEUDOHYPOPARATHYROIDISM

Jonathan Rizner¹; Carolyn M. Hofley¹; Jeffrey Xia³; Chun Hin Chan². ¹Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Hospital Medicine, University of California Los Angeles, Los Angeles, CA; ³Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4064926)

CASE: An 18-year-old female with hyperlipidemia and slipped capital femoral epiphysis presented to the hospital with one week of progressive paresthesia and muscle spasms. Exam was notable for tachycardia and positive Chvostek sign, with normal stature, BMI, and face/hand morphology. Work up was notable for severe hypocalcemia 5.2mg/dL (8.6-10.4mg/dL), elevated parathyroid hormone (PTH) 533pg/mL (11-51pg/mL), elevated phosphorus 6.0mg/dL, borderline low magnesium 1.5mEq/L, low 25-hydroxyvitamin D 19ng/mL, with normal albumin, 1,25-dihydroxyvitamin D, renal and thyroid function. ECG notable for prolonged QTc interval of 473ms.

Her hypocalcemia was managed with intravenous (IV) calcium gluconate (goal >8.6mg/dL), IV magnesium (goal >2.0mg/dL), oral calcium carbonate 2500mg three times daily, ergocalciferol 50000IU weekly, and calcitriol 1mcg twice daily. In total, she received 18g IV calcium gluconate and 18g IV magnesium over 3 days. On day 3, her serum calcium stabilized to 8.0mg/dL, and she was discharged with endocrinology follow up. Her serum phosphorus and calcium normalized at 1- and 11-days post-discharge, respectively. Her preliminary diagnosis is pseudohypoparathyroidism (PHP) type 1b, type 2b or other PTH resistance-related disorder pending genetic evaluation.

IMPACT/DISCUSSION: Severe symptomatic hypocalcemia often manifests as tetany ranging from paresthesia to cramps, muscle spasms, and seizure. PTH is the best test to determine the cause of hypocalcemia in addition to history and physical. Hypocalcemia with elevated PTH is commonly encountered in adult patients with vitamin D deficiency and chronic kidney disease due to appropriate physiological release of PTH to increase calcium resorption.

If hypocalcemia with elevated PTH is seen with hyperphosphatemia, consider pseudohypoparathyroidism (PHP) especially in children or young adults such as our patient. PHP is a heterogeneous genetic disorder marked by end-organ resistance to PTH due to impaired PTH signaling pathway. A presumptive diagnosis of PHP should prompt confirmatory genetic testing as certain PHP subtypes have varied clinical features including neurocognitive and other endocrine abnormalities.

Acute management of hypocalcemia involves diligent repletion of calcium and magnesium to prevent life threatening arrhythmia (such as QT prolongation) and laryngospasm. Referral to endocrinology for titration of calcium and vitamin D supplementation are often necessary to prevent overcorrection or undertreatment; hypercalcemia can suppress PTH leading to hypercalciuria and renal stones, while chronic hypocalcemia and hyperphosphatemia can lead to intracranial calcium deposition.

CONCLUSION: Pseudohypoparathyroidism (PHP) is a rare disease spectrum which may present in adulthood due to variable genetic and epigenetic factors. Management of PHP involves chronic supplementation of calcium and vitamin D. Endocrine and genetics follow up are important for improved long term outcomes.

WORKUP OF AUTOIMMUNE HEPATITIS THAT PROGRESSED TO CIRRHOSIS IN A YOUNG MAN

Adrian M. Alonso, Steve Shen. Internal Medicine, University of Florida, Gainesville, FL. (Control ID #4059823)

CASE: A 25-year-old man was admitted to the hospital with abdominal pain and abdominal swelling. Labs were significant for a total bilirubin of 2.7 mg/dL (reference <1 mg/dL), alkaline phosphatase of 229 IU/L (reference <150 IU/L), with normal transaminases and coagulation factors. CT of the abdomen showed decompensated cirrhosis with significant volume ascites. Social history was unremarkable for ethanol or IV drug use. Vitals on admission were normal. Due to his young age and advanced liver disease, the patient underwent an autoimmune workup. Labs were notable for an ANA 1:640 and positive anti-smooth muscle antibody. Subsequent biopsy of the liver showed cirrhosis, portal and lobular inflammation with lymphocytes, and occasional plasma cells. He was diagnosed with autoimmune hepatitis (AIH). Due to the advanced nature of his disease, the decision was to withhold initiating steroids as they would have minimal benefit at this point. He was treated medically with frequent paracentesis and diuretics. He underwent a TIPS procedure with an improvement of his ascites. He was presented to the institution review board for consideration of a liver transplant.

IMPACT/DISCUSSION: Autoimmune hepatitis is a progressive, debilitating disease that often leads to cirrhosis. The exact incidence rates are unknown; however, 100,000-200,000 patients are believed to be affected annually in the United States. Clinical presentations are similar to that of a failing liver, such as ascites, encephalopathy, and jaundice. There are two types of AIH: type 1, which is associated with anti-smooth muscle antibodies, and type 2, which is associated with anti-liver/anti-kidney microsome antibodies, most often identified in children. Workup usually consists of autoimmune testing and liver biopsy showing cellular infiltration in the portal tracts. This patient is an excellent example of this disease's acute presentation and workup. He ultimately was diagnosed with type 1 AIH. Treatment consists of immunosuppression and, in refractory or advanced cases, liver transplant.

CONCLUSION: AIH is a rare, chronic disease that is underrecognized. Early detection is imperative as immunosuppressive therapies can help slow disease progression. For young patients admitted to the hospital with cirrhosis, in addition to taking a thorough drug exposure history, internists need to work up autoimmune causes. Internists play an essential role in treating and consulting appropriate specialties for consideration of liver transplants as well.

“IT’S NEVER LUPUS…”

Olaoluwa Omotowa¹; Audrey York¹; Lara Hayes². ¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²General Internal Medicine - Hospitalist, University of Utah Health, Salt Lake City, UT. (Control ID #4064061)

CASE: A 69-year-old male with no significant past medical history presented to an outside Emergency Department (ED) with a two-week history of pleuritic chest pain, cough, and dyspnea. He was hospitalized and treated for pneumonia. A 4 cm anterior mediastinal mass was incidentally found on CT. Labs were notable for WBC of 16.7 and elevated C-reactive protein (CRP). Due to non-resolving symptoms he left and presented to our institution’s ED with complaints of pleuritic chest pain.

On arrival he was febrile, tachypneic, and hypoxemic. Physical exam showed elevated JVP, pericardial rub, and bibasilar diffuse crackles on lung exam. ECG showed diffuse ST elevations in inferolateral leads. Emergent cardiac catheterization showed non-obstructive coronary artery disease. CT chest demonstrated moderate pericardial effusion, bilateral pleural effusions, and mediastinal mass measuring 5.6 cm. TTE showed circumferential effusion. Thoracentesis removed 400ml of exudative fluid with lymphocytic predominance. WBC was 22.7 and CRP 22.5. ANA, dsDNA, and rheumatoid factor were elevated with CCP antibodies, ANCA panel, and C3/C4 normal. Infectious work-up was negative. Alpha fetoprotein, beta-hCG, acetylcholine receptor antibodies, and flow cytometry of peripheral blood was normal.

The patient provided additional history of migratory non-erythematous joint swelling. PET/CT demonstrated hypermetabolism in the right anterior mediastinal mass but no other FDG-avid lesions. CT surgery deferred biopsy of the mass due to concern for pleural seeding in setting of possible thymoma. Rheumatology was consulted due to patient’s positive serologies, serositis, and reported synovitis. His hypoxia and chest pain improved with hydroxychloroquine for presumed systemic lupus erythematosus (SLE), prednisone for serositis, and NSAIDs and colchicine for pericarditis. He underwent resection of the mediastinal mass after discharge with pathologic diagnosis of type AB thymoma.

IMPACT/DISCUSSION: This case represents an example of autoimmune disease associated with concurrent thymoma in an older patient presenting with signs and symptoms of SLE (serositis, joint involvement, fever, and positive serologies). The relationship between thymoma and autoimmune has previously been described in the literature with the most common presentations of SLE being joint involvement, cytopenias, cutaneous involvement, serositis, and renal involvement. While thymectomy is the recommended treatment, the effect on SLE disease activity is not clear, and further immunologic effects of thymectomy on the course of SLE is still to be elucidated.

CONCLUSION: - Our patient met diagnostic criteria for SLE based off of positive serologies, serositis, and reported synovitis.

- Diagnostic consideration of autoimmune conditions is warranted in patients presenting with mediastinal masses, even in older adults.

- Response to treatment with thymectomy is varied with reports for SLE both responding well to thymectomy, worsening, or occurring following thymectomy.

Clinical Vignette - Medical Education and Training

A DIAGNOSTIC AND THERAPEUTIC DILEMMA: DELIRIUM TREMENS OR ALCOHOLIC ENCEPHALOPATHY

Muhammad A. Khan¹; Sonia Mukhtar²; Kristin A. Swedish³; Muhammad A. Munir⁴. ¹Internal Medicine, Montefiore Wakefield Campus, Bronx, NY; ²Lahore Medical and Dental College, Lahore, Punjab, Pakistan; ³Medicine, Division of General Internal Medicine, Montefiore Medical Center, New York, NY; ⁴Internal Medicine, Montefiore Health System, Bronx, NY. (Control ID #4063999)

CASE: A 63-year-old man with alcohol use disorder and withdrawal seizures presented with jaundice, global confusion, visual hallucinations, and tremors. His last drink was two days before the presentation. He had tachycardia, tachypnea, scleral icterus, ascites, was disoriented with visual and tactile hallucinations, and ataxia. Labs revealed total bilirubin 6.3 mg/dl (<1.2 mg/dl), alkaline phosphate 145 U/L (<130 U/L), aspartate aminotransferase 100 U/L (50 U/L), Ammonia 46 umol/L (<60 umol/L) and INR 1.6 (0.9-1.2), MELD score of 19. CT abdomen revealed a cirrhotic liver with portal hypertension and splenic varices. He was initially started on Lorazepam with CIWA protocol, lactulose, rifaximin, and high-dose thiamine due to overlapping signs and symptoms of delirium tremens and alcoholic encephalopathy. His mental status deteriorated, and the decision was made to stop benzodiazepines. He was then started on intravenous N-acetylcysteine protocol with dramatic improvement in clinical condition, becoming alert and oriented with resolution of tremors and hallucinations.

IMPACT/DISCUSSION: Alcohol use disorder has a 17.8% lifetime prevalence. Abrupt discontinuation of alcohol intake results in the development of alcohol withdrawal symptoms that can range from tachycardia, tachypnea, and tremors within six to twelve hours of the last drink to seizures, hallucinations, delirium, and coma within 72 hours of the last drink. Benzodiazepines are the standard treatment for alcohol withdrawal. Alcoholic encephalopathy is diagnosed clinically, presenting with a triad of ataxia, ophthalmoplegia, and global confusion; its diagnosis is missed in almost 80% of cases, due to overlapping signs and symptoms of alcoholic withdrawal syndrome. Studies investigating the use of Benzodiazepines in patients with cirrhosis have revealed that use for more than two days can worsen encephalopathy. Our patient presented with overlapping signs and symptoms of Delirium tremens and Alcoholic encephalopathy leading to the therapeutic challenge of treating with benzodiazepines or not. Initial treatment with Lorazepam worsened his clinical condition. His rapid clinical improvement with high-dose thiamine, lactulose, rifaximin, and N-acetylcysteine indicated that he likely had alcoholic encephalopathy rather than withdrawal. As Benzodiazepines are metabolized by the liver, impaired liver function prolongs their half-life, leading to potential accumulation and increased sedation.

CONCLUSION: The decision to use benzodiazepines in patients with suspicion of alcohol withdrawal or worsening liver condition should be made on a case-to-case basis, assessing the risk of withdrawal symptoms and worsening encephalopathy.

APIXABAN INDUCED CUTANEOUS LEUKOCYTOCLASTIC VASCULITIS

Hillary K. Deveaux¹; Katelyn Garza¹; Laarni Quimson². ¹internal medicine, Advocate Christ Medical Center, Oak Lawn, IL; ²Rheumatology, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #4018615)

CASE: 88-year-old male PMH of stroke from carotid artery stenosis s/p endarterectomy, abdominal aortic aneurysm, peripheral vascular disease, coronary artery disease s/p coronary artery bypass graft and HTN, diagnosed with an unprovoked left common femoral and popliteal DVT October 2023 and initiated on apixaban. Three days later, he developed spontaneous ecchymosis and petechiae to bilateral lower extremities. Apixaban was reduced from 10mg to 2.5mg BID over two weeks. The rash progressed to his upper extremities. He denied dyspnoea, cough, hemoptysis, chronic nasal congestion, chronic sinusitis, epistaxis, xerostomia, recurrent pneumonia, haematuria, abdominal pain, diarrhoea, rectal bleeding or joint pain. He presented hypertensive with well-demarcated, violaceous palpable purpuric and petechial lesions on bilateral lower extremities, forearms and hands. Labs revealed Cr 2.46, WBC 3.6, Hb 11.2, platelets 363, INR 1.1, negative ANA/ANCA, hepatitis B/C and urinalysis without proteinuria/haematuria. Naranjo algorithm score was 9 (definite adverse drug reaction). Apixaban was withdrawn. Biopsy revealed superficial neutrophilic inflammation, endothelial necrosis, karyorrhexis and red blood cell extravasation, indicative of leukocytoclastic vasculitis. Corticosteroid taper was initiated and lesions progressively improved. He was discharged on Coumadin.

IMPACT/DISCUSSION: Cutaneous leucocytoclastic vasculitis (LCV) is a small-vessel vasculitis with an incidence of 38.6 per million. Aetiology is classified as; idiopathic (most common) or secondary (infectious: Hepatitis B/C, Syphilis, HIV, autoimmune: Sjogrens, Chron’s Disease, Rheumatoid arthritis, mixed connective tissue disease, malignancy: lymphoma, lymphoproliferative disorders, drug-induced: penicillin, NSAIDs, thiazides, phenytoin, allopurinol, methimazole, hydralazine, anticoagulants. Drug reactions cause 30% of cases. The interval between exposure to the culprit agent and rash onset is variable, occurring between 7-21 days. Systemic LCV is typically associated with positive ANCA titers, whereas cutaneous LCV is less frequently associated. Tissue eosinophilia is a reliable indicator of drug-induced cutaneous LCV, however was not observed in this case. Biopsies weren't performed to confirm the possibility of glomerulonephritis given negative urinalysis and ANCA. The mainstay of treatment is cessation of the inciting drug. Addition of corticosteroids is debatable, with no guidelines available to suggest dose and duration, unlike systemic LCV, refractory cases and those involving skin necrosis that does. Anticoagulation with a different molecular structure can be safely initiated, however, high-level evidence is lacking to confirm this.

CONCLUSION: Direct oral anticoagulants have exponentially increased in use, primarily due to their low side effect profile. Adverse reactions may become more prevalent with continued prescription for various diseases. Apixaban is a rare but important cause of leukocytoclastic vasculitis.

APPROACH TO EVALUATING A COMMONLY ENCOUNTERED COMPLAINT: WEAKNESS

Jessica Comerford. Internal Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4062261)

CASE: A 51-year-old male with history of Crohn’s and CIDP presented to the clinic in 4/2023 with several years of worsening upper and lower extremity weakness, pain, and numbness. He was initially evaluated in 10/2017 with nerve conduction studies (NCS) showing a demyelinating peripheral neuropathy, leading to diagnosis of acute inflammatory demyelinating polyneuropathy (AIDP), thought to be secondary to TNF-alpha inhibitor use. He was started on steroids with improvement, however, was re-hospitalized in 1/2018 for worsening symptoms, that again improved with treatment. Subsequently, he was lost to follow-up until he presented to the clinic in 4/2023, citing repeated incarcerations and homelessness as barriers to care. On re-evaluation his symptoms had progressed to profound weakness and ataxic gait. He has missed several neurology appointments, therefore has not been started treatment.

IMPACT/DISCUSSION: Weakness is a common complaint with a broad differential of neurologic and systemic causes (endocrine, autoimmune, infectious, medications/toxins). Evaluation starts with lesion localization. UMN involvement requires MRI to evaluate for CNS pathology, whereas LMN involvement, as in the case of my patient, requires evaluation with NCS/EMG to evaluate for a peripheral process. In this case, the patient had NCS findings supportive of large axon demyelination, prompting the diagnosis of demyelinating polyneuropathy (as opposed to the more commonly encountered distal axonopathies). The presence of elevated CSF protein without pleocytosis was suggestive of an inflammatory etiology. In the case of CIDP, a progressive demyelinating peripheral neuropathy, symptoms present with progressive weakness and pain over at least 2 months. There are many inciting triggers including infections (e.g., HIV, hepatitis), autoimmune disease (e.g., SLE, IBD), neoplasms (e.g., MGUS), and medications (e.g., TNF-a inhibitor), but the mainstay of treatment regardless of cause is immunosuppression with corticosteroids, plasmapheresis, and IVIG, with response in 50-75%, although generally with a relapsing, remitting course with eventual disability. This is likely more pronounced in patients who are homeless and experience barriers to accessing care leading to interruption in treatment and therefore worse health outcomes.

CONCLUSION: - The first step in evaluating weakness involves localization, followed by either MRI or NCS/EMG.

- CIDP is an inflammatory myelinopathy responsive to steroids, but with relapsing, remitting course.

- Patients with chronic diseases who are homeless have worse outcomes.

A RARE CASE OF ADULT ONSET STILL DISEASE

Mrudula Beesetty¹; Fadila Noor¹; Hussan Rahim²; 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 #4055614)

CASE: The patient is a 72-year-old male with past medical history of nonobstructive coronary artery disease, osteoarthritis s/p right hip replacement 7 years ago, hyperlipidemia who presented to the ER complaining of fever and arthralgias for one month. He reported fevers up to 102 °F and arthralgias in bilateral knees, hands, and fingers, associated with decreased appetite and 10-pound weight loss. Prior to presentation, he completed a 14-day course of doxycycline for possible tickborne illness. Due to lack of improvement in his symptoms, he presented to the ER. On presentation, he was noted to have leukocytosis with WBC 26,500 per μLc, elevated AST (42 U/L), elevated inflammatory markers (ESR 64 mm/hr, CRP 38.4 mg/liter). He was admitted for management of fever of unknown cause. CT chest/abdomen/pelvis showed bilateral pulmonary nodules but no acute processes. Tick borne disease panel was negative. Blood cultures were also negative. Due to suspicion for inflammatory disorder, further diagnostic work-up was pursued, and demonstrated: ferritin 7500 mcg/L, elevated LDH (295 U/L), but negative ANA, rheumatoid factor and anti-CCP. CPK was normal at 23 U/L and X-ray of hands showed polyarticular osteoarthritis. As the patient met four major Yamaguchi criteria and two minor criteria, he was diagnosed with adult-onset Still disease and was started on tapering dose of steroids which relieved his symptoms. He was discharged home on hospital day 5 with plan to follow up with rheumatologist outpatient.

IMPACT/DISCUSSION: Adult onset Still disease (AOSD) is a multisystemic auto inflammatory disorder.

It occurs secondary to macrophage and neutrophil activation, which leads to release of pro-inflammatory cytokines, including interferon gamma, tumor necrosis factor alpha, and interleukins 1, 6, 8, and 18. It can be triggered by infectious etiology or environmental triggers.

Potential pathogens include both viruses and bacteria. Rubella, measles, Echovirus 7, Coxsackievirus B4, Cytomegalovirus, and Epstein–Barr virus, Mycoplasma pneumoniae, Chlamydia pneumoniae, Yersinia enterocolitica, Brucella abortus, and Borrelia burgdorferi have all been reported as infectious triggers. The typical presentation for AOSD includes quotidian fever or double quotidian fever, skin rash, arthritis. Yamaguchi criteria are used to diagnose AOSD. It is comprised of 4 major and 5 minor criteria, of which a patient must meet five (with at least two major). Major criteria include: fever of at least 102.2 F lasting a week; arthritis lasting two weeks; leukocytosis; non-pruritic macular or maculopapular skin rash. Minor criteria are: sore throat; lymphadenopathy; hepatomegaly/ splenomegaly; abnormal liver function tests; negative tests for RF and ANA. The first line of treatment is usually NSAIDS or glucocorticoids with addition of DMRDs if symptoms are uncontrolled.

CONCLUSION: Although AOSD is an uncommon diagnosis, it is important to consider as part of the differential diagnosis of patients with daily fevers.

A UNIQUE CASE OF CHYLOUS ASCITES AS AN INITIAL PRESENTATION OF LUPUS NEPHRITIS IN A MIDDLE AGE MAN.

Mariya Pogorelova¹; Bright Thilagar². ¹GIM, Mayo Clinic Minnesota, Rochester, MN; ²Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4036323)

CASE: 54 years old male with past medical history of with CAD s/p CABG, diabetes mellitus with proteinuria presented with diffuse lymphadenopathy, 90 pound weight loss, peripheral edema, pleural effusions, ascites and pericardial effusion requiring pericardial window that complicated his post op recovery. He was also on Semaglutide which was thought to contribute to his weight loss. His primary complaint during the clinic visit was persistent ascites despite paracentesis done twice and ongoing weight loss. Our initial workup revealed proteinuria, severe vitamin-D deficiency, hypoalbuminemia, elevation of liver enzymes, hypocalcemia, elevated CRP, mild anemia, creatinine 1.48, cystatin C of 1.82, ANA with titer of 1:320, but DS DNA negative. Initial suspecion was a malignant process. Repeated paracentesis done post clinic visit revealed high total protein and high triglycerides. Cytology specimens was negative for malignancy. Cross sectional imaging including PET scan also did not reveal malignancy. Inguinal lymph node was biopsied twice and was found to be benign as well. Suspecting a possible liver pathology he underwent transjugular liver biopsy which only showed nonspecific inflammation and steatosis without cirrhosis. His creatinine continued to increase needing a kidney biopsy that showed membranous nephropathy with mesangial proliferation suggesting an underlying autoimmune condition likely lupus nephritis ISN/RPS class V. Arterioles showed no definite hyalinosis. No vasculitis, fibrinoid necrosis or thrombi was seen on the biopsy. Prednisone 60 mg daily was started and in 4 weeks he significantly improvement with improving renal function and normalizing of serum proteins and improved proteinuria.

IMPACT/DISCUSSION: Patients initial presentation was concerning for a cardiac etiology given his prior CABG surgery. However subsequent workup showed he had anasarca and thrid spacing due to significant lupus nephritis in the post operative period. He had extensive malignancy workup with PET scan, lymphnode biopsies and ascitic fluid cytology. Our case was unique as his renal function and inflammatory markers were not signficantly eleveted prior to development of ascites, pleural and pericardial effusions. His ascitic fluid was also chylous in nature which is not a common presentation of Lupus nephritis. It is important to consider an autoimmune pathology in a patient with a presentation similar to ours.

CONCLUSION: Ascites is a marker of peritoneal irritation and had been detected in 8 to 11% of lupus patients. Chylous ascites most always diagnosed at later stage of SLE and is uncommon to be initial presentation of disease. The underlying mechanism of chylous ascites and SLE is poorly understood. Chronic inflammation of lymphatic vessels results in lymphatic stenosis or obstruction, and increase in luminal pressure and permeability vascular walls. Glucocorticoids and immunosuppressants are suggested treatment options to relieve symptoms to improve prognosis in such patients.

COLD AGGLUTININ SYNDROME UNMASKED: LEGIONELLA AND G6PD AS STEALTHY CONTRIBUTORS

Muhammad H. Khan¹; Marlon Rivera Boadla¹; Samir Cabrera²; Triccia Aparicio². ¹Medicine, Maimonides Medical Center, Brooklyn, NY; ²Kaplan Inc, New York, NY. (Control ID #4064754)

CASE: A 66-year-old woman, morbidly obese with hypothyroidism, type 2 diabetes, and a history of unexplained anemia, was hospitalized for hematuria and a two-week productive cough worsening at night. Examination revealed tachycardia, tachypnea, and bilateral lung base crackles. Admission labs showed a WBC of 16.3 K/UL, Hb of 6.6 gm/dL, PLTs of 342 K/UL, total bilirubin 5.9 mg/dL, direct bilirubin 7 mg/dL, and indirect bilirubin 4.2 mg/dL. CT imaging revealed bilateral lower lobe bronchiolitis and consolidations. Two units of packed red blood cells were transfused, and empiric ceftriaxone and doxycycline were initiated. Hematology consultation due to indirect hyperbilirubinemia and hemolysis revealed positive findings: cold agglutinin (titer 1:1280), Mycoplasma IgG and IgM, direct antiglobulin test IgG and C3, legionella antigen, G6PD deficiency, and Haptoglobin levels <20. Negative results were obtained for viral hepatitis, Epstein-Barr virus, and HIV. Serum protein electrophoresis, serum-free light chain, and immunofixation were all negative. The diagnosis was cold agglutinin autoimmune hemolytic anemia secondary to Mycoplasma pneumonia, Legionella pneumonia, and G6PD deficiency. Treatment included prednisone (1mg/kg) and warmth. Hemolysis improved during pneumonia treatment, yielding clinical progress. Despite hemoglobin fluctuations, no extra transfusions were needed due to stable hemodynamics.

IMPACT/DISCUSSION: Autoimmune hemolytic anemia (AIHA) results from the immune system targeting red blood cell antigens, categorized as warm or cold. Cold agglutinin antibodies, linked to IgM, activate at 3-4°C. Secondary AIHA, associated with infections, autoimmune diseases, and lymphomas, often involves Mycoplasma pneumonia. Primary cases are idiopathic. Legionella pneumonia rarely correlates with AIHA; five reported cases associate Legionella with AIHA, one involving cold agglutinin. For new Legionella-related anemia, recommend LDH, haptoglobin, and peripheral smear. If hemolysis is evident, including microspherocytosis, order a Coombs test. Post-resolution, hematology follow-up is essential. Recognizing G6PD deficiency in AIHA cases is crucial. Secondary CAS treatment involves addressing the underlying cause and supportive care.

CONCLUSION: Healthcare practitioners play a crucial role in detecting CAS in patients with atypical pneumonia and new-onset anemia. While Mycoplasma is often implicated, it is vital to consider Legionella pneumonia and the potential influence of G6PD deficiency in CAS development. Prioritizing warmth and judicious antibiotic selection is essential for effective CAS management. This patient-focused approach emphasizes the need for physicians to remain attentive to diverse causes, ensuring thorough and holistic care

EOSINOPHILIA: A RED HERRING IN THE DIAGNOSIS OF ANCA VASCULITIS

Claire Lo¹; Jennifer A. Woodard². ¹Medical School, Medical College of Wisconsin, Milwaukee, WI; ²Geriatrics and Palliative Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4034477)

CASE: A 20-year-old male presented to clinic with multiple non-painful, non-pruritic lesions on bilateral elbows and palms and one month of worsening migratory polyarthralgia. He was treated with naproxen, but clinically worsened, developing hemoptysis, epistaxis, fatigue, and dyspnea. In the hospital, serologic tests were positive for cANCA (1:320) and PR3. CBC demonstrated anemia (5.3 g/dl) and peripheral eosinophilia (16%, 1.42). A punch biopsy of his skin lesions demonstrated palisaded neutrophilic granulomatous dermatitis and bronchoalveolar lavage suggested diffuse alveolar hemorrhage (DAH). He was diagnosed presumptively with EGPA due to the peripheral eosinophilia and treated with pulse dose steroids. His course was complicated by acute kidney injury with proteinuria and pulmonary embolism, both of which are now improved

IMPACT/DISCUSSION: Granulomatosis with polyangiitis (GPA) and Eosinophilic granulomatosis with polyangiitis (EGPA) are multisystem diseases characterized by inflammation in small to medium sized arteries within the family of antineutrophil cytoplasm antibody associated (ANCA) vasculitis. GPA is most diagnosed during the sixth decade of life, while EGPA is seen at a slightly younger age [1,2,3,4].

Despite the patients youth, initially, his case suggested an ANCA vasculitis; however, there was debate between if EGPA or GPA was more likely. Renal involvement, +cANCA and PR3 are more commonly found in GPA than EGPA. Lack of eosinophils in his GI biopsy or skin lesions also supports GPA, but at the time of his initial diagnosis peripheral eosinophilia made EGPA a promising diagnosis, especially given his young age, despite having no history of asthma or nasal polyps. After initial treatment with steroids and Rituximab, his peripheral eosinophilia quickly resolved, making it a likely red herring in the diagnosis of his ANCA vasculitis.

1. Chung, Sharon A, et al. “2021 American College of Rheumatology/Vasculitis Foundation Guideline for Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis.” Arthritis & Rheumatology, vol. 73, no. 8, Aug. 2021, pp. 1366–1383, https://doi.org/10.1002/art41773.

2. Jariwala, Mehul, and Ronald M Laxer. “Childhood GPA, EGPA, and MPA.” Clinical Immunology, 11 Dec. 2019, sciencedirect.com/science/article/pii/S1521661619305376?fr=RR-2&ref=pdf_download&rr=7deeedab4c1c813d.

3. Qasim, Abdallah, and Jayesh B Patel. Anca Positive Vasculitis - Statpearls - NCBI Bookshelf, www.ncbi.nlm.nih.gov/books/NBK554372/. Accessed 29 June 2023.

4. Seo, PHilip, and John H Stone. “The Antineutrophil Cytoplasmic Antibody–Associated Vasculitides.” The American Journal of Medicine, 19 June 2004, www.sciencedirect.com/science/article/pii/S0002934304002396.

CONCLUSION: - ANCA Vasculitis, although classically seen in middle aged to older adults can also affect the youth.

- Peripheral Eosinophilia, although is found in 100% of EGPA cases, may also be present in GPA.

HEAT WAVES: A CASE OF RECURRENT FEVERS

Claire Morley, Veena Ganesan, Kenneth M. Fifer. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4064218)

CASE: JR, a 42-year-old male with a history of portal vein thrombosis treated with transjugular intrahepatic portosystemic shunt (TIPS) due to prothrombin gene mutation, presented with recurrent febrile episodes lasting 1-3 days associated with arthralgias, chills, and epigastric pain. His fever pattern was characterized by one day of malaise and chills, followed by a day of persistent elevation in temperature up to 103 °F. Arthralgias affected his bilateral wrists, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints. After his fever resolved, he experienced stomach pain and bloating for 1-2 weeks. This cycle repeated approximately every 2-3 months. Family history included a brother with rheumatoid arthritis and an uncle with systemic lupus erythematosus.

During febrile cycles, his blood work was recurrently significant for leukocytosis (up to 16.2) and elevated c-reactive protein (up to 27.7). Imaging revealed patent TIPS without abdominal pathology. Lab results following symptom resolution normalized. Further lab work-up showed a positive ANA with nuclear dot and speckled patterns. Other work up, including rheumatoid factor, anti-CCP antibodies, anti-smooth muscle antibodies, and IL-1/IL-6 were all within normal limits.

IMPACT/DISCUSSION: Here we demonstrate the presentation and work-up of periodic fever syndrome, specifically Familial Mediterranean Fever (FMF), the most common diagnosis in this category. FMF manifests as short febrile attacks (>38°C, 12 hours to 3 days) and is autosomal recessive, associated with the MEFV gene, and is particularly prevalent in Mediterranean populations. In working up periodic fever syndromes, one should consider infectious, inflammatory, and oncologic causes of cyclical fevers.

The diagnosis of FMF is made via the Tel-Hashomer criteria, with one major or two minor criteria necessary. Major criteria include recurrent febrile episodes with serositis, AA amyloidosis, and positive response to colchicine. Minor criteria include recurrent febrile episodes, erysipelas-like erythema, and family history of FMF.

A major long term complication of FMF is nephrotic syndrome due to amyloidosis which can be prevented with use of daily colchicine (1-4 mg daily). Colchicine, a microtubule inhibitor, has effects in several immunoregulatory pathways and is thought to interfere with microtubule assembly with neutrophils, preventing their migration and inflammatory response. This subsequently decreases the number of flares and potential for amyloid formation and deposition.

CONCLUSION: ● Patients with recurrent fevers should have infectious etiologies and hematologic malignancies ruled out prior to genetic syndrome work-up

● Starting colchicine at 1 mg per day prevents FMF flares and subsequent nephrotic syndrome due to amyloidosis

HYDROCORTISONE: YOU CAN CONTROL MY BOWEL, BUT NOT MY POTASSIUM.

Karla De Jesus Nunez. Medicine, Montefiore Wakefield Campus, New York, NY. (Control ID #4064806)

CASE: 58-year-old man with ulcerative colitis presented with bloody diarrhea for three weeks, associated with weight loss, low energy and abdominal pain. On exam, he had pale conjunctiva and diffuse tenderness to abdominal palpation most prominent suprapubic and left lower quadrant area. Laboratories revealed a significant drop in hemoglobin from 15.5 to 9.2 g/dl, hypokalemia, acute kidney injury, and elevated inflammatory markers. Stool testing was positive for enterotoxigenic and enteroaggregative Escherichia Coli, treated with azithromycin. Colonoscopy findings were typical for a UC flare, so hydrocortisone therapy was initiated with significant clinical improvement. After six days of steroid therapy, steroid taper was attempted, however, he developed septic shock. Treatment for fulminant colitis was initiated with bowel rest, aggressive fluid resuscitation, hydrocortisone, and antibiotics, with a favorable response. However, he remained significantly hypokalemic, complicated by ventricular arrhythmias, even with significant decrease in diarrheal episodes and aggressive repletion. Hydrocortisone was found to be the etiology, given its mineralocorticoid properties; treatment with methylprednisolone significantly improved his hypokalemia.

IMPACT/DISCUSSION: Hypokalemia and bloody diarrhea could be multifactorial. Related to bloody diarrhea treatment, it is not recommended to treat all patients with infectious bloody diarrhea, given evidence shows it can prolong the symptom duration and increase bacterial resistance. However, patients with inflammatory bowel disease are an exception and need treatment for infection. Nowadays, we are facing an increased number of inflammatory bowel disease cases, with most patients presenting with hypokalemia due to significant diarrhea. In this case, hypokalemia was initially caused due to gastrointestinal losses, followed by drug induced hypokalemia. Well known causes of hypokalemia have been described in literature, however, when a patient has multiple explanations, the etiology could be assumed to be monofactorial, when it could be explained by additional factors. Hydrocortisone, part of the initial standard therapy for ulcerative colitis flare, resulted to be the culprit. Evidence favors the use of methylprednisolone instead of hydrocortisone due to its absence of mineralocorticoid properties.

CONCLUSION: Hydrocortisone mimics aldosterone mechanism of action and can cause refractory hypokalemia and hypertension even with topical use. Patients with inflammatory bowel disease flare can be treated with methylprednisolone instead of hydrocortisone to avoid drug induced hypokalemia. Fulminant colitis can be seen in the setting of acute ulcerative colitis flare, septic shock could be the initial presentation. Treatment is based on fluids resuscitation, antibiotics and steroids.

NONSECRETORY MULTIPLE MYELOMA WITH AN AGGRESSIVE EXTRAMEDULLARY PRESENTATION

Mai Hamaad¹; Jairah Shaikh¹; Eman Alhussain¹; Mohamed Sleem¹; Mousab Diab¹; Letisha Mirembe²; Doan Ngoc Chau Nguyen¹; Mahmoud Elbadrawy¹; Mazin Saadaldin¹. ¹Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX; ²Medicine, Texas Tech University System, Lubbock, TX. (Control ID #4059012)

CASE: A previously healthy 50-year-old male, with a 2-month history of intermittent headaches associated with nausea and fatigue, was found to have an intracranial mass on his right temporal bone on imaging. Elective craniotomy and biopsy of the mass revealed a soft extradural neoplasm of monoclonal lambda light chains compatible with plasmacytoma. He was discharged after an uncomplicated recovery but was readmitted within 1 week due to dyspnea. Upon evaluation, he was in acute pulmonary distress requiring 2 L/min O₂ to maintain saturation, tachycardic, hypertensive, afebrile, and rales were present bilaterally. Initial labs showed mild leukocytosis with neutrophilic predominance, elevated lactate (4 mmol/L), elevated LDH (486 U/L), normal hemoglobin (17.2 g/dL), slightly elevated creatinine (1.5 mg/dL), and normal Ca (9.5). Recurrent bilateral pleural effusions were seen on imaging and drained periodically to relieve his respiratory distress. The fluid was exudative with degenerated plasma cells and poorly detected light chains. Imaging revealed a sternal mass which was found to be consistent with lambda-chain plasmacytoma. Urine, serum immunofixation and free light chain assays were unrevealing. He was started on bortezomib, dexamethasone, cisplatin, doxorubicin, cyclophosphamide, and etoposide. He had developed transient febrile neutropenia but otherwise had good tolerance. However, prior to receiving his 2nd cycle, he developed fever and worsening respiratory failure. His condition rapidly deteriorated over the course of 1 week, and he ultimately succumbed to multiple organ-system failure.

IMPACT/DISCUSSION: MM is a proliferative disorder of plasma cells that results in an uncontrolled monoclonal secretion of gamma immunoglobulins, accounting for 17% of hematologic malignancies. MM arises from the bone marrow; however, approximately 15% have extramedullary presentation at the time of diagnosis. A subset of MM, known as non-secretory multiple myeloma (NSMM), occurs in less than 5% of cases, wherein, there is no detectable monoclonal gammopathy and a normal free light-chain ratio is seen in urine and serum immunofixation. Consequently, NSMM does not present with the typical symptoms associated with end-organ damage. Despite diagnostic challenges associated with NSMM, this case was recognized early, owing to a high degree of clinical suspicion, and appropriate chemotherapy was promptly administered. Unfortunately, this aggressive extramedullary presentation resulted in the patient’s demise within 3 months of symptom onset and 1 month of diagnosis.

CONCLUSION: The rarity of this disease, limited data, atypical presentation, and absence of biomarkers, pose significant challenges in diagnosis and management. The absence of a monoclonal protein in serum and/or urine does not rule out the diagnosis of MM. Diagnosis of non-secreting myeloma should be made in patients with clinico-biological and radiological characteristics of MM with a normal ratio of Kappa/Lambda free light chains.

OVERLAPPING AUTOIMMUNE CONDITIONS: AN UNCOMMON TRIAD.

Rukia Ramza¹; Hajra Nadeem¹; Kennedy Johnson¹; Natalia Plotskaya²; Daniel F. Goldsmith²; Ramza R. Hussain³. ¹Internal medicine, Capital Health, Trenton, NJ; ²Internal Medicine, Capital Health, Trenton, NJ; ³Internal medicine, Capital Health - East Trenton, Trenton, NJ. (Control ID #4065002)

CASE: A 49-year-old female with a past medical history of hypertension, longstanding Raynaud's phenomenon, and a 30-pack-year smoking history presented to the ED with worsening pain, numbness, and weakness of both hands and feet. She stated that symptoms started a year ago with her left foot and were initially mild, but progressed over the year to both feet and hands. The patient developed difficulty walking and was requiring a walker. She had difficulty holding utensils or performing other fine motor skills with her hands. A physical exam revealed minor sclerodactyly and telangiectasias on the face and chest. Cyanosis involved the third through fifth digit on the right foot. Digital ulceration was visualized on the left index finger. Muscle strength during wrist extension was 4/5 bilaterally, on finger flexion and extension was 3/5 bilaterally, dorsiflexion and plantar flexion was 3/5 bilaterally. Bilaterally decreased sensation to light touch, pain, and vibration from mid-forearm down to the fingertips and below the knee to the toes was more pronounced in the lateral aspect of the distal legs. MRI of the brain showed small acute infarcts in the right centrum semiovale, left thalamocapsular region, and left periatrial region. The patient was found to have positive ANA titer with centromere pattern >1:1280 along with a positive cardiolipin IgM antibody of 122 MPL unit/mL. Centromere B antibodies titer was above 8.0 AI, anti-dsDNA increased to 11 IU/mL, anti-cyclic citrullinated peptide (anti-CCP) antibodies were at 193 units, and rheumatoid factor was 50.9 IU/ml. She had persistent difficulty ambulating due to sustained numbness in both feet. She is currently receiving rituximab infusions, hydroxychloroquine, atorvastatin, and anticoagulation with warfarin and has reported improvement in joint pain and extremities paresthesia.

IMPACT/DISCUSSION: Antiphospholipid syndrome (APS) is common in the setting of systemic lupus erythematosus but its presence with other mixed connective tissue diseases is poorly studied. Antiphospholipid antibodies are found in about 14% of systemic sclerosis (SS) patients and about 30% of rheumatoid arthritis (RA) patients. APS hypercoagulability in the setting of SS patients with Raynaud’s phenomenon can lead to severe rare organ complications, such as digital necrosis requiring amputation. Yet the unique combination of APS, SS, and RA can be treated with a single medication, rituximab.

CONCLUSION: Autoimmune diseases within the same classification such as APS in the setting of SS and RA is an uncommon triad. Further studies are needed to better determine the prevalence of APS with SS and RA. Despite a low percentage of patients presenting with overlapping syndrome it is imperative to recognize the condition to prevent delay in starting immunotherapy and anticoagulation which can save the patient from cerebrovascular disorders and thrombotic complications.

SKIN ULCERS IN PERSONS WHO INJECT DRUGS

Sunam Kafle¹; Sally Tayel¹; Bryan Rubio²; Valerie Cluzet³. ¹Internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Internal Medicine, Vassar College, Poughkeepsie, NY; ³Medicine/Infectious Diseases, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4063987)

CASE: A 41-years-old male with history of seizures and IV drug use presented to the ED for multiple painful skin wounds that developed gradually over bilateral upper and lower extremities. In the ED, he was hypothermic (95.2 F) but otherwise vitally stable. Lab work showed leukocytosis (WBC 42.7 cells/ml) with neutrophilia (count 82.5/ml). Urine drug screen was positive for cocaine. Examination showed diffuse ulcers over upper and lower extremities with areas of necrosis, eschar, and purulent discharge. CT scan showed extensive wounds in all extremities with multilocular abscess in the lower extremities. The patient was admitted for sepsis secondary to cellulitis and was started empirically on vancomycin and piperacillin-tazobactam. He underwent serial surgical debridement and transferred to the ICU for postoperative care. Wound cultures grew group A beta-hemolytic streptococci and MRSA. The patient self-extubated the following day, and was stable from respiratory standpoint, but remained in the ICU for agitation requiring dexmedetomidine. Given the unknown cause of his ulcers, ANCA level was checked for suspected cocaine induced vasculitis, but was negative. Pathology report showed benign skin ulceration with acute inflammation and no evidence of vasculopathy. The patient remained hemodynamically stable and was transferred to the medical floors. He completed a 10-day course of antibiotics and was discharged on hospital day twelve.

IMPACT/DISCUSSION: Chronic skin ulcers have been reported in PWID (persons who inject drugs). Cocaine injection mixed with levamisole is known to cause skin lesions; however, it is associated with neutropenia, agranulocytosis, vasculopathy and positive ANCA levels, which was not shown in our patient. On the other hand, xylazine use with opioids is currently spreading to the drug supply and the number of cases reported with skin ulcers is increasing in PWID. Xylazine is an alpha-2 adrenergic receptor agonist that has direct vasoconstrictive effect on local blood vessels resulting in decreased skin perfusion with risk of ulceration, infection, and ischemia regardless the site of injection. Our patient presented with diffuse ulcers which were most likely secondary to xylazine. Patients can also develop acute toxicity manifesting as bradycardia, hypotension, and respiratory depression. Naloxone hasn’t shown benefit in overdose management since xylazine is not an opioid. Also, withdrawal is more complex and may require clonidine use

CONCLUSION: The use of xylazine has been significantly increasing and should raise clinical suspicion in PWID presenting with skin ulcers. More studies are needed to inform management of acute toxicity and withdrawal symptoms.

SYMPTOMATIC HYPOGLYCEMIA WITH COADMINISTRATION OF TRIMETHOPRIM-SULFAMETHOXAZOLE AND SULFONYLUREAS

Fadila Noor¹; Hussan Rahim². ¹internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4064055)

CASE: 78-year-old male with history of hypertension and type 2 diabetes was brought in by ambulance after a seizure-like episode witnessed by family. Emergency medical service providers found his blood glucose to be 26 by point-of-care measurement; he was given 10% dextrose after which he became responsive. At home, patient was on metformin 500 mg, glimepiride 2 mg and Jardiance 10 mg once daily. Two days prior to presentation he finished a seven-day course of trimethoprim-sulfamethoxazole(TMP-SMX) for an uncomplicated urinary tract infection. In the emergency department he was awake and oriented. Vitals and physical exam were normal. On arrival his blood glucose was 128. The metabolic panel lab work revealed blood glucose to be 32, glucometer revealed blood glucose 46. He was given 37.5 g of 50% dextrose and food with improvement in repeat blood sugar to 88. Critical care was consulted and the patient was admitted to step down for symptomatic hypoglycemia. Glucose was monitored every 2 hours. Glimepiride and other diabetes medications were held, patient was started on peripheral intravenous infusion of dextrose 10% in water at 20 ml/hour. The next day, HbA1c resulted as 5.5%, blood sugar had improved and consistently in 180s. The 10% dextrose drip was discontinued and patient discharged on sitagliptin 50 mg with close endocrinology follow up in two weeks.

IMPACT/DISCUSSION: Hypoglycemia may be an adverse effect of certain drugs. The likelihood of this adverse effect depends on the dose of the drug, coadministration with other drugs and comorbidities such as renal insufficiency. TMP–SMX may rarely cause hypoglycemia with mainly neurogenic symptoms, such as a change in mentation or seizures. It is more commonly seen in those over 60 years of age. The onset of hypoglycemia may be up to a week after TMP-SMX. The mechanism is thought to be related to a structural similarity between sulfamethoxazole and sulfonylurea; resulting in increased insulin secretion. Studies have found an elevation of insulin and C-peptide levels after administration of the drug. Consequently, hypoglycemia may persist for more than 8 hours in about 95%. The risk of recurrent hypoglycemia may be treated by discontinuation of the drug. Also, treating with intravenous glucose may be necessary to prevent recurrent hypoglycemia; glucagon in case of refractory hypoglycemia along with octreotide to reduce insulin release.

CONCLUSION: It is essential for providers to be aware of hypoglycemia as a potential adverse effect of drugs. Especially when prescribing medications in an elderly patient with renal insufficiency already on sulfonylureas.

THE LONE WOLF IN THE WILD: SOLITARY COLONIC POLYP DIAGNOSED AS MANTLE CELL LYMPHOMA

Carly Hubers¹; Mahvish Renzu²; Dakshin S. Padmanabhan²; Vinushree Swamy³; Adam M. Qazi⁵; Alexander M. Satei⁴; Geetha Krishnamoorthy². ¹Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Trinity Health Oakland Hospital, Pontiac, MI; ³Pathology, Trinity Health Oakland Hospital, Pontiac, MI; ⁴Radiology, Trinity Health Oakland Hospital, Pontiac, MI; ⁵Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4027208)

CASE: A 62-year-old Caucasian male, with a history of hypertension, psoriasis, anxiety, insomnia, benign prostatic hyperplasia, and basal cell carcinoma, presented with worsening dysphagia and a mild change in voice. Physical examination and routine labs were unremarkable. Gastroenterology referral led to esophagogastroduodenoscopy and colonoscopy; the latter revealed an ascending colon polyp. Biopsy confirmed mantle cell lymphoma (MCL). Immunohistochemistry (IHC) showed CD20, CD5, cyclin D1 positivity, and Ki-67 proliferation index of 10%. PET/CT imaging demonstrated left-sided peritonsillar uptake, bilateral mediastinal and hilar lymphadenopathy, and mild retroperitoneal lymphadenopathy, staging this as MCL stage 3. Bone marrow biopsy revealed no significant infiltration, and cytogenetic analysis showed no additional chromosomal abnormalities. This manifestation of MCL as an isolated gastrointestinal (GI) lesion without significant marrow involvement is atypical, emphasizing the need for a high index of suspicion in similar cases.

IMPACT/DISCUSSION: MCL is an aggressive form of non-Hodgkin lymphoma characterized by the translocation t(11;14)(q13;q32), leading to overexpression of cyclin D1, a crucial cell cycle regulator; this has been recognized as the key oncogenic step. Typically, MCL involves lymph nodes, bone marrow and extranodal sites like the spleen.

This case is a prime example of MCL's atypical presentation, uniquely manifesting as a solitary colonic polyp. This unusual presentation challenges the conventional understanding of MCL. The diagnosis of MCL in a patient with an isolated colonic polyp underscores the disease's heterogeneity and diagnostic complexity.

Given the patient's relatively younger age and good performance status, a more aggressive treatment approach was adopted. This involved ibrutinib, along with alternating cycles of R-CHOP and R-DHAP chemotherapy, targeting curative outcomes. Post-treatment, the patient exhibited clinical improvement, although he faced chemotherapy-related adverse effects. This underscores the importance of personalized treatment plans in MCL, considering individual patient factors.

Moreover, the case highlights the critical role of comprehensive histopathological evaluation and immunohistochemistry in MCL diagnosis. The identification of molecular markers, such as CD20, CD5, cyclin D1, and Ki-67 proliferation index, was instrumental in confirming the diagnosis and guiding treatment. The presence of a TP53 mutation further emphasizes the need for molecular profiling in predicting disease behavior and guiding therapeutic decisions.

CONCLUSION: This case reveals the rarity of MCL presenting as a lone colonic polyp, emphasizing the necessity for histopathological and immunohistochemical analysis in similar clinical scenarios. It demonstrates the importance of considering MCL in differential diagnoses of GI lesions, highlighting the value of detailed molecular characterization in guiding treatment strategies and prognostication.

THREE STUDENTS LIVING IN THE SAME DORMITORY CONSECUTIVELY VISITED WITH SIMILAR ABDOMINAL PAIN. WHAT HAPPENED?

Ukyo Inoue¹; Kazuo Komamura³; Takahisa Suzuki⁴; Mitsunori Iwase². ¹Clinical Division No.1, Toyota Kinen Byoin, Toyota, Aichi, Japan; ²Cardiology, Toyota Kinen Byoin, Toyota, Aichi, Japan; ³Dept. of Rehabilitation, Toyota Kinen Byoin, Toyota, Aichi, Japan; ⁴Gastroenterology, Toyota Kinen Byoin, Toyota, Aichi, Japan. (Control ID #4062741)

CASE: Case 1

On April X, the first 15-year-old student experienced vomiting and diarrhea, followed by epigastric pain at 12:00 a.m. He arrived at the emergency department by 2:00 p.m. Examination revealed epigastric tenderness without rebound or muscular guarding. CT scan confirmed thickening of the pyloric region of the stomach. Esophagogastroduodenoscopy (EGD) revealed map-like black spots and ulcers in the antrum with a positive rapid urease test. Blood tests showed positive H. pylori antibodies. acute gastric mucosal lesion (AGML) associated with H. pylori was diagnosed and, treated with vonoprazan for one week, resulting in symptomatic improvement. Subsequent eradication therapy was successful.

Case 2

On April X-1, the second 15-year-old student experienced vomiting, diarrhea, and epigastric pain. He visited our gastroenterology department on April X+1. Examination revealed epigastric tenderness without rebound or muscular guarding. The CT findings were similar to those of Case 1. Urea breath test and H. pylori antibody tests were positive. He was diagnosed with AGML associated with H. pylori, and received the same treatment.

Case 3

On April X, the third 15-year-old student complained of epigastric pain and vomiting. He sought outpatient care on April X+1. Examination revealed epigastric tenderness without rebound or muscular guarding. The CT findings were similar to those of Case 1. Urea breath test was positive, but H. pylori antibodies were negative. A diagnosis of AGML associated with H. pylori was made and the same treatment was performed.

IMPACT/DISCUSSION: The diagnostic criteria for AGML associated with H. pylori remain undefined, but include extensive swelling, adherent clots, or ulcers in the gastric vestibule on endoscopy, confirmation of H. pylori presence in the gastric mucosa, and negative serum antibodies. Case 3 fulfilled these criteria, suggesting AGML due to an initial H. pylori infection. Cases 1 and 2, despite simultaneous onset in the same dormitory, may indicate initial high-antibody onset, natural clearance, reinfection, or potential strain variation from persistent infection.

H. pylori transmission is primarily oral, including practices such as sharing saliva, well water, feces, endoscopes, or dental procedures, with some cases of unknown origin. The fact that all patients were freshmen and became ill within a month of living together suggests a communal route of infection through areas such as the cafeteria, toilets, showers, or large baths, although definitive evidence remains elusive.

CONCLUSION: Three concurrent cases of AGML were encountered in a dormitory setting, suggesting the possibility of communal H. pylori infection possibly due to the living environment.

TISSIERELLA PRAEACUTA BACTEREMIA IN THE SETTING OF NECROTIZING FASCIITIS

Sunam Kafle, Bryan Rubio, Sally Tayel, Nili Gujadhur. Internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4063977)

CASE: A 68-year-old female with history of diabetes, hypertension, and chronic sacral ulcer secondary to immobilization from a work-related injury presented to our hospital with altered mental status. On presentation, the patient was hypotensive (76/52 mmHg) and tachycardiac (102 bpm). Physical exam was remarkable for stage IV sacral ulcer measuring 13 cm x 24 cm x 4.5 cm with granulation, necrotic tissue and serosanguineous drainage. Laboratory work showed leukocytosis (WBC 21.4 cells/fl). She received fluid resuscitation, piperacillin-tazobactam and vancomycin. CT abdomen and pelvis showed acute diffuse posterior pelvic subcutaneous emphysema concerning for necrotizing fasciitis, so patient underwent sharp excisional debridement. Wound culture grew group G beta-hemolytic streptococci and few Bacteroides species. Blood culture subsequently showed gram-negative bacteremia secondary to Tissierella praeacuta, so antibiotics were transitioned to ampicillin-sulbactam. CT venogram of the abdomen and pelvis revealed increased tissue loss in the sacrum concerning for acute osteomyelitis. A central catheter was inserted to continue intravenous antibiotics for a total of six weeks. Patient’s condition remained guarded due to poorly healing sacral ulcer; she was continued on local wound care and discharged to subacute rehab facility.

IMPACT/DISCUSSION: Tissierella praeacuta is one of five species in the Tissierella genus that has lately been identified in clinically significant infections. It was found to be an etiologic agent in septic pseudoarthrosis, brain abscess, eye lid gangrene, diabetic foot osteomyelitis, and pyonephrosis with hepatic abscess. It was also reported to cause bacteremia in chronic infected ulcers. This is the first case to report Tissierella praeacuta bacteremia in a patient with necrotizing fasciitis of a chronic sacral decubitus ulcer. Although the wound cultures didn’t show the organism, the source of bacteremia was presumed to be from the patient’s sacral wound in the setting of constant fecal and environmental exposure. Identification of this organism was noted to be difficult and previously required specific systems to adequately isolate on culture which may mean this organism has historically been underdiagnosed. MALDI-TOF is an analytical technique that allows accurate identification of specific species, including Tissierella. It has been shown to have 95% accuracy and provides faster results.

CONCLUSION: This case highlights that with the advances in diagnostic systems in the microbiology lab, formerly considered rare organisms may be more frequently reported. Furthermore, physicians should consider Tissierella praeacuta when a patient presents with sepsis secondary to a chronic open wound.

Clinical Vignette - Medical Ethics and Humanities

EMPOWERING VOICES IN VULNERABILITY: PRIORITIZING PATIENT AUTONOMY AMIDST DECISION-MAKING CAPACITY CHALLENGES

Nita Chai²; Lauren M. Gensler¹; Abigail Clark³. ¹Internal Medicine/Psychiatry, Emory University School of Medicine, Atlanta, GA; ²General Medicine, Emory University School of Medicine, Atlanta, GA; ³Internal Medicine and Psychaitry, Emory University Woodruff Health Sciences Center, Atlanta, GA. (Control ID #4063721)

CASE: An 88-year-old woman presented with confusion, pneumonia, and bacteremia. We met the patient’s daughter, “S” at bedside and she agreed to antibiotic therapy and admission.

Our team then received calls from family claiming that “S” was starving, neglecting, and physically abusing the patient. They also said there were Adult Protective Service (APS) cases in other states, but that “S” moved the patient to avoid APS investigations. The patient’s ongoing delirium limited verification of claims.

After a few days, “S” expressed dissatisfaction with hospital care. She said she was medical Power of Attorney (mPOA), but did not bring documents to verify this, and would remove the patient against medical advice. Legally, the patient’s four adult children were next of kin in the absence of a mPOA or spouse and they had to make a unanimous decision for care to proceed. “S”, alone, wanted the patient to be discharged. The unit’s social worker was unable to verify any APS investigations or malintent, so “S” could not be removed as a surrogate.

Without surrogate consensus or the patient having consistent DMC, the medical team utilized sliding scale decision-making to prioritize patient autonomy and minimize surrogate involvement. This strategy considers 1) risk of the proposed treatment, 2) its degree of benefit, and 3) whether the patient can accept or refuse treatment1.

We modified decisions to the patient’s capacity level by simplifying treatment choices and minimizing treatment risks, ensuring choices were medically appropriate. We verified treatment choices with the patient, without family present, over multiple days and engaged unit staff to document the patient’s choices and understanding. This strategy allowed us to be patient-centered and respect patient autonomy. It removed the treatment team from familial discord, and led to a safe discharge plan for the patient.

IMPACT/DISCUSSION: Patient autonomy is a central tenant of medical ethics. When patients lack DMC, their surrogates are entrusted to use substituted judgement, choosing what they believe the patient would want2.

In this case, the surrogates could not reach consensus. This challenging legal and ethical scenario gave us an opportunity to use the patient’s capacity level as a guide to shape treatment choices. This case highlights the importance of engaging patients at their capacity level to improve autonomy and care.

CONCLUSION: -The sliding scale approach to medical management incorporates the nuanced nature of capacity

-It is a useful tool to support patient autonomy

INPATIENT MANAGEMENT OF INCARCERATED PATIENTS: A CASE OF ULCERATIVE COLITIS CAUSES ETHICAL DILEMMAS

Hannah Freibert¹; Anna Maria South². ¹College of Medicine, University of Kentucky College of Medicine, Lexington, KY; ²Internal Medicine, University of Kentucky, Lexington, KY. (Control ID #4036967)

CASE: A 47 year old man with ulcerative colitis (UC) on infliximab presented from state prison for acute severe UC (ASUC) flare. Colonoscopy revealed pancolitis and the patient was initiated on corticosteroids. Since the patient failed initial biologic therapy, a trial of upadacitinib was indicated to induce remission. Colectomy as alternative therapy was discussed. The patient elected medical therapy. The prison refused to pay for upadacitinib after discharge and voiced a preference for surgical management.

IMPACT/DISCUSSION: This case exemplifies ethical dilemmas that arise when caring for incarcerated patients. UC may progress to severe stage, causing systemic inflammation as seen in this patient. Given ambiguity in clinical guidelines for medical versus surgical management, it is helpful to consider the clinical outcomes, financial impact, and medical ethics that are specific to the patient case. Upadacitinib, a Janus kinase (JAK) inhibitor, functions as a salvage therapy for patients with ASUC who previously failed to respond to infliximab, an anti-tumor necrosis factor (TNF). A recent systematic review recommends trial of JAK-inhibitors in anti-TNF exposed patients prior to colectomy. Colectomies have increased risk for complications leading to readmissions compared to medically managed patients, though no studies directly compare upadacitinib to early colectomy. Adjusted hospitalization costs for patients with ASUC flare are higher with colectomy than medically responsive patients.

Autonomy is a core principle of medical ethics, but this tenant was obstructed when the jail failed to offer him access to both treatment options. Incarcerated persons are entitled to healthcare under interpretation of the 8th amendment, but this criterion does not ensure that therapy is the recommended standard of care. Detention centers are within legal right to deny medications given alternative therapies, including more invasive procedures, are offered. Given the risks associated with surgical management, increased hospital costs, and treatment barriers imposed in the setting of his incarcerated status, our case demonstrates a violation of all four medical ethics principles (beneficence, nonmaleficence, autonomy, and justice).

CONCLUSION: ASUC which has failed anti-TNF therapy can proceed to a third line agent, such as upadacitinib, or undergo surgical intervention with colectomy. Our case highlights challenges in medical decision making as well as medical ethics. Our patient’s autonomy to pursue an informed decision was compromised by his detention institution, which reserves the right to deny certain medications. While incarcerated patients are entitled to healthcare, current legal protections do not extend far enough to facilitate equitable care, making it imperative that hospitalists advocate for this vulnerable patient population. The hospitalist's continuous advocacy for this patient with the prison resulted in approval of upadacitinib, enabling equitable, patient-centered care.

RIGHT TO SELF-DETERMINATION: ETHICS IN CARING FOR A PATIENT LIVING WITH HIV DECLINING ANTIRETROVIRALS

Katia Vernord¹; Rebecca Glassman^2,1. ¹Internal Medicine, Westchester Medical Center Health Network, Valhalla, NY; ²medicine, Westchester Medical Center, Valhalla, NY. (Control ID #4064491)

CASE: A 29-year-old woman living with HIV and miliary tuberculosis (TB) was referred to a multidisciplinary HIV Primary care clinic for intensive case management and adherence support. The patient was receiving direct observed therapy (DOT) from the Department of Health (DOH) for miliary TB, but was failing this intervention and also inconsistently taking antiretrovirals (ART). In addition to side effects reported from medications, the patient had significant life stressors from childcare and her employment contributing to interruptions in her treatment course. The patient's health deteriorated, despite community outreach and attempts to gain her increased assistance with adherence. Ultimately, she had progressively worsening mental status and was admitted to the hospital. Her laboratory results revealed a CD4 count of 72 and an HIV viral load of 9460. CT brain showed a large right frontotemporal lesion concerning for an opportunistic infection. The patient was treated for viral and toxoplasmosis meningoencephalitis. Throughout her hospitalization, the patient’s mentation fluctuated with periods of declining life-saving interventions. The patient was ultimately determined to lack any capacity for decision-making. A sibling was designated as a surrogate for major health decisions and provided informed consent for gastrostomy tube placement for nutritional support and administration of essential medications. The patient’s immune system recovered. Her mental status improved slightly but did not return to baseline.

IMPACT/DISCUSSION: Ethical dilemmas commonly arise for clinicians when a patient declines life-saving interventions resulting in suboptimal care. It becomes challenging for clinicians to preserve the right to self-determination when a patient's decision-making capacity is impaired by a severe illness. This case highlights ethical considerations in caring for an HIV-positive patient with inconsistent adherence to antiretroviral therapy resulting in an AIDS-defining illness. The right to forgo life-saving treatment, despite its adverse health consequences, is well-rooted within the concept of patient autonomy. When patient counseling fails, clinicians have little ethical or legal power to coerce a patient into treatment adherence. When a patient lacks decision-making capacity, the clinician might rely on substitute judgment from a healthcare proxy or surrogate to act in the patient's best interests. In this case, a family member, acting on behalf of the patient, provided informed consent for a gastrostomy tube for administration of antiretroviral therapy and adequate nutrition which was life-saving.

CONCLUSION: A patient's medication non-adherence often interrupts optimal care delivery, especially in cases where treatment can be curative and life sustaining. Limited health literacy, limited social determinants of health (SDOH), and mental health conditions are important factors contributing to therapeutic adherence, and need to be addressed by a multidisciplinary team.

Clinical Vignette - Mental/Behavioral Health and Substance Use Disorders

A CASE OF COMPLICATED PRECIPITATED OPIOID WITHDRAWAL IN THE ERA OF HIGH-POTENCY SYNTHETIC OPIOIDS

Samuel Trump¹; Geoffrey Pucci²; Mim Ari³. ¹Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Department of Pharmacy, The University of Chicago Medicine, Chicago, IL; ³Medicine, University of Chicago, Chicago, IL. (Control ID #4064384)

CASE: A woman presented to the emergency room requesting treatment for opioid use disorder (OUD) having used heroin 1 day prior. Her Clinical Opiate Withdrawal Scale (COWS) score was 0 but she endorsed mild withdrawal symptoms. Her toxicology screen was positive for fentanyl. She was given 4-1mg of buprenorphine-naloxone (BUP-NLX) at 8am and 8-2mg at 9am. At 10am, her COWS score was 17, prompting another dose of 8-2mg BUP-NLX at 11am. She became increasingly agitated and soon stopped following commands. Her COWS score increased to 24 by 12pm, and she was given benzodiazepines and clonidine. She was then intubated for airway protection and required fentanyl, propofol, and dexmedetomidine while in the intensive care unit. The patient was extubated two days later. She declined BUP-NLX re-initiation and was started on methadone. She had a self-directed discharge two days later but agreed to follow up at an opioid treatment program the day after discharge for methadone continuation.

IMPACT/DISCUSSION: There are increasingly high rates of high-potency synthetic opioids (HPSO), including non-pharmaceutical fentanyl (NPF), in illicit drugs in the United States. NPF poses increased overdose risk because of greater potency and half-life compared to heroin. Patients and providers may be unaware of how NPF might affect opioid withdrawal and initiating treatment for OUD.

BUP-NLX is highly effective in treating OUD, but initiation can precipitate withdrawal if administered while full-opioid agonists are present. Prior to the NPF era, buprenorphine could be safely initiated with predictable effect based on withdrawal symptoms and last opioid use. With higher rates of NPF, clinicians should take a thorough history, measure accurate COWS scores, and evaluate for presence of NPF on urine toxicology to avoid precipitated opioid withdrawal (POW). In this case, buprenorphine induction likely precipitated severe withdrawal leading to intubation. Preventing POW is important for patient safety and to avoid worsening buprenorphine stigma among both patients and providers. Using low-dose induction protocols, which are designed to mitigate POW, is one strategy, though the longer time to reach a therapeutic dose is a drawback. Another strategy to combat POW is high-dose induction, in which patients are rapidly initiated on high doses of buprenorphine once mild withdrawal symptoms are present. This promotes full agonist blockade while still mitigating withdrawal symptoms via adequate partial agonism with large doses.

CONCLUSION: Providers should be aware of increased presence of HPSO in illicit drugs.

Further study and continued adaptations to buprenorphine initiation, as well as education for both health care teams and patients, are necessary to optimize use of this life-saving medication for OUD.

A LAUGHING GAS MATTER

Tatiana Correa, Pranav S. Ramamurthy, Gunjan Gupta, Christine Bryson, Lauren Meade, Mihaela Tiru, Zaid Obaida, Vincent Mariano. Baystate Medical Center, Springfield, MA. (Control ID #4063924)

CASE: The use of nitrous oxide (NO) is a rising concern for its euphoric and hallucinogenic effects, particularly among adolescents. Chronic use of NO leads to complications of vitamin B12 deficiency including macrocytic anemia, peripheral neuropathy, and spinal cord compromise. NO also induces homocysteinemia predisposing an individual to thrombotic events. This case report explores the complex manifestations of NO use, emphasizing the need for awareness and comprehensive management strategies.

IMPACT/DISCUSSION: A 43-year-old male with a past medical history of alcohol, marijuana use, and NO use presented with altered mental status, urinary retention, and progressing left leg swelling for three months. Social history revealed substance use in his teenage years requiring rehabilitation. Upon presentation, he was tachycardic, but remained hemodynamically stable without hypoxia. Positive findings included left leg swelling, lethargy, hallucinations and mimicking NO inhalation. Initial workup revealed normocytic anemia and a negative toxicology and infectious screen. CT head with/without contrast was normal. Chest CT angiography revealed multifocal bilateral pulmonary embolism in the left and right upper and lower lobe segmental, subsegmental branches and in the distal right pulmonary artery. Ultrasound of the left leg revealed evidence of extensive thrombus and a heparin drip was started.

The patient had a cobalamin level of 172pg/mL. He showed improvement in mental status, urinary retention and gait after receiving daily cobalamin 1000mg IV, thiamine 200mg IV three times a day with pyridoxine, and olanzapine at 2.5mg twice a day for five days.

After being discharged on apixaban, the patient denied further NO use. However, labs showed elevated homocysteine and methylmalonic acid levels, prompting suspicion. Following an empowering discussion, the patient acknowledged continued NO use and sought treatment for substance use disorder.

CONCLUSION: Most cases of nitrous oxide (NO) use occur in young adults, primarily in their late teens to early 30s and a few cases in middle-aged adults. While literature documents instances of peripheral neuropathy due to NO abuse, only a limited number involve simultaneous presentation of encephalopathy, peripheral neuropathy, and pulmonary embolism. Recovery from NO-related complications poses challenges during and after hospitalization, but a patient-centered approach led to the patient acknowledging NO use and seeking assistance for substance use disorder.

A NOVEL USE OF METHADONE UNDER THE “72-HOUR RULE” TO FACILITATE A LOW-DOSE BUPRENORPHINE INDUCTION

Sabetta Singh¹; Minaliza Shahlapour²; Paul J. Christine³; Jordana Laks^4,5; Natalija Farrell^6,7; Karim Khan^4,5; Jessica Taylor^4,5; Hallie Rozansky^4,5. ¹Internal Medicine Residency Program, Boston Medical Center, Boston, MA; ²East Boston Neighborhood Health Center, East Boston, MA; ³Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ⁴Section of General Internal Medicine, Boston Medical Center, Boston, MA; ⁵Grayken Center for Addiction, Boston Medical Center, Boston, MA; ⁶Department of Pharmacy, Boston Medical Center, Boston, MA; ⁷Department of Emergency Medicine, Boston Medical Center, Boston, MA. (Control ID #4054163)

CASE: A 36-year-old man with opioid use disorder (OUD) presented to an outpatient bridge clinic to start buprenorphine. He had a history of severe precipitated opioid withdrawal (POW) when he tried to switch from fentanyl to buprenorphine on his own. He was therefore offered a low-dose buprenorphine induction, a novel strategy that may reduce the likelihood of POW.

Patients typically continue to use non-prescribed opioids (i.e., fentanyl) during the early phases of a low-dose induction, since the subtherapeutic doses of buprenorphine initially used do not effectively treat opioid withdrawal symptoms. This patient wished to stop fentanyl use immediately. Thus, after shared decision-making, he received methadone under the “72-hour rule” for withdrawal treatment during his low-dose induction. He successfully transitioned to buprenorphine without POW or significant concomitant fentanyl use and remained stable on buprenorphine for seven months, his longest period in remission at the time.

IMPACT/DISCUSSION: The “72-hour rule” allows providers to administer methadone for up to 72 hours to treat opioid withdrawal or initiate OUD treatment even if they do not work in licensed opioid treatment programs (OTPs). The “72-hour rule” has primarily been used for patients entering long-term methadone treatment. Here, we describe how short-term methadone facilitated a buprenorphine induction in a patient who wished to continue long-term buprenorphine.

POW is a well-described challenge in transitioning from full opioid agonists to buprenorphine. Patients using nonprescribed fentanyl anedoctally report higher rates of POW, potentially due to fentanyl’s lipophilicity, and challenges achieving sufficient periods of abstinence to avoid POW. Low-dose inductions may mitigate the risk of POW, but most rely on initial continuation of a full opioid agonist (i.e., fentanyl, in the absence of an alternative option). However, ongoing fentanyl use carries a risk of opioid overdose and further morbidity.

The success of this patient and others in transitioning to buprenorphine with overlapping methadone prompted us to formally incorporate methadone withdrawal management in our bridge clinic’s low-dose buprenorphine protocol. Anecdotally, we see less POW with methadone than with ongoing nonprescribed fentanyl use. This case demonstrates the powerful impact of effective outpatient opioid withdrawal management with methadone and introduces a novel application of the “72-hour rule.”

CONCLUSION: Low-dose buprenorphine induction with overlapping methadone treatment has potential to expand buprenorphine access to patients unwilling or unable to do traditional inductions, including those with a history of POW.

BREAKING THE CHAINS OF THE MIND: INVESTIGATING PSYCHOGENIC ORIGINS OF BRITTLE DIABETES.

Daniela Carralero-Somoza¹; Michael Sabina²; Juan C. Rivera Martinez¹; Luis Daniel Lugo Rosado¹. ¹Internal Medicine Residency, Lakeland Regional Medical Center Inc, Lakeland, FL; ²Internal Medicine - GME, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4014882)

CASE: Patient is a 28-year-old female with past medical history of type 1 diabetes mellitus, hypertension and chronic kidney disease who was admitted to the intensive care unit (ICU) with diagnosis of diabetic ketoacidosis (DKA). DKA management and protocol was initiated. Patient also complained of acute on chronic back pain, and she was given morphine in the emergency department. Shortly after patient developed pruritus in her whole body and requested Benadryl. During her stay in the ICU patient still complained of back pain and continuously requested stronger pain medications and Benadryl. Upon physical examination patient cried upon palpation of the paraspinal lumbar region. She also complained of bilateral lower extremity pain upon palpation of the calf muscles. Multiple diagnostic testing including bilateral lower ultrasound, and multiple imaging of the back showed no acute or chronic abnormalities. Patients pain medication protocol was lowered and narcotics tried to be avoided for possible sedative interest or drug seeking behavior. Patient's DKA resolved within 2 days, but patient still reported acute pain. When she was ready to be transferred to the floors, patient started developing episodes of hypoglycemia after 12 AM every day. This prevented the ICU from transferring her to the floors given the fluctuations of blood sugars. Her hypoglycemia episodes, were single events and were unexplainable given the amount of insulin and food intake patient was receiving every night. Upon chart investigation patient was seen for the past 3 years every month with similar symptoms. Patient in her last hospitalization was found to have unexplainable episodes of hypoglycemia and security was called and found used insulin syringes in her purse. She also complained of pain in different body parts in every admission. During this hospitalization patient was questioned and denied any use of home insulin. Psychiatry was consulted and counseling was provided to the patient. Patient did not have any more episodes of hypoglycemia and was transferred out of the ICU with resolutions of her symptoms.

IMPACT/DISCUSSION: Thorough chart review can give answers that might help elucidate possible causes of discrepancies on patient's presentation. A multidisciplinary approach can lead to accurate diagnosis and appropriate management for improved patient outcomes. It is important to assess and investigate the reasons for patients presenting with frequent visits to the hospital and rule out underlying psychological diagnosis or stressors. In depth chart review is of essence to assess previous visits and hospital courses.

CONCLUSION: When confronted with patients exhibiting unexplained symptoms despite multiple investigations, healthcare professionals should remain vigilant for potential psychogenic causes, besides medical factors. Distinguishing between medical and psychogenic causes requires a comprehensive evaluation, including medical history, clinical examinations, laboratory tests and specialist team.

CONCURRENT TRANSCRANIAL MAGNETIC STIMULATION AND KETAMINE THERAPY: A MORE ACCESSIBLE ALTERNATIVE TO ELECTROCONVULSIVE THERAPY FOR TREATMENT-RESISTANT DEPRESSION?

Katherine Sommers¹; Ronald Sommers². ¹Wayne State University School of Medicine, Detroit, MI; ²Psychiatry, Therapeutic Solutions, Spokane, WA. (Control ID #4025368)

CASE: A 46-year-old female with a prior medical history of severe TRD visited her psychiatrist in a small outpatient clinic endorsing an active relapse into a major depressive disorder (MDD) episode with severe symptoms impacting her work, social life, and physical health. The patient’s psychiatrist administered a Hamilton Depression Rating Scale Assessment (HAM-D) to the patient, and her score was 29. A HAM-D score of 23 or higher indicates very severe depression. She previously achieved remission during a prior MDD episode by an electroconvulsive therapy (ECT) course performed 5 years ago, but has been unable to receive ECT again due to accessibility issues. She reported that she was referred to a hospital that offered ECT on a limited basis to those strictly receiving inpatient care. The patient was unwilling to receive care in an inpatient setting because she would be unable to work and care for her family. She reported worsening symptoms of depression, hopelessness, and suicidal ideation despite a treatment regimen consisting of cognitive behavioral therapy and therapeutic doses of duloxetine, buspirone, olanzapine (as antidepressant augmentation) and doxepin for insomnia. After thoroughly discussing her options with her psychiatrist, concurrent trials of subacute intravenous ketamine infusions and theta burst transcranial magnetic stimulation (TMS) therapy sessions were started. The patient received intravenous ketamine infusions twice weekly for three weeks followed by one treatment per week as maintenance and TMS sessions performed in office by her psychiatrist five times weekly for seven weeks. After both trials were finished, she endorsed a full recovery and a HAM-D score of 0.

IMPACT/DISCUSSION: TRD is a severe subset of major depressive disorder defined by the failure of two adequate antidepressant medication trials. ECT is the current gold standard for TRD. Although ECT has proven to be efficacious in the treatment of TRD, it has been under-utilized in TRD cases due to accessibility issues. Access to ECT in the United States is limited in rural areas, outpatient settings, and to the underinsured and uninsured.

This case highlights how concurrent TMS and intravenous ketamine infusion therapy can improve severe symptoms in TRD patients that have otherwise only been responsive to ECT. TMS is safe, well-tolerated, does not require patients to undergo generalized anesthesia, and can therefore be performed in small outpatient clinics with minimal staffing requirements. Ketamine similarly can be administered in small outpatient clinics. The effectiveness of TMS and ketamine individually as interventions for TRD is well-established, however data is scant on combining these interventions in prior ECT-responders. Due to the inaccessibility of ECT, it is worthwhile for providers to consider combination TMS and ketamine therapy to effectively treat severe TRD.

CONCLUSION: TMS and intravenous ketamine therapy have become increasingly popular as ECT remains inaccessible to many.

EXPERIENCING HEALTHCARE AS A VETERAN PATIENT WHO INJECTS DRUGS: LESSONS FOR HEALTHCARE PROVIDERS

Beth Dinges¹; Tessa L. Rife-Pennington^2,4; Minh Q. Ho³; Brandie Wilson⁵. ¹Pharmacy, VA Illiana Health Care System, Danville, IL; ²Pharmacy, San Francisco VA Health Care System, San Francisco, CA; ³Infectious Disease, Orlando VA Healthcare System, Orlando, FL; ⁴University of California San Francisco, San Francisco, CA; ⁵Transforming Re-entry Services, Chicago, IL. (Control ID #4057636)

CASE: This is a 60-year-old male Veteran who is employed at a community syringe services program and resides in subsidized housing on the rural West coast. He has long history of homelessness, intravenous methamphetamine use, and healthcare avoidance. “I’m treated like dirt, as soon as they see my arms”. One year ago started a string of frequent emergency room visits and admissions to a community hospital, related to a new diagnosis of heart failure, bluntly communicated to him as “meth heart”. Patient-reported conversations with healthcare providers fixated on drug use and the need for abrupt cessation; however, “I’m upfront about my use, but then it’s every 15 minutes someone’s asking if I just shot up.” “I said my body couldn’t handle cold turkey. Maybe I could slow down or benefit from medication, but that wasn’t mentioned.”

Later while visiting his friend/former employer/healthcare proxy in rural Midwest, he was admitted to a regional community hospital where his experience was markedly different. This entailed in-depth conversations about medications options/importance and respect/recognition for his Veteran status. Only once was he asked about drug use. These interactions spurred positive harm reduction outcomes, including improved medication adherence, changing from injecting to smoking/snorting, and reduced overall methamphetamine use. It also spurred his decision to voluntarily enter private residential treatment after returning home to rural West coast.

He was provided transportation to the residential treatment facility located eight hours from his home. Soon after, he expressed desire to leave; however, the facility would not his return belongings or arrange for transportation until four days later, requiring ample time and outreach from his healthcare advocates. Fortunately, he has not experienced recent acute issues, but ongoing challenges impact his care, including ineligibility for Veterans Affairs cardiac telehealth due to current methamphetamine use and lack of local contingency management therapy.

IMPACT/DISCUSSION: People who use drugs (PWUD) experience incredible stigma in healthcare settings, often presented with abstinence as the only option. Evidence supports harm reduction strategies, such as switching from injecting to other routes of use, to reduce risk for overdose and infections; however, these conversations were not intiially had. Further, lack of inclusive healthcare clinic policies, regulatory oversight, and geographic proximity to evidence-based treatments represent ongoing barriers to care. There are no standardized decision aids for the clinical care of PWUD and because of the complexities of each case, there may never be; hence the need to learn from them at the individual level.

CONCLUSION: There’s a long way to go to change the engrained paternalistic and policing culture of healthcare towards PWUD. Sharing cases such as his helps each of us to examine our own bias and to how to push for broader change.

GETTING A RHYTHM ON METHADONE

Suraj S. Shah, Erin Rieger, Erik S. Carlson, Roger Lin, Mytra Haerizadeh. Internal Medicine, Columbia University Irving Medical Center, New York, NY. (Control ID #4064790)

CASE: A 72-year-old female on high dose methadone – 230 mg/day – for opioid use disorder presented to the Emergency Department (ED) after a witnessed fall. In the ED, she was found to have an acute hip fracture and planned for urgent surgical management. In the pre-operative area, she went into polymorphic ventricular tachycardia. She was electrically cardioverted and dosed IV magnesium. Electrocardiogram after this episode was notable for a corrected QT interval (QTc) of 752 milliseconds suggesting a diagnosis of torsades de pointes (TdP) in the setting of methadone use. She was admitted to the cardiac intensive care unit for transvenous pacing and QTc monitoring. Post-operative hip pain and opioid dependence management were key issues in the remainder of the hospital course. She preferred to remain on methadone for both of these indications and declined buprenorphine initiation, citing various biopsychosocial preferences. Multidisciplinary meetings were held amongst cardiology, orthopedics, acute pain management, and psychiatry to find a safe and patient-centered pain regimen. Following successful surgical repair of her hip fracture, she was ultimately discharged to a rehabilitation facility one month later on low dose methadone – 30 mg/day.

IMPACT/DISCUSSION: This case highlights the role of collaboration between multidisciplinary providers and taking a patient-centered approach, especially in persons with substance use disorders. A substance use disorder should be considered an active problem during hospitalizations. Methadone cardiotoxicity is dosedependent. Relevant risk factors include concurrent electrolyte abnormalities as the mechanism of toxicity relates to ion channel modulation in cardiac myocytes. QTc prolongation > 500 ms is seen in up to 16% of individuals, with TdP occurring in nearly 4% of individuals. Buprenorphine has significantly less cardiotoxicity; however, it may precipitate opioid withdrawal, a risk that concerned this patient. Various initiation regimens for buprenorphine have been studied to help minimize this side effect. The pharmacologic properties of buprenorphine also limit its analgesic effect – another consideration for this patient’s post-operative pain management. Ultimately, a patient-centered discussion that acknowledges risk and benefits is the most appropriate to ensure favorable patient-centered outcomes.

CONCLUSION: High dose methadone places patients at risk of long QT syndrome and requires close monitoring with dose escalation. The titration of methadone in a patient with methadone dependence requires patientcentered conversations grounded in an understanding of a patient’s social determinants of health and their existing medical co-morbidities.

MANAGEMENT OF BUPRENORPHINE-PRECIPITATED OPIOID WITHDRAWAL IN THE INPATIENT SETTING: TWO APPROACHES

Santana Sanchez¹; Catherine Callister². ¹Internal Medicine, University of Colorado Anschutz Medical Campus, University of Colorado Anschutz Medical Campus, Aurora, CO, US, academic/health, Denver, CO; ²Hospital Medicine, University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #4036463)

CASE: Case 1

A 28-year-old man with opioid use disorder (OUD) presented with opioid withdrawal. He was treated with 16 mg of buprenorphine (BUP), resulting in precipitated withdrawal characterized by worsening anxiety, restlessness, tachycardia, miosis, diarrhea, and the Clinical Opiate Withdrawal Scale (COWS) rising to 33. He was admitted to internal medicine and a high-dose BUP strategy was attempted to treat his precipitated withdrawal. An additional 16 mg of BUP was administered, COWS remaining at 33. Soon after, another 16 mg of BUP was given, and COWS decreased to 11. In total, he received 48 mg of BUP over 2 hours to control withdrawal symptoms. Over the following days, he was transitioned to scheduled BUP three times a day.

Case 2

A 38-year-old man with polysubstance use disorder presented for suboxone induction, with COWS of 7. He was treated with 8 mg of BUP, resulting in precipitated withdrawal, and his COWS increased to 28. A high-dose BUP strategy was then attempted, and an additional 32 mg of BUP was administered over the following 4 hours, without significant improvement in withdrawal symptoms, with his COWS remaining elevated at 25. At this point, the patient was transitioned to mu-opioid full agonist therapy. He received a total of 40 mg of methadone and 60 mg of oxycodone over the next 8 hours, with his COWS decreasing to 8. The following day he was transitioned to scheduled BUP, with the dose quickly titrated up to 8 mg three times a day by that evening. He was discharged on BUP 8 mg three times daily.

IMPACT/DISCUSSION: BUP, a mu-opioid partial agonist, is commonly used for the treatment of OUD. Because of its high affinity for the mu-opioid receptor, BUP has a propensity to displace other opioids, causing precipitated withdrawal if there is still full opioid agonist occupying the mu receptor at the time of BUP induction. Recently, fentanyl has become more prevalent among patients who use opioids, and these patients are at increased risk for developing precipitated withdrawal. Currently, there is no universally accepted method for the management of this condition. This case series demonstrates two distinct methods for managing BUP-precipitated opioid withdrawal in the inpatient setting. In the first case, higher doses of BUP were used to treat precipitated withdrawal symptoms. The second case demonstrates how this strategy can fail, as withdrawal persisted despite high-dose BUP. In this case, mu-opioid full agonists were used to manage withdrawal symptoms. In each case, the patient was successfully transitioned to a stable dose of BUP for ongoing treatment of OUD.

CONCLUSION: Precipitated withdrawal is characterized as the rapid onset or significant increase in intensity of opioid withdrawal symptoms within 1-2 hours of the administration of BUP.

Precipitated withdrawal can be managed with increased doses of BUP or by transitioning to mu-opioid agonists.

RECOGNIZING AND MANAGING STEROID-INDUCED CARDIOMYOPATHY IN AT-RISK POPULATIONS

Jody Tai. Internal Medicine, UCLA Medical Center Olive View, Sylmar, CA. (Control ID #4064443)

CASE: 47-year-old male with no known medical history presented for dyspnea that started six months ago most notably correlating with his first cycle of anabolic steroids (AS) that were taken to build muscle mass. He endorsed shortness of breath, paroxysmal nocturnal dyspnea, orthopnea and bilateral lower extremity edema that worsened in the past two weeks coinciding with the start of a second cycle of AS. Key social history involved smoking methamphetamines last 16 years ago and South America as country of origin. Physical exam was notable for a left lower sternal border systolic murmur, jugular venous distension to 12cm, and bilateral 3+ pitting edema to the knee. Labs showed pro-BNP of 1,587 pg/mL and chest x-ray with severe cardiomegaly and pulmonary vascular congestion. Transthoracic echocardiogram demonstrated reduced ejection fraction of 30-35% and severe hypokinesis in the right coronary artery distribution, but no epicardial disease on left-heart coronary angiogram. The patient was diuresed with IV furosemide and started on appropriate guideline-directed medical therapy including a beta blocker, angiotensin receptor blocker, SGLT2 inhibitor, aldosterone antagonist, and loop diuretic. He continues to follow with primary care and cardiology.

IMPACT/DISCUSSION: AS are defined as “any drug or hormonal substance chemically and pharmacologically related to testosterone” and are DEA schedule III drug due to their potential for abuse for enhancing muscle mass, with an estimated 1 million Americans experiencing AS use disorder(1). Although most side effects are reproductive or psychiatric, cardiovascular risk includes myocardial dysfunction, coronary atherosclerosis, arrhythmia, and concentric left ventricular hypertrophy. The pathophysiology behind AS-induced cardiomyopathy is not well understood, but a prevailing theory includes the induction of tissue fibrosis and apoptosis via androgen receptors present on cardiac myocytes(2). In this particular case, other differentials of new cardiomyopathy included both ischemia and non-ischemic causes including Chagas disease given the endemic region, viral, and methamphetamine-induced – all of which were ruled out with the appropriate workup.

CONCLUSION: AS abuse can lead to several cardiovascular complications, and unlike other drug-induced causes of cardiomyopathy such as amphetamines, it is unclear whether cessation of AS can also lead to reversal of the cardiomyopathy(2). Although no specific AHA guidelines have yet been developed in the management of AS-induced cardiomyopathy, this patient responded well to extrapolation of guideline-directed medical therapy management. Healthcare providers should maintain a high clinical suspicion of AS use in at-risk populations including athletes, men, but also non-athletes or patients of all genders and age presenting with signs of hyper- and hypogonadism. Recognizing the cardiovascular complications of AS use and a multidisciplinary approach should be implemented early in AS use management.

RESPIRATORY FAILURE REQUIRING INTUBATION FOLLOWING HIGH DOSE BUPRENORPHINE INDUCTION

Daniel Liauw, Evan Gale. Addiction Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4064235)

CASE: JJ is a 52yo caregiver with a history of severe opioid use disorder (OUD; 10g intranasal and injection use daily), moderate benzodiazepine use disorder, and mild COPD who was admitted for a fever to 105F.

JJ’s goal was to return home quickly to care for her partner after an expedited transition to buprenorphine. She previously sustained OUD remission with buprenorphine and preferred avoiding methadone, even for a time-limited period. She feared precipitated withdrawal. Inflexible methadone systems previously interfered with her caregiving capacity.

Thus, we held a PARQ (Procedure, Alternative, Risk, Question) conference and pursued a high-dose buprenorphine induction (HDBI) with informed consent. With last fentanyl use 24h prior to presentation, JJ was bridged with scheduled hydromorphone for 51h to afford fentanyl washout. This was followed by an 11h period without opioid agonists, representing 86hrs since fentanyl use. She received buprenorphine-naloxone 24-6mg over 3min. In 1h, her Clinical Opiate Withdrawal Scale escalated from 11 to 31, despite clonazepam 2mg. With a respiratory rate of 40 and SpO2 70% on bilevel positive airway pressure, she was intubated. Her exam was notable for flat neck veins and lack of peripheral edema.

Chest X-ray, compared to admission, demonstrated new pulmonary edema with pleural effusions, and echocardiography was without systolic or diastolic dysfunction. With mild diuresis, she was rapidly extubated to room air.

IMPACT/DISCUSSION: In the era of fentanyl and the overdose epidemic, there has been growing interest in HDBI. This approach utilizes buprenorphine’s increased mu-opioid receptor activation at high doses (i.e. > 8mg) to relieve withdrawal symptoms. However, data supporting the safety and efficacy of HDBI remains limited.

This case highlights a rare, adverse reaction to HDBI: non-cardiogenic pulmonary edema in the setting of precipitated withdrawal. Pulmonary edema has been associated with naloxone and opioid overdoses. Naloxone can trigger an adrenergic crisis, increasing pulmonary vasculature permeability; precipitated withdrawal might induce a similar adrenergic state.

Clinicians should consider the diagnosis of non-cardiogenic pulmonary edema, along with early initiation of diuretic therapy and positive pressure ventilation, in management of respiratory distress in the setting of precipitated withdrawal or opioid overdose. This case highlights the importance of caution and shared decision-making when considering HDBI. A PARQ conference offers standardization by explaining the planned procedure, alternative methods, associated risks, and questions. This is critical regardless of a patient’s prior buprenorphine experience, as safety of novel buprenorphine induction protocols continues to be understood.

CONCLUSION: Non-cardiogenic pulmonary edema is a rare, adverse outcome of precipitated opioid withdrawal. A PARQ conference offers standardization of shared decision-making, critical when considering novel buprenorphine induction protocols.

SICKLE CELL PAIN CRISIS EXACERBATED BY ANXIETY: A COMPLEX CASE REPORT

Neil K. Vuppala. Medical Student, Alabama College of Osteopathic Medicine, Dothan, AL. (Control ID #4023668)

CASE: We present the complex case of a 17-year-old African-American female referred to the child psychiatry clinic by St. Jude's Hospital. Her referral stemmed from recurrent, debilitating chronic pain episodes, leading to frequent visits to the emergency department and hospitalizations. Her primary medical condition is sickle cell anemia, with her struggle against pain crises commencing at the age of 10 only intensifying throughout her adolescence, resulting in substantial school absences. Concurrently, she was diagnosed with anxiety at 13, forming a complex interplay where one condition exacerbates the other. Additionally, her medical history includes a prior diagnosis of prolonged QT syndrome, which reached a critical point when she experienced a cardiac arrest with torsade de pointes. This medical history necessitated a careful approach to medication selection due to the expected adverse effect of QT prolongation associated with many 1st-line medications to treat her anxiety. In her family history, her younger sister was diagnosed with sickle cell anemia, while her brother possesses the sickle cell trait. The patient's surgical history includes a cholecystectomy and wisdom teeth extraction, and her medication regimen initially included folic acid, hydroxyurea, Asmanex, and Lortab.

IMPACT/DISCUSSION: Sickle cell anemia represents a genetic hemoglobin disorder marked by the distortion of red blood cells into a sickle shape, rendering individuals more susceptible to episodes of vaso-occlusive crises. These painful crises are known for their severity, with their frequency and intensity influenced by various factors, including emotional stress and anxiety. Additionally, anxiety can initiate a chain reaction of physiological responses. The release of stress-related hormones like adrenaline and cortisol may induce vasoconstriction, further obstructing the normal blood flow and exacerbating the sensation of pain. Additionally, anxiety can lower an individual's pain threshold, intensifying the perception of discomfort. This heightened pain perception may lead to "pain catastrophizing," wherein individuals interpret their pain as more severe than objective measures suggest. Furthermore, anxiety can profoundly affect an individual's overall quality of life, potentially leading to withdrawal from social interactions, heightened levels of worry, and intrusive obsessive thoughts. While the physiological mechanisms driving these vaso-occlusive crises are well-established, the impact of psychological factors remains a subject of significant clinical interest.

CONCLUSION: This case showcases the intricate relationship between chronic pain crises in sickle cell anemia and the amplifying effects of anxiety. The patient's heightened pain perception, physiological responses, and emotional distress underscore the crucial requirement for comprehensive care. This case emphasizes the necessity of a multidisciplinary approach to maximize the patient's overall well-being and quality of life.

SUICIDAL IDEATION IN COMPLEX REGIONAL PAIN SYNDROME

Jarom Morris, Sarah S. Petelinsek, Vidya Gopinath. Medical School, University of Utah Health, Salt Lake City, UT. (Control ID #4064777)

CASE: A 52-year-old male with a past medical history of complex regional pain syndrome (CRPS) diagnosed in 2017 presented for Emergency Room (ER) follow-up and persistent passive suicidal ideation (SI). The patient was seen in the ER two weeks prior for active SI and alcohol intoxication in the setting of worsening, intractable pain related to CRPS. He has tried multimodal pain management treatments with minimal success including opioids, lidocaine infusion, nerve blocks, and neurectomy. He began drinking alcohol as a pain management strategy. However, he does not have a history of alcohol use disorder and had not consumed alcohol since his ER visit two weeks ago. He has had no cravings or withdrawal symptoms. The patient has a history of active SI and multiple plans for ending his life but has made no suicidal attempts. He is married with a fulfilling career and is future-oriented with a good support system. He describes SI as exclusively secondary to his pain.

On general appearance, the patient had a limping gait with no assistive devices. He had no active SI, his mood was normal and appropriate, and he was oriented.

Comprehensive work up had been performed at time of CRPS diagnosis including evaluation by pain medicine, PM&R, sports medicine, general surgery, and gastroenterology. However, the patient had a minimal response to most treatments. We referred him to a psychiatrist, a new anesthesiology pain specialist, and an acupuncturist.

IMPACT/DISCUSSION: The overall prevalence of CRPS is low, but patients with CPRS are often high utilizers of healthcare. This patient was seen 92 times in the first year after symptom onset. Therefore, understanding CRPS management is important despite its rarity.

Psychiatric diagnoses commonly coexist with CRPS, including high rates of depression and anxiety. Rates of SI and suicide attempts in individuals with CRPS far exceed those in the general population. A survey of patients with CRPS estimated 20 percent had attempted suicide and 46 percent had experienced SI, with severity of pain as a significant risk factor. Given this population’s high risk, universal suicide screening is reasonable.

Studies on patients with chronic pain have found that detection and treatment of depression is decreased in this population. We suspect this is due to a general focus on pain management by both the patient and provider during clinical visits. Screening and management of comorbid psychiatric conditions is an important aspect of CRPS care.

CONCLUSION: - Screen CRPS patients for suicidality given their increased risk

- Multimodal management of CRPS should include diagnosis and treatment of psychiatric comorbidities

Clinical Vignette - Quality Improvement and Patient Safety

AN AUTOMATED AND ALGORITHMIC APPROACH TO TREATING HEART FAILURE EXACERBATIONS IMPROVES DIAGNOSIS

Priyanka Solanki¹; Eric J. Dueweke². ¹Department of Medicine, UPMC, Pittsburgh, PA; ²Heart and Vascular Institute, UPMC, Pittsburgh, PA. (Control ID #4064785)

CASE: A 92-year-old woman with grade 3 diastolic dysfunction heart failure (LVEF 65-70%) and valvular disease presented with two days of general malaise and dyspnea. She was found to have a new oxygen requirement, JVD of 13 cm H₂O, Cr 1.2 mg/dL, BNP 512 pg/mL, and pulmonary edema on her chest x-ray. She was admitted for a congestive heart failure (CHF) exacerbation. An institutional nurse driven CHF algorithm was immediately initiated. The algorithm allows for twice daily dosing of IV furosemide with or without additional thiazide diuretics based on daily changes of patients’ weights and creatinine. After three days of effective diuresis, the patient appeared to approach euvolemia but the algorithm triggered additional diagnostics given her ongoing oxygen requirements. A subsequent CT thorax demonstrated previously undiagnosed small airway disease for which she was prescribed a 5-day steroid course. Her O2 requirement quickly resolved and she was discharged on long-term ICS/LABA as well as maintenance diuretics.

IMPACT/DISCUSSION: CHF exacerbations rank among the leading causes of hospitalizations in the US, with a 1-year survival rate of only 30-40% for patients. Despite its high prevalence, few algorithms exist which guide the inpatient management of and treatment for CHF exacerbations. Many guidelines are generalized and recommend the expertise of a trained cardiologist. In comparison to other physicians, patients with CHF exacerbations managed by cardiologists have lower readmission rates and improved 30-day mortality. Yet, increasingly non-specialized providers are treating these patients thus clinical algorithms can improve and guide management. This protocolized approach emphasizes evidence-based methods for managing CHF exacerbations, including frequent and aggressive diuresis, daily monitoring of weights and serum creatinine, and allowing providers the opportunity to consider additional diagnoses. For this patient, after the algorithm indicated euvolemia, additional diagnostic evaluation with CT imaging allowed for a concurrent diagnosis of reactive airway disease with subsequent appropriate management with inhalers and steroids.

CONCLUSION: > As the frequency of hospital admissions and readmissions for CHF exacerbations continues to rise, the implementation of algorithmic approaches serves to enhance management and treatment of patients, particularly for hospitalists and other non-specialist healthcare providers.

> Early and robust initiation of diuresis during CHF exacerbations is a faster and more effective approach to attaining euvolemia.

> Persistent symptoms after diuresis warrants additional workup into other underlying pathologies.

A PROPER HOME MEDICATION RECONCILIATION UNMASKING WITHDRAWAL IN A CRITICALLY ILL PATIENT

Keshav Dixit¹; Deborah Edelman²; Amir Ahmadi³. ¹Internal Medicine, Mount Sinai Morningside Hospital, New York, NY; ²Internal Medicine, Mount Sinai Health System, New York, NY; ³Cardiology, Mount Sinai Morningside Hospital, New York, NY. (Control ID #4060824)

CASE: 56-year-old female patient with a past medical history of severe aortic stenosis (status/post transcatheter aortic valve replacement), coronary artery disease with multiple stents, hypertension, hyperlipidemia, diabetes, asthma, stroke, Hodgkin’s Lymphoma (status/post chemotherapy and radiation), pituitary adenoma (status/post transsphenoidal resection), metastatic breast cancer (status/post-mastectomy, chemotherapy), chronic kidney disease who initially presented to the hospital with chest pain and shortness of breath. She was admitted to the cardiac care unit (CCU) for pulmonary edema and acute respiratory failure, for which she was intubated for airway protection. She underwent a cardiac catheterization, during which she had a stent and an intra-aortic balloon pump placed. Her vital signs were stable until after extubation, when she developed persistent tachycardia with intermittent fevers, tachypnea, lethargy and headaches. She was treated empirically with antibiotics. Repeat infectious workup, and pan-imaging of the head, chest, abdomen, and pelvis were all unremarkable. An ultrasound of the lower extremities revealed a thrombus in the right common femoral vein. However, she tested negative for a pulmonary embolism. A heparin drip was started for treatment but her symptoms persisted. Following a thorough, negative workup, a medication reconciliation was performed. It was discovered that before admission, she was taking Duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI). Following its resumption, her symptoms and vital signs improved. She was transferred out of the CCU for further management.

IMPACT/DISCUSSION: SNRIs are now being increasingly prescribed for the treatment of mood and anxiety disorders, as well as chronic pain and menopausal symptoms. Antidepressant discontinuation syndrome from SNRIs can cause flu-like symptoms such as lethargy and headaches, as our patient experienced, with myalgias and diaphoresis; other symptoms include insomnia, hyperarousal (i.e. anxiety, agitation, irritability), balance difficulties (i.e. vertigo, dizziness) and more. These symptoms, which may often have a late onset, can last for several days to weeks. Withdrawal symptoms can occur during transitions of care, a vulnerable time for patients during which medication discrepancies arise due to inaccurate or delayed reconciliations.

CONCLUSION: Vital sign abnormalities commonly occur, often with unclear etiologies. In patients with nonspecific symptoms, including those critically-ill, consider medication withdrawal as a possible cause, including from SNRIs.

Completing early medication reconciliations with accurate medication histories will increase patient safety during and post hospitalization

COGNITIVE BIAS IN AN ATYPICAL PRESENTATION OF CHRONIC PANCREATITIS AND CONCURRENT CHOLECYSTITIS

Garrett Cotter, Keaton Wieschhaus, Charles F. Hawk, Matthew Schirtzinger. Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4060158)

CASE: A 40-year-old female with a history of alcoholic cirrhosis, chronic pancreatitis, pseudocyst with cystgastrostomy, and recurrent pancreatic duct (PD) obstruction presented to our ED with several days of abdominal pain, nausea, and PO intolerance. She denied fevers, presyncope, dyspnea, hematemesis, bowel changes, and edema. Of note, she recently underwent PD stent placement, and interval CT demonstrated stable pancreatic morphology and debris with nonspecific periportal edema. Abdominal examination revealed diffuse pain with marked intensity in the epigastrium, LUQ, and LLQ. She also endorsed new back and left CVA pain. Murphy’s sign was negative on admission. Labs were unremarkable except for mild elevations in ALP (158) and ALT (50). A focused differential included acute pancreatitis, PD stent migration, ERCP-related pain, recurrent pseudocyst, obstruction, and ileus.

She was admitted for treatment of likely acute on chronic pancreatitis. Despite receiving IV fluids, antiemetics, and pain medication, she denied improvement over several days. She tolerated clear liquids with IV antiemetics but repeatedly failed attempts to introduce solid food. Liver enzymes sharply increased on HD4, and she reported worsening RUQ pain. Murphy’s sign was positive on HD5, yet US only demonstrated a heterogenous pancreas and stable PD dilation without evidence of cholecystitis. We ordered a repeat CT which found acute on chronic pancreatitis, proper stent position, and indeterminate signs of cholecystitis. HIDA scan on HD6 was consistent with cholecystitis. She underwent urgent cholecystectomy without complications on HD8. Her diet was advanced over the next 36 hours, and she was discharged on HD10 with antiemetics and pain medication.

IMPACT/DISCUSSION: Cognitive bias impacts clinical reasoning and hinders timely diagnostic and therapeutic interventions. Studies have shown anchoring and framing biases contribute to delays and errors. Atypical presentations and failure to consider alternatives are also linked to inaccuracies. Our patient’s presentation was framed by her recent procedure and complex history, and we may have overlooked true RUQ tenderness given her worse left-sided pain. While US was negative, this modality has a sensitivity of 81% and can yield false negatives. We attributed her periportal edema to pancreatitis, but this finding likely represented concurrent biliary pathology. It is critical to consider the role of cognitive bias when evaluating patients with complex histories and recent admissions.

CONCLUSION: - Cognitive bias can delay diagnosis and treatment in patients with complex conditions and recent admissions. Clinicians must maintain a broad differential and reassess these patients often.

- Cholecystitis is a clinical diagnosis. When suspicion remains high, an absence of Murphy’s sign and expected imaging results should not preclude further evaluation.

I FEEL IT IN MY BONES

Abigail Clark¹; Hayalneh Gessessew²; Patricia Cheung²; Jed P. Mangal¹. ¹Internal Medicine and Psychaitry, Emory University Woodruff Health Sciences Center, Atlanta, GA; ²Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4031213)

CASE: A 75-year-old male with chronic osteoarthritis presented to an emergency department with acute on chronic right hip and back pain which impaired his ability to walk. This was his fifth presentation for similar symptoms in the last year. Physical exam revealed a limited range of motion in his right hip and lumbar spine. His pain was attributed to progressive osteoarthritis, as it had been at previous presentations. When the patient did not improve with conservative interventions, his medical team, as a group, questioned if his symptoms could be due to another condition. Further investigation revealed he had immigrated from Ghana thirty years earlier, and since then had resided in a log cabin in the woods, without running water or electricity, and amongst large groups of immigrant people. Whole-spine MRI revealed T12/L1 vertebral osteomyelitis, a right psoas abscess and a small right empyema. These findings were concerning for hematogenous spread of an atypical infection. An infectious workup included T12 bone biopsy and subcarinal lymph node biopsy. Although tissue biopsy results were negative for infection, QuantiFERON TB GOLD test was positive. Infectious disease consultants recommended treating the patient with rifampin, isoniazid, pyrazinamide, and ethambutol for disseminated tuberculosis. He discharged home with primary care, neurosurgery and orthopedic surgery follow-up, as well as a referral to his local county health department.

IMPACT/DISCUSSION: Heuristics are decisional shortcuts influenced by cognitive bias, and are most useful when completing low-impact, simple tasks. Using heuristics in medicine--where decisions are often complex and high-impact--increases the risk of misjudgment. A common heuristic used in medicine is anchoring bias, which is when clinicians “anchor” on specific information to make a diagnosis without adjusting for other clinical data. In this case, the patient’s history of chronic osteoarthritis served as an “anchor” to which his medical team attributed his right hip and back pain. His social history was considered less relevant initially, but was key to diagnosing him with disseminated tuberculosis. The use of teams can reduce anchoring, and in this case group discussion allowed the patient's clinicians to actively seek information to disprove the original diagnosis. Other strategies the patient's clinicians might have used to avoid anchoring include explicitly creating an expanded differential diagnosis, considering the base rate of tuberculosis in immigrant communities and using computerized decision support tools.

CONCLUSION: This case demonstrates the power of anchoring bias in clinical medicine. Reflecting on emotions that sway objectivity, intentionally evaluating the influence of confirmatory bias on reasoning and using specific strategies to reduce anchoring can help clinicians avoid misjudgment in patient care.

MIS-MET-INFORMATION ON DISCHARGE: MEDICATION RECONCILIATION AND PREVENTING RECURRENT METFORMIN ASSOCIATED LACTIC ACIDOSIS

David Newhouse¹; Casey N. McQuade². ¹Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #4064939)

CASE: The patient is a 69-year-old male with type 2 diabetes and hypertension who was recently hospitalized at a local hospital for multisystem organ failure, shock, and severe lactic acidosis, thought due to severe community acquired pneumonia. There was also concern for metformin-associated lactic acidosis (MALA) contributing to his presentation. He improved with supportive care. On discharge, metformin was discontinued. The patient filled a combination-pill metformin prescription a few weeks after his discharge.

A week later, the patient presented to a nearby hospital for evaluation of hypotension and altered mental status after feeling unwell for a few days prior. He had hypoglycemia, hypotension, and a lactate of 25 on presentation. He subsequently PEA arrested with ROSC at two minutes. The patient was transferred to our hospital for emergent dialysis for acidosis.

On admission to the ICU, the patient was on norepinephrine, epinephrine, vasopressin, and bicarbonate continuous infusions to maintain a mean arterial pressure goal of greater than 65 mmHg. On examination, he was intubated not on sedation, making no movements and not breathing above the ventilator set rate. Heart sounds were normal, lungs sounds were coarse. Labs were notable for WBC 28, Hb 8, Plt 306, Na 147, K 4.9, Cl 96, HCO3 8, BUN 53, Cr 10.2, PO4 11.7, AST 384, ALT 320, INR 1.5, pH 6.99, pCO2 47, Lactate 24, hs-Tn 142.

Nephrology and Toxicology were consulted for renal replacement and concern for recurrent MALA. The patient started continuous hemodialysis for rapid correction of his acidosis, electrolyte disturbances, and removal of metformin, which required further vasopressor support to tolerate. A metformin level was sent and was 47 times greater than the upper limit of normal.

The patient was successfully weaned off vasopressors and extubated after improvement of his mental status and recovery of his renal function. He was eventually discharged from the hospital on day 17 to an inpatient rehabilitation unit. Metformin is now listed as an allergy in the patients medical record.

IMPACT/DISCUSSION: The Swiss Cheese model describes a schema of safety, where many levels of security are required to fail to cause an adverse event. As a corollary to this idea, many stakeholders need to be informed of a medication change on discharge to prevent an adverse outcome. This case highlighted the importance of medication reconciliation and outpatient provider collaboration to prevent recurrent drug reaction.

CONCLUSION: 1. Medications that cause a serious hospitalization should be listed as an allergy

2. In addition to discontinuing harmful medications on discharge, it is good practice to call the home pharmacy and primary care physician to discuss discontinuation of the medication

3. Combination pills are especially prone to medications errors as they are easily overlooked

POST-PYLORIC NASOENTERIC FEEDING ACCESS TUBE PLACEMENT THROUGH A CHOLECYSTODUODENAL FISTULA

Gabriel Heering, Zilan Lin, Michael Rosman, Alexander Levstik, Shekher Maddineni, Kartik Prabhakaran, Frederick Yick. Internal Medicine, Westchester Medical Center, Valhalla, NY. (Control ID #4055215)

CASE: A 76-year-old man with no known past medical history was admitted with shortness of breath. He was found to have community acquired pneumonia at an outside hospital (OSH) and later developed acalculous cholecystitis. Due to severe sepsis, he was deemed to be a poor surgical candidate, and a percutaneous cholecystostomy tube was placed by interventional radiology. During the hospitalization, a nasoenteric tube was placed for feeding. Subsequently, a CT revealed a duodenal fistula to the gallbladder. The patient was then transferred to our institution for surgical evaluation of the cholecystoduodenal fistula. Upon review of the OSH imaging, a nasoenteric tube was noted traversing through the fistula and into the gallbladder fossa. Therefore, it was immediately removed. Afterwards it became apparent that enteric feeds were present in the percutaneous cholecystostomy drain. Esophagogastroduodenoscopy (EGD) visualized the opening of the fistula and air in the duodenal tract. Another nasoenteric tube was replaced endoscopically into the second portion of the duodenum, guided by a snare. It was bridled to minimize the chance of displacement back into the cholecystoduodenal tract.

IMPACT/DISCUSSION: Nasoenteric tube placement is typically considered a safe and benign procedure. Discomfort, sinusitis, epistaxis, and aspiration are common complications, which usually would resolve with tube removal or medical management. Rare complications have been reported in previously published case reports and include passage of tubes through an injured cribriform plate into the brain, oropharyngeal perforation leading to parapharyngeal abscess, and esophageal perforation and entry into the left pleural space leading to pneumomediastinum. We describe a patient found to have a nasoenteric tube placed through a cholecystoduodenal fistula.

CONCLUSION: More than 1.2 million nasoenteric tubes are placed annually in the United States. Nasoenteric tube placement is used to obtain enteral access for nutrition and medication delivery, to rule out upper gastrointestinal (GI) bleeding via lavage, and to decompress the stomach. The tubes can be placed blindly, with an electromagnetic sensing device, endoscopically, or under fluoroscopic guidance. Although generally considered as a low-risk procedure, rare devastating complications do occur. This case shows that placement method, abnormal GI anatomy, and GI surgeries such as gastric bypass, hiatal hernia repair, and cholecystectomy should be all considered prior to placement. To our knowledge, this is the first case report of a nasoenteric tube discovered in gallbladder via a cholecystoduodenal fistula.

RAISE THE ANCHOR: A COMPLEX CASE OF STREPTOCOCCUS ANGINOSUS ENDOCARDITIS INITIALLY PRESENTING AS LOW BACK PAIN AND DYSURIA

Madeline G. Edgerly, Ann Maguire, James Kleczka, Peter Sohnle. Internal Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4064261)

CASE: A 76-year-old male with a history of bicuspid aortic valve and prostatitis presented with lower back pain. He was treated with cyclobenzaprine. Four days later, the patient was hospitalized for worsening pain. MRI confirmed spondylosis and moderate foraminal stenosis. Lab work including CBC was normal. The pain did not resolve with therapy, lidocaine patches, tizanidine, and prednisone. Two weeks later, he returned with new symptoms including dysuria, urinary frequency, fever, chills, and mild confusion. With a prior history of prostatitis, empiric ciprofloxacin was ordered. Urinalysis was negative, but WBC was 17,000/microliter. After 24 hours without improvement and worsening fever to 104 the patient was readmitted. Blood cultures and echocardiogram revealed a large echogenic mass on the aortic valve (3.6 x 2.4 cm) with new severe aortic regurgitation and possible perforation of the noncoronary cusp. Blood cultures were positive for Streptococcus anginosus. Treatment was initiated with vancomycin and cefepime and CT surgery was consulted for aortic valve replacement and debridement of the aortic root abscess. After surgery, it was discovered that the patient saw a dentist two months prior for a minor procedure.

IMPACT/DISCUSSION: This patient had an uncommon presentation of a rare form of S. anginosus infection. Viridans streptococci collectively account for 17% of all cases of native valve infective endocarditis. Less than 10% of all Viridans cases are caused by S. anginosus. Infective endocarditis affects 2-5% of individuals with bicuspid aortic valve. Isolated bicuspid aortic valve is not an absolute criterion for prophylaxis prior to dental procedures. Most cases of endocarditis in these patients occur due to bacteremia caused by toothbrushing, chewing, and other activities of daily living. Fever and chills are present in the vast majority (90%) of infective endocarditis cases, and only 10% of endocarditis cases involve low back pain. In complex cases it is easy to give too much weight to the first pieces of information, leading to Anchoring Bias. The delay in diagnosis of this patient demonstrates the importance of guarding against Anchoring Bias and the need to consider alternative diagnoses when the working diagnosis shows an atypical progression or later information does not fit the pattern.

CONCLUSION: 1. Common manifestations of infective endocarditis include fever, chills, weight loss, and cardiac murmurs. Although uncommon, musculoskeletal symptoms can be associated with infective endocarditis.

2. Activities of daily living pose a greater threat of endocarditis infection than dental procedures.

3. In patients with an atypical presentation, it is important to resist Anchoring Bias in order to reach the correct diagnosis.

UNVEILING THE UNSEEN: A THOROUGH PHYSICAL EXAMINATION REVEALING AN ANCHORING BIAS

Joshua Tsai¹; Anas Bizanti². ¹Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; ²IM, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4064978)

CASE: In the context of acute flares in multiple sclerosis (MS), it is important to consider acute illness or systemic inflammation as potential triggers. The following case involves a patient who presented to the emergency department during an acute MS flare initially presumed to be associated with a urinary tract infection.

The patient is a 31-year-old female with multiple sclerosis and a history of a seizure disorder who presented to the emergency department with a 3-day history of paresthesias of the left upper and lower extremities that was associated with blurriness of the left eye and urinary incontinence. She was hemodynamically stable. Complete blood count and metabolic panel were unremarkable. Urinalysis was suggestive of a urinary tract infection. MRI revealed periventricular plaques that have been unchanged since 2020. Ceftriaxone was started. Neurology was consulted and her symptoms began to improve with intravenous steroids. However, several days into her hospital stay, after establishing rapport with the medical team, she reported pain following the use of genital sanitary products. A physical examination of the genital region revealed a singular erythematous ulcer. Further laboratory testing demonstrated a reactive PRP titer, along with positive results for HSV-1 and Chlamydia nucleic acid tests.

IMPACT/DISCUSSION: Sexually transmitted diseases, specifically syphilis and chlamydia, have become more prominent in the past decade. Medical interventions are more effective when the infection is detected early in the disease process. Unfortunately, numerous cases of STDs remain undetected and eventually progress to worse clinical presentations.

Syphilis consists of three stages, early, late, and neurosyphilis, with a high likelihood of progression if untreated. Infection via Chlamydia trachomonas is another sexually transmitted disease that has widespread prevalence. Without early and proper treatment of Syphilis and Chlamydia, clinical progression of the infection may occur. Possible complications of untreated infection include pelvic inflammatory disease, infertility, and even debilitating neurologic disease. A thorough physical examination should be performed by clinicians in any individual at high risk for infection, or those displaying symptoms.

CONCLUSION: In cases of suspected non-monogamous patients presenting with an acute exacerbation of a neurologic disease, it is imperative to investigate sexually transmitted diseases (STDs). The identification of STDs and awareness of potential neurologic consequences may have been overlooked without a comprehensive physical examination. Unfortunately, the increasing workload of clinicians has resulted in a diminished emphasis on thorough physical examinations. Through the publication of this case, we aim to emphasize the significance of a comprehensive physical examination and the establishment of patient rapport to mitigate anchoring biases in disease management.

Clinical Vignette - Social Determinants of Health

A NOVEL APPROACH TO MEDICATION MANAGEMENT IN A PATIENT EXPERIENCING HOMELESSNESS

Grace Perry¹; Laura Macke². ¹School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²General Internal Medicine, University of Colorado, Denver, CO. (Control ID #4058982)

CASE: A 61-year-old male experiencing homelessness with a medical history of type 2 DM complicated by peripheral neuropathy, CKD, chronic pain and depression presented to an internal medicine (IM) clinic. The patient stayed with friends from 2020 to 2/2022 and in assisted living from 2/2022 to 8/2022. He then lost his facility placement and has since lived on the streets and in shelters. Since then, the patient has had difficulty taking medications: he is unable to self-administer injectables due to peripheral neuropathy, his medications were being stolen and he didn’t have access to refrigeration, which his GLP-1 receptor agonist requires. In response, in September 2022 the clinic team initiated weekly nurse visits to fill his pill box for the week and to administer his weekly GLP-1 RA injection. The weekly visit has permitted nursing triage of medical concerns such as wound infections, medication tracking, frequent touches with his social worker and PCP, and informal health counseling. The patient’s average hemoglobin A1c value was 8.7 mg/dL before initiation of weekly medication management visits and 8.5 mg/dL after initiation of visits. He had 6 emergency room (ER) visits, with 15 days in the hospital, the year before he lived on the streets (9/2021 to 9/2022). He had 10 ER visits, with 14 days spent in the hospital, after becoming homeless (10/2022 to 10/2023).

IMPACT/DISCUSSION: This patient has chronic medical conditions resulting from uncontrolled DM and worsened by homelessness, which is a major factor in his difficulty with medication adherence. Weekly nursing visits to administer medications and fill pill boxes are not the traditional role of the IM clinic, and the impact on his health is difficult to quantify. There is no profound difference observed in A1c values, ER visits, or hospital days before or after he began weekly visits. Of course, there are confounding factors that impacted his interactions with healthcare, including psychosocial stressors, chronic pain, and medication regimen changes.

Nationally, the primary structure for medication management is home health (HH), which is often not an option for people experiencing homelessness (PEH) as they may not have access to a designated space for the HH team to visit. Medication management for PEH presents a challenge that is inadequately addressed. Various programs attempt to bring healthcare to PEH, but the accessibility and consistency of care provided is unclear. Weekly nurse visits will not be effective for every PEH with chronic disease, but this case demonstrates that in addition to systemic change, individualized solutions at the clinic-level are important for PEH to access consistent treatment for chronic disease.

CONCLUSION: - PEH face unique challenges regarding management of chronic disease and these challenges are frequently inadequately addressed by the health care system

- Management of chronic disease among PEH requires the health care team to think creatively to identify individualized treatment plans

BEYOND SKIN DEEP: UNRAVELING THE TAPESTRY OF PSORIASIS, DEPRESSION, AND SOCIAL DETERMINANTS THROUGH AN INTERDISCIPLINARY APPROACH

ThanhThanh Vo, Angela M. Bassal, Kirti Malhotra. General Internal Medicine, University of California Davis Medical Center, Sacramento, CA. (Control ID #4063344)

CASE: A 49-year-old recently immigrated Vietnamese woman with a history of major depressive disorder (MDD) and psoriasis c/b multiple admissions, presented to the ED with a subacute diffuse pruritic rash, arthralgia, and passive suicidal ideation. She was prescribed daily Cyclosporine during the previous hospitalization but socioeconomic barriers kept her from following her treatment plans.

Physical exam was significant for dactylitis and interphalangeal finger joint tenderness, swan neck deformities, limited wrist motion, and well-demarcated erythematous psoriasiform coalescing over her entire body. ESR and CRP were elevated. Her other labs were within normal limits.

Her presentation was consistent with a severe erythrodermic psoriasis flare and oligoarticular inflammatory arthritis, a subtype of psoriatic arthritis in the setting of many socioeconomic stressors and worsening depression. Dermatology was consulted and treatment included increased Cyclosporine dose, topical Clobetasol 0.05% solution, and topical Triamcinolone 0.1% ointment. Fortunately, the patient was able to get full-scope Medi-Cal, so the Dermatology team and case management teams could secure insurance authorization for Infliximab.

Her MDD and erythrodermic psoriasis were likely exacerbated by her socioeconomic barriers including limited insurance, financial constraints, unstable housing, transportation issues, language barrier, and recent immigration. Thus, a comprehensive plan was developed: referrals to outpatient Dermatology, Rheumatology, Psychiatry, and occupational therapy for hand function evaluation. She was also referred to our outpatient complex care team to address social determinants of health and connect her with support services to promote follow-up care. During her stay, the patient's mood and skin condition improved with less erythema, scaling, and pruritus, and her arthritis subsided.

IMPACT/DISCUSSION: This case highlights the interplay between psoriasis and depression, illuminating the substantial impact of social determinants on disease exacerbation. Gupta et al. link increased psoriasis flare-ups to heightened depressive symptoms, partly due to elevated cytokines, which can be alleviated by biologics, as Patel et al. suggest. In this case, as she started the Infliximab and witnessed coordinated care among healthcare disciplines, the patient reported feeling more empowered to manage her chronic condition.

CONCLUSION: The case contributes to the literature by highlighting the unique challenges faced by individuals from marginalized communities as they deal with chronic conditions like psoriasis and the need for a comprehensive approach in managing these complex cases. An interdisciplinary approach focused on addressing social determinants of health is essential in improving patient outcomes, reducing acute care utilization, and providing equitable healthcare.

BIAS OBSCURES A STROKE: A DELAYED STROKE WORK UP IN AN ATYPICAL PATIENT

Benjamin Salwen¹; Jonathan Jalali¹; Corinne Zalomek¹; Yasin Khan². ¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4062598)

CASE: A 40-year-old Spanish-speaking male with a past medical history of polysubstance use was brought to the hospital following a syncopal episode after smoking marijuana. En route to the hospital, he was given two doses of Narcan, with minimal response. He was initially obtunded and did not participate in physical exam or respond to verbal prompts. This was confounded by the fact that he only spoke Spanish. Laboratory workup was only remarkable for marijuana and cocaine on urinary drug screen. Initial non-contrast CT (computed tomography) head showed no acute abnormality. As the patient became more responsive, a Spanish interpreter was used to assist with communication. Repeat physical exam revealed right-sided hemineglect and global aphasia. 2.5 hours after his initial head CT (six hours following presentation) he was stroke-activated. CT angiogram and CT perfusion showed a large left medial cerebral artery infarct. Tissue plasminogen activator was not administered as the patient was out of the administration window. Neurosurgery and neurology were then consulted. Due to the presence of midline shift, cerebral edema, and risk of reperfusion injury the decision was made to continue with conservative management. The patient was admitted to the medical intensive care unit for intensive monitoring. Following a protracted hospital course, he was discharged home with significant, but improving neurological deficits.

IMPACT/DISCUSSION: Implicit racial/ethnic bias is a well-documented phenomenon in healthcare, with individuals of color having significantly worse hospital outcomes than their white counterparts. Reports have shown this is also true for those with substance abuse as well as for those who do not speak English. In this case, the patient was subject to multiple forms of bias due to his ethnicity, social habits, and inability to speak English. His stroke was further obfuscated by his lack of common comorbidities that predispose to stroke, such as cardiovascular disease, hyperlipidemia, hypertension, or diabetes. In the setting of acute drug intoxication and inability to communicate in English, bias likely contributed to delayed recognition of this patient’s focal neurologic deficits and stroke. As healthcare professionals, it is essential to acknowledge our own implicit biases in order to minimize their effect on our diagnoses. Awareness and recognition of potential biases can prevent anchoring on a specific diagnosis, allowing for more equitable care.

CONCLUSION: Implicit bias is inherent in medical practice and can negatively impact patient outcomes. It is imperative to recognize racial, demographic, and linguistic bias to avoid negative outcomes. In this case, drug intoxication should not cause focal neurologic deficits and their presence should prompt immediate stroke workup.

HOW AN UNDOCUMENTED STATUS CAN CAUSE DELAYS IN CARE IN DIAGNOSIS OF METASTATIC CHOLANGIOCARCINOMA

Janhavee Deshpande, Jacob Agronin, Nicholas Talabiska, Alexis Coulis, Shreya Makkapati, Kaitlyn E. McSurdy. Internal Medicine, Temple University Hospital, Philadelphia, PA. (Control ID #4025568)

CASE: A previously healthy, undocumented 35-year-old Latino man presented with two weeks of progressive jaundice and dark urine. Initial work up showed severely elevated liver enzymes with negative viral hepatitis testing. Liver ultrasounds and abdominal CT showed a dilated common bile duct (CBD) and pancreatic mass. CA 19-9, CEA, AFP, and IgG4 levels were markedly elevated and anti-smooth muscle antibody was positive. Sentinel node biopsies from an endoscopic retrograde cholangiopancreatography (ERCP) and two endoscopic ultrasounds (EUS) were nondiagnostic. Outpatient explorative laparoscopy was planned given the high suspicion for malignancy. The patient was unable to acquire adequate insurance, and despite assignment of a community health worker, outreach from oncology and gastroenterology navigators, the patient was unable to receive this care.

The patient represented nine months later with a new cough, abdominal pain, and significant weight loss. CT imaging showed a new pleural effusion, found to be a chylothorax. MRCP revealed persistent CBD dilation, lymphadenopathy, new intrahepatic and spinal lesions, and a portal vein thrombus. Repeat ERCP with biopsies were again nondiagnostic. IR guided bone biopsy of the spinal lesions was positive for metastatic carcinoma of a pancreatobiliary source. The patient was initiated on palliative chemotherapy and returned home to his family for further oncologic care.

IMPACT/DISCUSSION: There are approximately 11 million undocumented immigrants in the United States, and cancer is known to be one of the leading causes of death in this population. For undocumented immigrants, the challenges of navigating the healthcare system are compounded by underinsurance, delays in care, lack of social support, legal repercussions, cultural and language barriers, and financial issues. This often results in presentation of advanced or end-stage disease. Our patient’s presentation was strongly suspicious for malignancy, but standard testing, multiple non-diagnostic biopsies, and sampling error delayed care. Being undocumented, he was unable to acquire adequate insurance to pursue rapid outpatient testing and follow up. Insurance coverage is positively linked with improved access to care, and studies show that providing insurance to undocumented immigrants results in improved healthcare outcomes.

CONCLUSION: In conclusion, social determinants of health, such as immigration status play a significant role in access to care and can result in delays of care and advanced progression of disease. Undocumented immigrants are more likely to present with advanced disease, which often require more aggressive care and have limited opportunity for end-of-life care discussions. The disparities that we have discussed highlight a significant, systems-based healthcare gap that surrounds undocumented immigrants and have the potential for detrimental consequences.

NEW-ONSET HEART FAILURE IN A YOUNG-ADULT WITH END STAGE RENAL DISEASE

Sonal Sharda, Varun Ayyaswami. Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4057107)

CASE: A 19-year-old male with history of dextrocardia and end stage renal disease (ESRD) presented to the emergency department due to inability to drain peritoneal fluid during dialysis sessions. He endorsed dyspnea, but denied fevers, chest pain, or syncope. Vital signs were within normal limits and physical exam was unremarkable. Laboratory work-up was notable for TSH of 6.44 with normal free T4. Creatinine was consistent with ESRD. EKG demonstrated new anterior T wave abnormalities. Chest X-Ray revealed mild pulmonary interstitial edema, while transthoracic echo showed new onset reduced ejection fraction (EF) of 20-25%, left ventricular hypertrophy, and moderate mitral regurgitation as compared to a normal baseline 6 months prior. BNP was elevated at 3,974 pg/mL and ESR at 29. He was given Aspirin and unfractionated heparin for a rising Troponin which peaked at 0.09, consistent with diagnosis of Type 2 NSTEMI. Cardiology recommended an extensive work-up revealing normal CK and CRP as well as negative ANA, ANCA, and HIV antigen/antibody test. As he was born in South America, T. cruzi IgG antibody was obtained and negative. Coronary CT had no evidence of obstructive coronary artery disease. Etiology of new-onset heart failure (HF) was concerning for stress cardiomyopathy versus left ventricular noncompaction (LVNC). He was transitioned to hemodialysis and discharged on guideline directed medical therapy for HF. He was readmitted multiple times due to episodes of chest pain and dyspnea, complicated by a new diagnosis of generalized anxiety disorder. Treatment adherence was also impacted by adverse social determinants of health (aSDOH) such as transportation and language barriers, resulting in re-evaluation for kidney transplant candidacy. Repeat echocardiograms over the course of 8 months showed improved EF of 45%, though definitive diagnosis of acute EF reduction remains undetermined.

IMPACT/DISCUSSION: HF in the pediatric population is distinct from adults both in terms of etiology and clinical presentation. Based on the patient’s clinical course and work-up, the differential included stress cardiomyopathy and LVNC. As the latter diagnosis is a relatively rare congenital cardiomyopathy, defined by persistent endomyocardial trabeculations leading to thickened myocardium, there is a lack of awareness regarding its detection and treatment. In turn, this increases the risk of complications such as thromboembolism and arrhythmia, underscoring the value of timely diagnosis and management of new onset HF, especially in this age group. Further, the patient experienced a range of aSDOH that contributed to exacerbation of symptoms and hospital readmissions for medical intervention.

CONCLUSION: This case highlights the evaluation of new onset, non-ischemic cardiomyopathy with unclear etiology in young adults and the necessity of identifying aSDOH when tailoring therapeutic recommendations.

PERILOUS POLYPHARMACY: A MYSTERIOUS CASE OF A WIDESPREAD BLISTERING SKIN ERUPTION

Johnathon Lueck¹; Emily Henkel²; Shoshana Zhang⁴; Jadranko Corak³. ¹Student, The University of Texas at Austin Dell Medical School, Austin, TX; ²Division of Dermatology, Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ³Department of Internal 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 #4055164)

CASE: A 49-year-old woman with a history of epilepsy, chronic kidney disease, diabetes, hypertension, chronic pain, and schizophrenia presented to the emergency department (ED) for fatigue, weakness, and vomiting. Of note, the patient was uninsured and had been to five EDs the month prior to receive care, where she received NSAID, anti-epileptic drug (AED), and antibiotic prescriptions. Initial workup revealed a blood pressure of 215/126, blood glucose of 335, and urinalysis indicative of a urinary tract infection. Treatment was initiated with antihypertensives, insulin, and ceftriaxone. Due to her inability to provide a comprehensive history, she was continued on multiple AEDs thought to be “home” medications. Within hours, a blistering eruption appeared that within days evolved to cover >50% body surface area. Flaccid bullae, erythema, and desquamation were noted on the face, extremities, and torso, suspicious for Stevens-Johnson Syndrome (SJS). Eventually, generalized bullous fixed drug eruption (GBFDE) proved more likely due to the lack of mucosal involvement and extensive chart review with collateral information describing similar, limited reactions in the past. She was treated with corticosteroids, IVIG, and daily dressing changes; antibiotics were given for secondary infection with pseudomonas. The patient’s prolonged hospital stay was fraught with many complications including pain control and difficulty identifying a culprit medication. Her kidney function deteriorated, requiring the initiation of dialysis. Despite her cutaneous condition improving, she ultimately succumbed to renal failure two months after discharge.

IMPACT/DISCUSSION: This case highlights a rare and severe presentation of GBFDE, likely secondary to anti-epileptic drugs. It emphasizes how GBFDE can mimic SJS/TEN but can be distinguished by a history of repeated exposures with subsequent increased severity of the eruption and by less commonly involving mucosa, whereas SJS will always demonstrate mucosal involvement. Lastly, our patient’s high ED utilization and polypharmacy created significant barriers to identifying the offending agent, which is the cornerstone of treatment in addition to supportive care. The case required the help of case management to obtain multiple outside records and significant time from specialists to help piece together drug timelines. Her history of chronic pain also contributed to significant difficulty providing wound care, ultimately requiring sedation.

CONCLUSION: - GBFDE is associated with multiple medications, including AEDs, and severe cases may mimic SJS/TEN.

- When it is suspected that a patient is unable to provide an accurate history, collateral information must be obtained to lessen the risk of adverse reactions.

- High ED utilizers with complex co-morbidities may need more guidance regarding transitions of care, with careful follow-up to improve outcomes.

SOCIAL DETERMINANT-DRIVEN MEDICATION NON-ADHERENCE LEADING TO HEART FAILURE DECOMPENSATION

Prachi Shah¹; Nihar Rama²; Daniel Aldrich³; Venkatesan R. Krishnamoorthi⁴. ¹Pritzker School of Medicine, The University of Chicago, Chicago, IL; ²Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ³Hospital Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ⁴Medicine, University of Chicago, Chicago, IL. (Control ID #4065101)

CASE: A 60-year old woman with metabolic dysfunction-associated steatotic liver disease and heart failure with preserved ejection fraction, managed with bumetanide and spironolactone, presented to the emergency department (ED) for abdominal distension, leg edema, and orthopnea. She reported running out of medications 2 weeks prior; they are usually delivered. She lacked transportation, so she could not refill them. For the fourth time in 12 months, the patient was admitted for volume overload. After intravenous diuretics, she was soon discharged.

IMPACT/DISCUSSION: Many barriers exist for patients to reliably access prescription drugs. One is cost; 25% of patients have struggled to fill their prescriptions, [1] and nearly 30% of patients have taken less than their prescribed doses due to cost. [2] One reason is that Pharmacy Benefit Managers (PBMs) negotiate with drug makers, often secretly, to position their brand/high price drugs preferentially on formularies in exchange for rebates. As a result, generic drugs may get pushed to higher tiers, raising patients’ out-of-pocket cost for even generic medications.

Additionally, patients without access to a vehicle, or who lived in the lowest quintile of poverty, were significantly less likely to fill their prescriptions. [3] To improve adherence and lower costs for insurers, PBMs often auto-enroll patients in mail-order services, and by controlling retail pharmacy reimbursement, they can push prescriptions into their mail-order business. However, mail-orders can result in delays, confusion with refills, dosing errors, and errors in use. Patients cannot review medications with a pharmacist, and prescribers may not be able to adjust dosing and identify medications. Thus, mail-order or online options cannot replace the need for retail pharmacies and the transportation to get to them.

CONCLUSION: While some hospitalizations seem preventable through easier medication access, drug prices and transportation barriers are health system-level issues beyond the control of individual clinicians. Advocacy by healthcare providers for health policy that addresses drug costs and social determinants can play an important role in improving medication access for all patients [4].

1. Kirzinger A, Montero A, Sparks G, Valdes I, Published LH. Public Opinion on Prescription Drugs and Their Prices. KFF.

2. Chisholm-Burns MA, Spivey CA. The “cost” of medication nonadherence: consequences we cannot afford to accept. J Am Pharm Assoc (2003).

3. Hensley C, Heaton PC, Kahn RS, Luder HR, Frede SM, Beck AF. Poverty, Transportation Access, and Medication Nonadherence. Pediatrics.

4. Abrams E, Louisias M, Blumenthal K. The importance of physician advocacy. Annals of Allergy, Asthma, and Immunology.

TWO OPTIONS FOR FRAGMENTED CARE: A WOMAN WITH AN UNDIAGNOSED ESOPHAGEAL MASS AND MEDICAID MANAGED CARE

Spencer Asay²; Matthew Cerasale^1,2; Venkatesan R. Krishnamoorthi^1,2. ¹Medicine, University of Chicago, Chicago, IL; ²Division of the Biological Sciences, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #4061146)

CASE: A 55-year-old woman with no medical history was admitted with abdominal pain, vomiting, dysphagia, and weight loss. CT imaging revealed a thickened esophagus, suspicious for malignancy. The gastrointestinal consult service recommended upper endoscopy with biopsy. However, a case manager informed the team that the hospital is outside the patient’s Medicaid managed care (MMC) network. Two options arose: 1) Perform the biopsy at their facility knowing all follow-up must take place at another, in-network facility or 2) Discharge the patient without diagnosis and arrange for follow-up and biopsy at an in-network provider. Option 1 would require transport of pathology samples to the in-network providers and significant coordination after discharge, prone to error and delays in care. Option 2 would delay biopsy with no guarantee of timely scheduling at an in-network provider, risking further delay in diagnosis and potential loss to follow-up.

IMPACT/DISCUSSION: Since the passage of Medicaid expansion through the Affordable Care Act in 2010 and due to rising healthcare expenses for states’ Medicaid programs, states have increasingly contracted with private insurers to cover Medicaid beneficiaries through Medicaid managed care (MMC) plans. To control expenses, MMCs cover only a narrow network of providers. Studies show MMC recipients are more likely than those in other plans to report network difficulties. Moreover, studies suggest network adequacy standards, established and enforced by states, may not reflect actual care access.

Network adequacy problems especially arise when MMC recipients are taken by ambulance to out-of-network hospitals, often close to where they live. Were this patient and her providers not limited by network restrictions, this undesirable scenario may have been avoided.

Reimbursement is a critical factor for network adequacy. Studies show that low Medicaid reimbursement relative to private payers and Medicare have led to a low Medicaid acceptance by providers. The hospital in this case is located in a state that ranks in the bottom 10 for Medicaid reimbursement. As a result, despite being in a high-poverty area in which nearly 40% of residents are Medicaid-eligible, this hospital accepts a limited number of Medicaid beneficiaries.

Another related issue is that of “auto-assignment,” a policy whereby Medicaid beneficiaries who do not select an MMC plan within 30 days of enrollment are assigned to a plan by the state. Reports have shown that a large plurality of MMC beneficiaries in our state have consistently been assigned to one of the lowest-quality plans available. In other states, beneficiaries assigned to MMC plans report difficulty getting appointments and lower care quality.

CONCLUSION: Ideally, this patient’s diagnosis, follow-up, and treatment would take place within a single, conveniently located facility or system to ensure timeliness, quality, and continuity of care. The phenomenon of narrow networks in managed care made this ideal plan of care impossible.

UNVEILING THE HIDDEN DANGERS: A CASE SERIES ON ADVERSE EFFECTS OF AN OVER-THE-COUNTER SUPPLEMENT

Steven Chrysafides¹; Jonathan Scott¹; Almira Yang^2,1. ¹Internal Medicine, Riverside University Health System, Moreno Valley, CA; ²Endocrinology, Riverside University Health System, Moreno Valley, CA. (Control ID #4064895)

CASE: 1. A 57-year-old male with a history of diabetes, hypertension, and hydrocele presented to the emergency room with symptoms of nausea, vomiting, dizziness, and headaches. Vital signs showed a blood pressure of 99/62 and a pulse of 118. On exam, he had facial plethora, truncal obesity, abdominal striae, and an enlarged, erythematous scrotum. With hypotension thought to be septic shock due to scrotal cellulitis, he was admitted for antibiotics and norepinephrine infusion. After failing to improve on antibiotics, a deeper assessment of his history revealed he had been taking Artri King (AK) for the past 2 years and was stopped 2 weeks prior. Cosyntropin stimulation testing showed basal cortisol of 7.3, 30-minute cortisol of 22.1, and 60-minute cortisol of 17.8. He required a prolonged corticosteroid taper for many months.

2. A 52-year-old male with a history of bilateral knee osteoarthritis, diabetes, and hypertension presented with facial rash and swelling. On exam, he also had abdominal striae. After discovering he had been taking AK for the past 3 years, it was stopped, and a prednisone taper was started. Cosyntropin stimulation testing showed basal cortisol of 4.3, 30-minute cortisol of 9.6, and 60-minute cortisol of 11.2. He required corticosteroids for several months.

3. A 78-year-old female with a history of hypothyroidism, recurrent falls, fractures, and fatigue was found to be taking AK for pain relief. After discontinuation of AK, a three-week prednisone taper was started with significant improvement in fatigue. Cosyntropin stimulation testing showed basal cortisol of 16.3, 30-minute cortisol of 21.0, and 60-minute cortisol of 25.3.

IMPACT/DISCUSSION: Over-the-counter supplements are not regulated by the Food and Drug Administration (FDA), meaning they may contain harmful ingredients not listed on the product label. AK is one such supplement, sold as an over-the-counter pain relief medication, which contains the hidden ingredients diclofenac and dexamethasone. Presented are 3 cases of adrenal insufficiency (AI) that resulted from AK.

Long-term steroid use leading to AI and Cushing’s syndrome (CS) has been well documented in the literature. Diagnosing these conditions is challenging, given the wide range in presentation, from fatigue and striae to shock and death. Patients often overlook supplement use in their medication history, which is further complicated by the fact that many supplements contain hidden ingredients.

CONCLUSION: These cases make it clear that supplements such as AK require heightened FDA regulation. Although AK was recalled from the United States market after causing harm, it remains available in Mexico. This lack of regulation disproportionately affects people of color due to socioeconomic, racial, and societal restrictions that limit their access to care, forcing them to use over-the-counter medications without physician guidance. Until then, physicians should actively inquire about supplement use in their patients, particularly for foreigners.

Clinical Vignette - Women’s Health, Sex, and Gender-Informed Medicine

"I THOUGHT HE WAS GOING TO KILL ME." - IDENTIFICATION AND EVALUATION OF STRANGULATION.

Andrea Reilly. General Internal Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4061634)

CASE: An 18 year old woman presented to the ED with headache, neck pain and abdominal pain. Symptoms began after she was assaulted by her boyfriend. She was punched, kicked, thrown to the ground and strangled. She felt “dazed” but denied loss of consciousness. She denied vision changes, dizziness, numbness /weakness in the extremities, nausea, vomiting, incontinence, worsening depression or suicidal ideation. Past history included depression and suicide attempts. No substance use or smoking, rare alcohol use. Vital signs were stable. Voice was soft. She was A&Ox 3. BP was 10/70, HR 78, O2 sat 100%. She had a bruise on her forehead, conjunctiva was clear, EOMI, PERRL, OP was clear and moist. Neck ROM was normal. Ligature marks present. No midline tenderness, no step off. CV and lung exam normal. Abd soft. She had cuts to forearm and abrasions on her back. Urine tox screen was negative. She initially refused imaging, but the ED attending urged evaluation with a CT angiogram of the neck, the results of which was normal. In follow up in outpatient clinic she continued to have headaches, emotional dysregulation, and anxiety for 2 years. When speaking about the assault she often referred to her fear that “he was going to kill me.” Now 4 years later she is in college and doing well.

IMPACT/DISCUSSION: Strangulation is a mechanism of violent and potentially fatal assault. It can be used to both control and harm the survivor. Strangulation is the obstruction of blood vessels and/or airway by external pressure to the neck resulting in decreased oxygen supply to the brain. The vasculature of the neck is relatively unprotected and vulnerable. Application of 11 lbs of pressure to the carotid arteries can cause loss of consciousness in approximately 10 seconds. Strangulation can be fatal in four to five minutes.

Fifty percent of strangulation cases have no visible physical findings. The lack of obvious injury, coupled with a fearful patient who minimizes symptoms, often leads to under evaluation. Initial exam needs to include careful inspection of the skin, head and neck, mouth, O2 sat and imaging of neck. Scratches, petechiae and subconjunctival hemorrhage may be seen, but bruising may not be apparent for a few days. Pulmonary edema, aspiration, arterial dissection, stroke, mental status changes, hyoid or tracheal cartilage fracture are other potential injuries. Late effects include headaches, seizures, inattention, flat affect, depression, PTSD, memory impairment.

In intimate partner violence, strangulation is a hidden form of control. There is growing awareness in emergency medicine and some in mental health and neurologic literature, but general internists need to be aware of this too.

CONCLUSION: Many patients are unaware of the dangers of strangulation. It is potentially lethal in very few minutes.

Physical findings may be minimal. The internist needs to maintain a high index of suspicion.

Neurological symptoms and airway compromise may be delayed. Consider CT angiography for evaluation.

A CASE OF ACUTE PERSISTENT ABDOMINAL PAIN IN A NON-PREGNANT WOMAN

Stephanie Braunthal¹; Elisa McEachern¹; Anais Ovalle^2,1; Terry Marryshow^2,1; Alicja Kreczko³; Jeanette Thibault⁴; Kristen Hannigan⁴; Erica Hardy^5,1. ¹Medicine, Brown University Warren Alpert Medical School, Providence, RI; ²Infectious Disease, Care New England Health System, Providence, RI; ³Obstetrics & Gynecology, Brown University Warren Alpert Medical School, Providence, RI; ⁴Hospital Medicine, Care New England Health System, Providence, RI; ⁵Infectious Disease, Brown University Warren Alpert Medical School, Providence, RI. (Control ID #4064252)

CASE: A 35-year-old cis-female presented to the emergency department with off-cycle vaginal bleeding, progressive generalized abdominal pain, chills, and poor oral intake over one week. Her past medical history included kidney stones, ovarian cysts, cervical dysplasia, depression/anxiety, asthma, and prior alcohol use disorder. She reported a monogamous relationship with a cis-male, and had negative chlamydia and gonorrhea testing two months prior. Vital signs: temperature 36.7 degrees Celsius, blood pressure 110/60 mmHg, heart rate 92 bpm, respiratory rate 18 breaths/min, SaO2 98% room air. Exam: Moderate diffuse abdominal tenderness, minimal guarding; no cervical motion or adnexal tenderness; dark red blood visualized in the vagina. Initial labs showed no leukocytosis, a mild anemia and thrombocytosis (Hb 10.4 g/dL, PLT 472 x 10^3/mcL). She had mild abnormalities of chemistries, liver, and renal function. Urinalysis was positive for nitrites, leukocyte esterase, 52/HPF WBC, 0/HPF RBC, and mucus; culture grew E. coli, resistant only to first generation cephalosporins. CT abdomen/pelvis showed focal cecal wall thickening, mid-anterior abdominal and pelvic stranding, diffuse peritoneal thickening, and a small amount of free fluid. Intravenous ceftriaxone and metronidazole were initiated, and she remained hemodynamically stable, afebrile, but without symptomatic improvement. Imaging findings of peritonitis and ascites persisted on transvaginal ultrasound and two additional CT scans, without clear evidence of infectious or non-infectious etiology. Diagnostic laparoscopy was being considered when on hospital day 5, vaginal Chlamydia trachomatis NAAT came back positive. Abdominal pain improved with the resumption of doxycycline 100 mg BID (she had received three doses earlier in the stay). The presumed diagnosis was Chlamydia associated peritonitis and a 14-day course of doxycycline was recommended. The Department of Health was notified per protocol and expedited partner therapy was declined by the patient.

IMPACT/DISCUSSION: Fewer than 10 cases of Chlamydia trachomatis associated with acute peritonitis appear to be published. This case adds to the literature and highlights an atypical presentation of chlamydia, in which vaginal bleeding and peritonitis were present in the absence of cervical motion and adnexal tenderness, as well as signs of pelvic inflammation on imaging. Given the concurrent association with pelvic inflammatory disease, which can cause infertility, chronic pelvic pain, and increase the risk for ectopic pregnancy, internists should have a low threshold to test and treat sexually transmitted infections.

CONCLUSION:

Sexually transmitted infections should be included in the differential diagnosis for acute peritonitis.

Maintain a high index of suspicion for sexually transmitted infections, even when presentations are atypical.

A CASE OF RECURRENT BILATERAL SPONTANEOUS PNEUMOTHORACES ASSOCIATED WITH THE MENSTRUAL CYCLE

Claire Arnold. Internal Medicine, Mayo Clinic Department of Internal Medicine, Rochester, MN. (Control ID #4063777)

CASE: A 35 year-old female with a history of total abdominal hysterectomy for uterine leiomyoma presented with chest pain, scapular pain and shortness of breath. Her past medical history was notable for recurrent bilateral spontaneous pneumothoraces with prior pleurodeses. Chest X-ray on admission confirmed bilateral pneumothoraces. She was hemodynamically stable and saturating well on room air. There was no tension physiology. She underwent bilateral chest tube placement with successful lung re-expansion followed by bilateral pleurodesis. Pelvic MRI revealed endometriosis invovling the vaginal cuff, ovaries and tethering of the rectosigmoid colon with findings suspicious for bowel invasive disease. Previous imaging had failed to provide evidence for thoracic endometriosis, nor was endometriosis identified on previous VATS procedures. There was no evidence of cystic lung disease on prior imaging or other cause to explain recurrent pneumothoraces. She was started on hormonal suppressive therapy per gynecology for thoracic endometriosis syndrome.

IMPACT/DISCUSSION: The diagnosis of thoracic endometriosis is usually made clinically; histopathologic confirmation is ideal, but not required. The clinical characteristics that set thoracic endometriosis apart from other diseases that present similarly include temporal association with menstruation, right lung predominance, and demographics (i.e. young, female with recurrent disease). Patients with thoracic endometriosis may have higher serum carbohydrate antigen (CA) 125 and CA 19-9, however, these markers are poorly sensitive and non-specific. At times, pleural fluid is sent for evaluation of endometrial cells, but the diagnostic yield is thought to be low. Hormone suppressive therapy should be used to treat the majority of patients with pneumothoraces related to endometriosis, however, even with the combined strategy of hormonal suppression and surgery, recurrence still occurs.

CONCLUSION: Endometriosis is when endometrial glands and stroma develop outside of the uterus and the most common extra-pelvic site is the involvement of the thoracic cavity. Thoracic endometriosis most commonly presents with catamenial pneumothorax, which refers to a temporal association with menstruation. The pathophysiology is unknown, but thoracic endometriosis should be suspected in any female of reproductive age presenting with catamenial pneumothorax.

A CLOT AND A HARD PLACE

Son Quyen H. Dinh. Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4063859)

CASE: A 56-year-old transwoman with a history of hypertension, diabetes mellitus type 2, and peripheral vascular disease has been on gender-affirming hormone therapy for the past 2 years. While on sublingual estradiol 4mg in the morning and 2mg at night, progesterone 100mg daily, and spironolactone 50mg twice a day, her testosterone was appropriately suppressed at 15 ng/dL, and estradiol was within goal range at 111 pg/mL. She presented to the emergency room with acute shortness of breath. A computed tomography pulmonary angiogram showed extensive bilateral pulmonary emboli (PE) with flattening of the interventricular septum suggesting of right heart strain, which was confirmed on transthoracic echocardiogram. She was initially treated with systemic heparin and transitioned to apixaban with plans to repeat an echocardiogram in 6 months to determine the course of anticoagulation. Hypercoagulability work-up was negative for prothrombotic mutations, and it was felt her current hormone regimen may have contributed to her development of PE. However, the patient expressed significant depression and suicidal ideation prior to starting gender-affirming hormones and requested to remain on therapy. A consensus among the vascular medicine, endocrinology, and primary care team was reached to continue therapy but stop progesterone and switch sublingual estradiol to transdermal estradiol patches to minimize the risk of clotting.

IMPACT/DISCUSSION: Transgender individuals experience significant health disparities with 81% reporting suicidal ideation in their lifetime and 42% attempting suicide. Gender-affirming care has been shown to improve depression and suicidality, yet there are record high anti-LGBTQ+ bills, many of which focus on restricting gender-affirming care. Understanding the available options for gender-affirming care is an important aspect of bridging the gap in healthcare disparities for transgender individuals.

Transgender patients on hormone therapy first diagnosed with venous thromboembolism (VTE) should be worked up for hypercoagulability, and anticoagulation should be managed per guidelines for non-transgender patients if a prothrombotic etiology is found. Consultation with vascular medicine or hematology can be beneficial in determining the appropriate anticoagulation plan for transgender patients with VTE while on feminizing hormones. Studies looking at the use of transdermal estradiol in menopausal women show no increased risk of VTE. There are no absolute contraindications to feminizing hormones, although estrogen therapy should be avoided in estrogen-sensitive cancer.

CONCLUSION: Gender-affirming care can be a lifesaving treatment. VTE is not an absolute contraindication for gender-affirming estrogen therapy, and transdermal estradiol can be utilized to minimize VTE risk.

A GLOBAL BURDEN: TWO CASES OF INFERTILITY CAUSED BY FEMALE GENITAL TUBERCULOSIS

Jordan Cahn¹; Ayesha H. Sundaram¹; Linda Shipton². ¹Internal Medicine, Cambridge Health Alliance, Cambridge, MA; ²Infectious Diseases, Cambridge Health Alliance, Lincoln, MA. (Control ID #4060193)

CASE: Patient 1 is a South Asian immigrant woman in her late 20s who was treated for peritoneal tuberculosis 4 years prior. She presented with persistent oligomenorrhea and after attempting to conceive for over a year and sought treatment for infertility. Hormonal evaluation was normal but a hysterosalpingogram showed distal left hydrosalpinx. An endometrial biopsy was obtained and showed granulomatous endometritis with culture positive for Mycobacterium tuberculosis (TB) complex. She was diagnosed with endometrial and fallopian tube TB. After 3 months of treatment, her menses became regular and a surveillance endometrial biopsy showed no granulomas with negative TB culture. She was treated for 9 months of TB therapy and is now again attempting to conceive.

Patient 2 is a North African immigrant woman in her early 30s who was evaluated for infertility after 8 months of attempting to conceive and several unsuccessful rounds of in vitro fertilization (IVF). She had a hysterosalpingogram which found that neither fallopian tube was patent. A subsequent diagnostic laparoscopy and bilateral salpingectomy was performed given evidence of improved IVF success with removal of inflammatory tissue. Pathology showed non-necrotizing granulomas but mycobacterial cultures were negative. Ultimately, an endometrial biopsy was done and confirmed TB by culture. She was started on treatment for FGTB, and at 2 months a repeat endometrial biopsy was negative for TB. She completed 9 months of treatment. Less than one year later, she became pregnant through IVF and had a successful delivery.

IMPACT/DISCUSSION: FGTB is likely underdetected because it is often only diagnosed during evaluation for infertility. TB infection of the urogenital tract causes pelvic inflammatory disease resulting in infertility. It is estimated that FGTB accounts for up to 25% of cases of infertility in some countries. While FGTB can present with clinical signs such as oligomenorrhea, dysmenorrhea, abnormal vaginal discharge, and lower abdominal pain, a significant proportion have no symptoms other than infertility. Typical symptoms associated with TB such as fevers, night sweats, and weight loss are generally absent. A high index of suspicion is therefore needed to include FGTB on the differential for infertility in patients with risk factors for TB infection. Diagnosis includes visualization of the genital tract by hysterosalpingography and biopsy of the involved areas for pathology and microbiology. Early detection of FGTB can lead to early treatment, prevent permanent damage to the reproductive organs, and increase chances of a successful pregnancy.

CONCLUSION: In immigrant patients with infertility, female genital tuberculosis should be considered on the differential.

A HAIRY CONUNDRUM: THE CASE OF HIGH TESTOSTERONE

Morgan Baudoin, Anne Cioletti. Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4065016)

CASE: A 27-year-old female with polycystic ovarian syndrome (PCOS) for 12 years presents to her PCP with rapid weight gain of 16lbs in 5 months despite lifestyle modifications. She reports hirsutism but denies other signs of virilization: deep voice, hair loss, clitoromegaly. Preferring supplementation to contraception for PCOS treatment, she was taking multiple supplements marketed as hormone balancing including Diindolylmethane (DIM), curcumin, akkermansia, berberine, cranberry, L-carnitine, magnesium, and adrenal cortex. She and her partner deny use of exogenous testosterone.

Initial labs were notable for testosterone 187 ng/dL (increased from 92 two years prior), normal A1c, TSH, and CBC. Further workup revealed normal dehydroepiandrosterone sulfate (DHEAs) and 17-OH-progesterone. Pelvic ultrasound revealed over 25 peripheral follicles in the right ovary. Pelvic MRI also showed mildly enlarged ovaries with multiple follicles and no adnexal masses. The patient was advised to discontinue all supplementation. Repeat testosterone 5 weeks later decreased to 155. After endocrine consultation, it is presumed that PCOS is the main cause of her severe hyperandrogenism with potential impact of her supplementation.

IMPACT/DISCUSSION: A testosterone of 187 designates severe hyperandrogenism despite her lack of virilization. Although PCOS is the most common etiology in premenopausal women, levels over 150 warrant further evaluation including a good history and exam for virilization, HPA axis disorders and a review of all medications, supplements, and sources of inadvertent androgen exposure. Laboratory testing should include total testosterone, DHEAs to look for adrenal causes, and morning 17-hydroxyprogesterone if menstrual irregularities are present.

Transvaginal ultrasonography is the preferred first line imaging modality but cannot exclude ovarian tumors. If negative, pelvic MRI is warranted to identify small ovarian tumors. If DHEAs is over 700, dedicated CT of the adrenal glands is indicated. If there is high suspicion for androgen producing tumor but negative imaging, ovarian and adrenal vein sampling can be used to localize a source of increased testosterone production.

In this case, work up was consistent with PCOS; the recent increase in testosterone was attributed to two of her supplements. DIM, a phytochemical found in cruciferous vegetables, has been shown to have dose-dependent effects on estrogen receptor and aromatase activity in-vitro. Also, varying levels of steroid hormones including androstenedione and pregnenolone have been found in adrenal cortex supplements. This case highlights the importance of a thorough history including supplement use and calls attention to potential risks of unregulated supplement use.

CONCLUSION: Severe hyperandrogenism (testosterone over 150) warrants additional workup, with DHEAs helping to differentiate between adrenal versus ovarian etiologies. A thorough history, including supplements, can help identify potential etiologies of high testosterone.

AN UNEXPECTED TWIST UNDER THE MICROSCOPE: SCHISTOSOMIASIS MASQUERADING AS ENDOMETRIOSIS

Aung Sitt Naing¹; Harrison Dai¹; Abby Hargis¹; Catherine Derber². ¹internal medicine, Eastern Virginia Medical School, Norfolk, VA; ²Infectious Diseases, Eastern Virginia Medical School, Norfolk, VA. (Control ID #4043675)

CASE: A 24-year-old woman presented with chronic pelvic pain, dysmenorrhea, and dyspareunia. She had no prior history of sexually transmitted infections. She had no fever, urinary symptoms, irregular menstrual cycles, vaginal bleeding or discharge. Her pelvic exam was notable for tenderness on the right uterosacral ligament with a 1-2 cm nodule. Diagnostic laparoscopy revealed a small amount of endometrial implants on the anterior cul-de-sac, which was cauterized. She was then prescribed oral contraceptives. However, her pelvic pain persisted for several months. Pelvic MRI was normal without any findings of endometriosis. A second laparoscopy demonstrated an enlarged uterus and endometriotic tissues on the colonic serosa associated with surrounding fibrosis and scarring. Excised tissues were sent for pathology. Light microscopy of the specimen did not show endometriotic characteristics, but a background of granulomatous inflammation interspersed with calcified Schistosoma eggs, later identfied as S. mansoni. Upon reviewing her exposure history, she reported spending two months in Uganda and Rwanda, during which she participated in baptisms in Lake Victoria, about 2 years prior to the onset of symptoms. Notably, she never had eosinophilia but had an elevated Schistosoma IgG level. She was started on a 60mg/kg dose of praziquantel over 24 hours together with a course of oral prednisone. She completed a second dose of praziquantel 4 weeks later. She had two subsequent stool studies which were negative for ova and parasites. Unfortunately, her pelvic pain did not improve.

IMPACT/DISCUSSION: Schistosomiasis is a parasitic infection endemic to Asia, Africa, and South America, but an unusual cause of pelvic pain in the United States. Our patient had a longstanding schistosomiasis due to a misdiagnosis and delayed treatment. S. mansoni enters the host via the skin, migrates through blood and settles in mesenteric vessels. It can present as an acute hypersensitivity reaction or a chronic granulomatous inflammation. The prolonged inflammation and fibrotic changes on laparoscopy due to delay in treatment explain why this patient did not improve after laparoscopy and anthelminthic therapy. The diagnosis of schistosomiasis can be made through various approaches including parasite egg-microscopy in urine or stool samples, parasite antigen, or antibody assays. Praziquantel is the preferred treatment option for Schistosomiasis with relatively few adverse effects. A second dose is often recommended to kill juvenile worms 3-6 weeks after the initial treatment. Steroids are sometimes added to reduce the risk of complications related to the host inflammatory response.

CONCLUSION: Due to varying clinical manifestations of the disease, diagnosing schistosomiasis can be difficult or even mistaken for another pathology when it is encountered outside of endemic regions. This case emphasizes the importance of obtaining a comprehensive exposure history in patients with long-standing unexplained pelvic pain.

CEREBROVASCULAR ACCIDENT IN A PATIENT RECEIVING HIGH DOSE HORMONE PELLET THERAPY ACQUIRED FROM COMMUNITY

Samuel C. Fountain¹; Tyra Fainstad². ¹Internal Medicine, University of Colorado System, Denver, CO; ²Internal Medicine, University of Colorado, Denver, CO. (Control ID #4063340)

CASE: Our patient is a 74-year-old woman with a history of hysterectomy in her fifth decade, hyperlipidemia, on chronic hormone replacement therapy since age 46, who presented to the emergency department with symptoms of dizziness and left-sided weakness. The morning prior to admission, the patient had undergone subcutaneous testosterone, estradiol, and progesterone pellet implantation at a local wellness clinic. That evening, she felt dizzy prior to going to sleep and awoke in the morning with weakness in her left arm and leg. She had no prior history of cardiovascular disease and is a lifelong non-smoker. Medications included levothyroxine, amlodipine, and hormone replacement as described. Vital signs and fingerstick blood glucose were normal. Physical exam revealed pronator drift and moderate weakness in the left arm and leg. Magnetic resonance imaging of the brain showed acute ischemic infarction in the region of the right thalamus and posterior limb of the right internal capsule. Laboratory workup was unremarkable. Total testosterone level prior to receiving pellet implantation the day before presentation was 114 ng/dl (upper limit of normal for post-menopausal women is 32 ng/dl). Other work-up, including vascular imaging of the cervical and intracranial vessels, a two-week cardiac monitor and transthoracic echocardiography was unrevealing.

IMPACT/DISCUSSION: This case highlights a cerebrovascular accident in a patient receiving long term androgen, estrogen, and progesterone supplementation. While testosterone therapy in doses that approximate physiological levels is a safe and beneficial treatment for hypoactive sexual disorder according to the most recent guidelines approved by The Endocrine Society, this does not apply to injectable or pellet formulations of testosterone. These formulations, as seen in our patient, result in supraphysiologic levels of free and total testosterone. In our patient, total testosterone was 3.5 times the upper limit of normal for post-menopausal women. In addition, there is also a known risk of ischemic stroke associated with estrogen therapy for post-menopausal patients. In our patient, the combination of androgen, estrogen, and progesterone therapy potentially elevated her risk of adverse cardiovascular events leading to an ischemic stroke.

CONCLUSION: Extended use of hormone replacement therapy in post-menopausal patients requires the use of the lowest effective dose and safest route of administration

Testosterone and other hormone pellets lead to supraphysiologic levels of free and total testosterone in post-menopausal women

There is insufficient evidence surrounding risk of cardiovascular events in post-menopausal patients receiving high dose androgen therapy

DOUBLE JEOPARDY: A MULTIFACETED APPROACH TO SCAD RECURRENCE AND RISK FACTOR MODIFICATION

Usnish Majumdar¹; Audrey Y. Lim². ¹Medicine, UPMC, Pittsburgh, PA; ²Medicine, UPMC, Pittsburgh, PA. (Control ID #4063775)

CASE: A 55-year-old woman with prior myocardial infarction (MI) at age 41, metastatic breast cancer (on leuprolide and letrozole), hypertension, and hyperlipidemia, who presented for evaluation of 3 weeks of jaw pain. She initially presented to a dentist, but the pain then began to radiate down her left arm, reminiscent of her prior MI diagnosis, prompting her presentation to the ED. On arrival, initial vitals HR 68, BP 164/106, T 36.9 C, SpO₂ 97% on room air. Initial EKG revealed normal sinus rhythm without S-T segment changes. Labs were significant for high-sensitivity troponin elevated to 1411. She received an aspirin load and was started on a heparin infusion. Coronary angiography revealed a double lumen consistent with spontaneous coronary artery dissection (SCAD) of the distal left circumflex artery. Echocardiography revealed hypokinetic basal inferior wall. Dual-antiplatelet therapy (DAPT) and ß-blockade was initiated. Troponin level peaked at 12117. Her jaw pain resolved, and she was discharged with referral to cardiac rehabilitation (CR).

In the outpatient setting, angiograms from prior MI at age 41 were reviewed. What was initially read as 50% stenosis of posterior descending artery was re-interpreted as SCAD due to its tubular nature, associated intraluminal thrombus, and resolution on most recent film. Labs notable for a lipid panel of LDL 87, HDL 45, but markedly elevated lipoprotein(a) (lp(a)) level at 410 nmol/L. Axial imaging showed no evidence of fibromuscular dysplasia. Genetic testing for connective tissue disorders was negative. Regarding her oncologic history, she was exposed to one cycle of docetaxel/cyclophosphamide before being transitioned to tamoxifen. Tamoxifen therapy was stopped after MI at age 41, and she has since been on leuprolide and letrozole. After a risk/benefit discussion, hormone therapy was continued, and she was enrolled in a trial of novel lp(a)-lowering agent.

IMPACT/DISCUSSION: SCAD is an underrecognized cause of ACS in women, who comprise 90% of all cases. It accounts for 35% of all ACS in women younger than 50, in whom atypical cardiac symptoms can increase the risk of a missed diagnosis. The pathogenesis of SCAD is not precisely known, hindering prevention. Here, we describe a patient with a complex risk profile, including elevated lp(a), exposure to taxanes, and active hormone therapy for breast cancer. Guidelines currently recommend DAPT, ß-blockade, and CR. There is insufficient evidence to withhold hormone therapy for breast cancer in patients with SCAD; we suggest that a risk/benefit discussion inform this decision. Research is needed to clarify the relationship between lipoprotein(a), hormone therapy, and SCAD.

CONCLUSION: While more research is needed to risk stratify patients with SCAD, it is important for internists to recognize and assess for common risk factors and, in collaboration with cardiologists, offer patients guideline-based therapy.

FACIAL HEMI-SPASMS: CHECKING CAFFEINE INTAKE OR OUR BIASES?

Erin E. Finn^1,2; Gail M. Boriel². ¹Neurology, Mayo Clinic Department of Neurology, Rochester, MN; ²Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4063585)

CASE: A 52-year-old post-menopausal woman with medical history notable for resolved syncopal spells of unknown origin and binge drinking in recovery presents to an academic medical center outpatient clinic for progressively worsening right-sided hemifacial spasm. The spasms arise acutely and occur daily. Initially, they only involved her right eyelid, but around four years ago progressed to involve her right cheek and upper lip. The spasming has become increasingly bothersome and obtrusive, occasionally affecting her vision, ability to fall asleep, and social wellbeing. She denies lip smacking, tongue-rolling, left facial involvement, other muscle spasms, or other symptoms. Initially, the spasms were attributed to caffeine intake and stress, so she was instructed to limit her caffeine intake and moderate her stress; she was also trialed on escitalopram to control these hypothetically stress-induced spasms. As noted above, her symptoms progressed despite these interventions, and it was not until presentation to a new physician years later that a neurologic etiology of her symptoms was considered. She proceeded for brain MRI/MRA/MRV, which was notable for interval progression since 2006 in an extra-axial pre-medullary cistern cystic mass located in the distribution of the seventh cranial nerve with imaging findings suggesting neurenteric cyst. She was seen by Neurosurgery and given the options of medical management with carbamazepine, botulimun toxin injections, or surgical decompression. She proceeded with suboccipital craniotomy and microvascular decompression of the right facial nerve with cyst drainage. This procedure went without complication and she has not had any facial spasming since.

IMPACT/DISCUSSION: This case is important because a woman with focal neurologic deficits was dismissed as having functional, stress-induced facial spasming for years, seriously impacting her quality of life, when a neurologic diagnosis could have provided her much prompter relief. Even more frustratingly, she had prior imaging notable for a neuroenteric cyst in 2006 in the exact distribution of the cranial nerve responsible for her symptoms, but this imaging was not reviewed and/or her symptoms were not deemed serious enough to be considered neurologic in origin. This case highlights the importance of performing a good neurologic exam and recognizing focal neurologic deficits. It also emphasizes that functional and stress-induced symptoms should be diagnoses of exclusion, especially when treatments targeting functional etiologies are ineffective. It adds to the literature because it identifies populations whose neurologic complaints our profession has a tendency to overlook.

CONCLUSION: Functional and stress-induced disorders are diagnoses of exclusion, but there are some populations, such as women and those with histories of substance use, whose neurologic complaints might be dismissed. It is essential to recognize our biases and perform good neurologic exams and thoughtful workups on patients.

FROM WOMB TO LUNG: AN ASTONISHING JOURNEY – UNRAVELING THORACIC ENDOMETRIOSIS IN A FASCINATING CASE REPORT

Zein Barakat, Felix Carrillo, Kamal Haider. Internal medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4060338)

CASE: 31-year-old female presented with complaints of recurrent episodes of hemoptysis over the past two years. She denied any significant medical history, including underlying pulmonary disease. Patient denied any recent travel or sick contact. Patient’s vitals were stable and afebrile. Physical exam and routine laboratory tests were unremarkable. Upon further investigation, the patient revealed that the episodes were cyclical and coincided with her menstrual cycle. A chest CT scan was performed during the menstrual phase, which revealed a subtle nodular lesion measuring approximately 3.3 cm by 2.4 cm within the right upper lobe, exhibiting ground-glass opacities with surrounding airspace opacity. The patient underwent further evaluation with bronchoscopy during menstruation which showed active bleeding from the right upper lobe posterior segment. Samples from bronchial washing were subjected to cytology studies, microbiological cultures, and immune compromised panels, all of which were unremarkable. Interventional radiology was consulted for embolization, however, they were unable to cannulate the actively bleeding artery. In view of the persistent symptoms and the radiological findings, surgical intervention was deemed necessary for both diagnostic and therapeutic purposes. Mini-thoracotomy was employed as a surgical intervention to remove the nodular lesion. A wedge resection was performed and the excised tissue, including three multifocal subpleural nodules ranging from 0.8 cm to 3.7 cm in greatest dimension, was sent for histopathological examination. Pathology report demonstrated thickened alveolar septae, mild chronic inflammation, and evidence of old and recent intra-alveolar hemorrhage. Notably, some bronchial epithelium lost its ciliated pattern, which given the patients’ clinical history, could represent metaplasia to endometrial type epithelium. The patient was closely monitored postoperatively and remained asymptomatic.

IMPACT/DISCUSSION: Catamenial hemoptysis, a rare and intriguing manifestation of thoracic endometriosis, is characterized by the recurrent coughing up of blood during menstruation. Thoracic endometriosis is a rare condition and its pathophysiology remains incompletely understood. Although pulmonary involvement in endometriosis is rare, it should be considered in the differential diagnosis of recurrent hemoptysis, particularly in reproductive-age females, even in the absence of pelvic endometriosis.

CONCLUSION: Further studies are warranted to explore the underlying pathophysiology and optimal treatment strategies for thoracic endometriosis. Our case report aims to contribute valuable insights into the clinical profile, diagnostic approach, and management of catamenial hemoptysis, thereby enriching the medical community's understanding of this exceptional presentation.

GLUTEAL STERILE ABSCESSES AS A COMPLICATION OF LEUPROLIDE ACETATE INJECTIONS

Cihang Gu¹; William Levin². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²General Internal Medicine, University of Pittsburgh Medical Center, Gibsonia, PA. (Control ID #4060719)

CASE: A 29-year-old female patient with a history of BRCA-2 positive metastatic breast cancer treated with abemcicilib, letrazole, and leuprolide presents with a 3-month history of pain in her gluteal region. She has had several similar prior admissions during which CT abdomen/pelvis has found two rim-enhancing lesions in her gluteal region. Leuprolide was stopped 5 weeks prior due to concern for abscess. Previous drainage of one lesion had grown light Staphylococcus aureus, although antibiotic treatment did not improve her symptoms. Vital signs and laboratory results were within normal limits. Physical exam of buttocks was normal besides pain with palpation. CT abdomen/pelvis redemonstrated the rim-enhancing lesions, 6.8 x 3.7 cm in the right gluteus maximus muscle and 7.6 x 2.1 cm in the left gluteus maximus muscle, without drainable pockets. The patient was started on antibiotics, but they were stopped after a lack of infectious signs for over 24 hours. Biopsy with interventional radiology demonstrated granulation tissue with focal necrosis, acute and chronic inflammation and foreign body type giant cell reaction. Patient was discharged with methylprednisolone taper with interval improvement in symptoms. However, patient was readmitted with an enlarging left-sided sterile abscess again three months later requiring drainage.

IMPACT/DISCUSSION: Leuprolide is a gonadotropin-releasing hormone agonist used for treatment of central precocious puberty, prostate cancer, endometriosis, uterine fibroids, and off-label for breast cancer as well as hormonal therapy for transgender patients. Sterile abscess formation as a reaction to depot leuprolide acetate has been reported mostly in children, with prevalence ranging from 3 to 13 in 100 children on the therapy. A MEDLINE search of previous literature also found one case report of sterile abscess formation in one adult prostate cancer patient, but no reports of adult female patients with this reaction have been found. The reaction is thought to be caused by the copolymer of the leuprolide suspension in the depot format. The mainstay of treatment is cessation of the offending agent. However, treatment of symptoms associated with the sterile abscess as well as prevention of recurrence is less clear given the rarity of the condition. A lavage protocol was developed for sterile abscesses secondary to hyaluronic acid filler injections including saline and triamcinolone. Our patient seems to have temporarily benefited from systemic steroids; however, the effect was not sustained.

CONCLUSION: Sterile abscess formation is a known rare reaction to leuprolide acetate depot injections, which has not been previously reported in adult female patients. The mainstay treatment is the discontinuation of leuprolide, however further treatment options are unclear.

HYPERCALCEMIA DUE TO ADVANCED SMALL CELL CARCINOMA OF THE OVARY HYPERCALCEMIC TYPE

Clare R. Rudman¹; Erin Onat²; Sierra Sandler³; Jennifer Griffith¹. ¹GME - Internal Medicine, Sky Ridge Medical Center, Lone Tree, CO; ²Rocky Vista University College of Osteopathic Medicine, Parker, CO; ³GME - Neurology, Swedish Medical Center, Englewood, CO. (Control ID #4062005)

CASE: A 36 year-old woman with no past medical history presented to our hospital with 2 weeks of abdominal pain and loss of appetite plus 2 days of decreased oral intake and urine output. She endorsed 80 pounds of weight loss in the preceding 6 months. On admission she was hypotensive and oliguric. Initial labs revealed a corrected serum calcium of 15.9 mg/dL. Diagnostic imaging revealed multiple masses throughout the chest, abdomen, and pelvis. She had bilateral adnexal masses, both larger than 15 cm, extending into the abdomen. Additional lesions were also noted in the liver, mediastinum, and retroperitoneal and pelvic lymph nodes. Biopsy of the liver mass revealed small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) with SMARCA4 loss of expression. Subsequent laboratory evaluation found a CA-125 level of 193 U/mL and elevated parathyroid hormone-related peptide (PTHrP). She reported a family history of breast and ovarian cancers in her mother, maternal grandmother, and maternal aunt.

IMPACT/DISCUSSION: An estimated 62% of patients with SCCOHT present with hypercalcemia, possibly related to PTHrP, although the precise mechanism is not yet understood. While SCCOHT is the most common undifferentiated ovarian tumor in women under age 40, it is extremely rare, representing less than 0.01% of ovarian neoplasms. SCCOHT affects young women and pediatric patients with a mean age at diagnosis of approximately 24 years old, compared with 63 years old for other ovarian cancers. SMARCA4 mutations are highly associated with SCCOHT (>95%) and considered essential to diagnosis. Elevated CA-125 is often seen. Tumors are typically unilateral though familial cases can be bilateral, such as in our patient. Patients most commonly present with abdominal pain, similar to other causes of both hypercalcemia and ovarian cancer. Due to the subacute course of this disease they may also complain of ongoing bloating, fatigue, weight loss, and constipation.

Given its rarity, there are no international guidelines for treatment of SCCOHT. Recent approaches include a combination of surgery and chemotherapy. One of the most common chemotherapy protocols is vinblastine, cisplatin, cyclophosphamide, bleomycin, adriamycin, and etoposide (VPCBAE). In this case, 6 cycles of VPCBAE were initiated separated by 3 weeks.

CONCLUSION: Hypercalcemia is a rare laboratory finding among young women. SCCOHT is a potential cause with a poor prognosis that should be recognized among women with a concerning prodrome of unexplained abdominal pain and weight loss. Although the disease is rare, it is extremely aggressive with only a 10% to 33% survival rate when diagnosed early. Rate of relapse is up to 65%. The advanced nature of our patient's SCCOHT at diagnosis confers a poor prognosis, but her case can inform all providers of this deadly cancer and possibly inspire earlier diagnosis and treatment in the future.

MITIGATING PERSONAL AND SOCIETAL PRESSURES SURROUNDING FERTILITY IN PULMONARY HYPERTENSION

Liyan Fan, Alyssa Kelder. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4063934)

CASE: A 27-year-old G3P2002 (6w4d) female with WHO Group I PAH and WHO Group IV PH presented after 3 syncopal episodes in cardiogenic and obstructive shock. One month prior, patient reported she was advised to discontinue Riociguat, Ambrisentan, and Apixaban in setting of pregnancy. On admission, TTE demonstrated severely dilated RV and estimated PASP 181mmHg, and CTA revealed a large clot in the main pulmonary artery. Given the life-threatening nature of pregnancy in the setting of severe PH and shock, a meeting was held with the patient and a multi-disciplinary team. Patient elected to undergo D&C with DMPA for contraception and plans for partner vasectomy. Following D&C, patient struggled with grief over the loss of her pregnancy and experienced conflict with her support system regarding her choice to terminate the pregnancy. Supportive care was consulted to provide emotional and spiritual support.

A 26-year-old female with anxiety and depression presented with left-sided pleuritic back pain and was found to have new HFrEF, a large pulmonary embolism, and severe PH in the setting of antiphospholipid syndrome. Patient was initiated on Riociguat therapy. During initial conversations regarding necessity of contraception, she was very hesitant due to fear of IUD placement, impact on future fertility, and long-standing cultural beliefs. After multiple conversations with her and trusted family members to address concerns, the patient eventually agreed to receive IUD, which was placed by Gynecology prior to discharge.

IMPACT/DISCUSSION: Women of reproductive age are a unique population given the risks that pregnancy confers to existing disease and the potential harm that teratogenic medications can cause to the fetus. PH during pregnancy is associated with significantly increased risk of adverse cardiac outcomes, pre-term labor, fetal demise, and maternal death. These cases underscore the importance of shared decision making and timely counseling on risks of pregnancy with PH and necessity of contraceptives. Our patients, along with many others, struggle with contraceptives and pregnancy termination due to fear (e.g. of procedure pain, impact on fertility), moral and cultural beliefs, societal stigma, assumptions about pregnancy risk, and feelings of guilt. These cases demonstrate that thoughtful conversations addressing these concerns and utilizing resources such as the expertise of Supportive Care and/or OBGYN can be extremely helpful in shared decision making regarding fertility.

CONCLUSION: Pregnancy with PH poses high risks; timely conversations with reproductive-age women about effective contraception can prevent future complications and mortality.

Successful shared decision making may require multiple conversations addressing fears and questions and a multi-disciplinary approach.

PATIENT EDUCATION STRATEGIES FOR DILATOR USE

Orly Morgan²; Minal Kale¹; Julie B. Schnur³. ¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²University of Miami Miller School of Medicine, Miami, FL; ³Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4054110)

CASE: Mrs. M, a 65-year-old G4P4 Hispanic female treated for pelvic brachytherapy for Stage 2 cervical cancer two years ago, had been experiencing vaginal dryness and dyspareunia since finishing treatment, reporting symptoms diminish her quality of life and self-esteem. She was given a plastic dilator to mitigate vaginal stenosis and preserve ability for penetrative sex, and found the dilator difficult and painful to use, stating “It’s like you have a scab and every time you use it and touch the scab it irritates and opens up.” To make dilator treatment work for her, Mrs. M looked online and found a web-based community of women undergoing male to female gender affirmation surgery using dilators for pelvic floor rehabilitation. The community videos and comments informed her how to use the dilator correctly and in a less painful manner, and which types of dilators might be more comfortable, inspiring her to try different options. She found silicone dilators were notably more comfortable, helping her with adherence, and in turn sexual function. Perhaps most important, Mrs. M found that connecting with this community increased her self-esteem, teaching her that a sense of oneself as feminine or as a woman need not be tied to one’s anatomy.

IMPACT/DISCUSSION: Dyspareunia as a side effect of pelvic radiation experienced by ~40-100% of gynecologic cancer survivors. Few studies assess the quality of patient education on dilator use, however, a recent study found only 50% of gynecologic cancer patients given a dilator end up using it, and 63% of those who stopped reported discomfort as their primary reason. Mrs. M’s willingness to step outside the silo of “cancer education for cancer patients” to get advice from everyone working to mitigate the symptom should encourage patients and providers to think outside the box to find patient educational materials that are clear, informative and promote acceptance and understanding. Dilators are used by patients undergoing pelvic radiation and vaginoplasty procedures, as well as those experiencing dyspareunia from menopause, vaginismus, vulvodynia, endometriosis, Mayer-Rokitansky-Küster-Hauser Syndrome, and other congenital conditions affecting vaginal tissue development. If a patient is dissatisfied with the dilator information available in their patient community, different materials and training on how to best use the same piece of equipment in other settings can be a tremendous resource.

CONCLUSION: Providers should encourage patients to share online information they learn to evaluate it for safety and identify possible resources to help future patients. Physicians should be open to recommending cross departmental patient educational materials, as relevant information might come from a different patient population entirely. Thinking about how to treat the symptoms (e.g., dilator discomfort) rather than how to treat the disease (e.g., stenosis after brachytherapy), we may find persuasive and affirming materials that our patients need.

PELVIC EXAMINATION LEADING TO DISCOVERY AND EXPEDITING CARE FOR LARGE OVARIAN MASS

Zaina Siraj¹; Nazish Tarar¹; Megan R. Gerber². ¹Albany Medical College, Albany, NY; ²Medicine, Albany Medical College, Albany, NY. (Control ID #4060997)

CASE: A 65-year-old postmenopausal woman presented for annual primary care wellness visit. She was healthy with a past medical history of hypothyroidism treated with Armour thyroid 60 mg. During the interview, she reported a single episode of postcoital bleeding one week prior. She denied pelvic pain or vaginal dryness. She had no shortness of breath, cough, changes in bowel or bladder function but did endorse some chronic bloating. The patient saw a gynecologist annually and her last cervical cancer screening was negative at age 60. On exam, the patient appeared well. The genitourinary exam revealed normal external genitalia, mild vaginal atrophy and a non-friable exophytic polypoid lesion at the 5 o’clock position. Bimanual exam demonstrated no cervical motion tenderness, and a large mobile mass palpable at the midline right above the uterine fundus. The patient underwent an urgent pelvic ultrasound that showed a mixed solid and cystic 9.5 cm adnexal mass. With the input of gynecologic oncology, CT abdomen and pelvis with contrast was performed next demonstrating a heterogenous low-attenuation right ovarian structure measuring 8.4 x 10.1 x 6.0 cm displacing the uterus to the left. A CA-125 was 126 (0-38.1), CEA and CA 19-9 were within normal limits. A chest x-ray was negative. The cervical mass was biopsied and found to be an inflamed endocervical polyp. The patient underwent exploratory laparotomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy with intraoperative pathology notable for a benign mass consistent with benign sex cord stromal tumor and final pathology confirming ovarian fibroma. The procedure was performed without complications and the patient did well postoperatively.

IMPACT/DISCUSSION: This case underscores the significance of a thorough physical examination in patient care. Ovarian fibromas constitute 4% of total ovarian tumors and typically manifest asymptomatically. Undetected, large (10cm or greater) ovarian fibromas, as observed in this patient, may occasionally give rise to emergent complications such as torsion, necrosis, rupture, and peritonitis. During routine annual visits, particularly when prompted by multiple seemingly benign complaints, there may be a tendency to forgo a comprehensive examination and instead refer the patient to a specialist. This practice, while intended to streamline the visit, may introduce delays in initiating timely treatment. In the case of this patient, performing an exam and ultrasound expedited her care. In our region, had she been referred to a gynecologist for evaluation of post-coital spotting, she might have waited 2-3 months as an established patient.

CONCLUSION: The quality of a thorough physical examination, even in the setting of seemingly minor complaints in history, is pivotal for early detection and prevention of worsening pathologies. These observations are especially relevant in low resource areas, where healthcare disparities are often significantly more pronounced.

SEX MATTERS IN MATTERS OF THE HEART: ACUTE ON CHRONIC MITRAL VALVE REGURGITATION IN AN ELDERLY FEMALE

Samir Shah, Dhaval Trivedi. Internal Medicine, New York Presbyterian - Brooklyn Methodist Hospital, New York, NY. (Control ID #4065082)

CASE: A 63-year-old female with medical history of hypothyroidism, PVCs, and mitral valve prolaspe (MVP) with mild mitral regurgitation (MR) presented from cardiology clinic for hypotension (98/64 mmHg), tachycardia (110 bpm), hypoxia (89% SpO2), and pyrexia (100.1 F). Presentation was preceded by 3 of days burning epigastric pain and concurrent dyspnea, both worse with exertion. Associated symptoms include dry cough worse when supine. CXR showed normal cardiac size and bilateral multifocal consolidation with pulmonary edema. Empiric antiboitics and fluid resuscitation were initated. EKG was notable for sinus tachycardia, crista supraventricularis pattern, and no ischemic changes. Echocardiogram demonstrated LVEF of 55-60%, flailed posterior mitral valve leaflet, severe MR, and moderate left atrial dilation. Respiratory failure requiring intubation in the emergency room gave concern for acute valvular heart failure and cardiogenic shock due to torrential MR. Coronary angiography showed no evidence of atherosclerotic disease and PCWP of 30, IABP was inserted. Patient underwent mitral valve repair with quadrangular resection of P2 segment of posterior leaflet and annuloplasty with 30 mm Cosgrove Band, and LAA ligation with Atricure clip. Post-operative course was complicated by paroxysmal atrial fibrillation treated with amiodarone, and fevers with infectious work up demonstrating Achromobacter in BAL treated with IV antibiotics. Post-operative TTE showed LVEF 30-35% without non-trivial MR or stenosis. Patient underwent slow weaning of milrinone and was discharged to subacute rehabilitation for reconditioning.

IMPACT/DISCUSSION: With worldwide aging populations, the burden of valvular heart disease has also increased with epidemiologic studies showing MR of either primary or secondary cause as the most prevalent valvular disorder affecting 9 to 10% of elderly patients in the United States. In this group, MVP is the most common cause of chronic primary MR. Although screening studies have shown MVP to generally be asymptomatic in large populations, the disease is strongly associated with heart failure, valvular surgery, atrial fibrillation, and increased mortality proportional to the quantitative severity of associated MR.

CONCLUSION: Women with valvular heart disease have been underrepresented in foundational landmark studies which form the basis of guideline recommendations including those informing important metrics of disease severity and timing of surgery. Worldwide, MVP and primary MR disproportionately affect the female sex although men outnumber in patients with non-rheumatic mitral valve disease undergoing surgery. This case demonstrates the importance of scheduled echocardiographic surveillance of mitral valve disease in female populations. It is also unique in that sex-related differences in mitral valvular morphology generally predispose women to myxomatous valves and bi-leaflet MVP and men to posterior MVP with flail, the latter of which is described in this case.

UNUSUAL CASE OF JOINT PAIN IN PREGNANT WOMAN

Katherine Bopp¹; Cecilia Scholcoff^1,2. ¹Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; ²General Internal Medicine, VA Milwaukee Healthcare System, Milwaukee, WI. (Control ID #4055965)

CASE: A 31-year-old G3P2 woman at 32 weeks gestation presents to the clinic for joint pain. The joint pains began two to three months ago and have worsened. The pain was initially located at the base of her left thumb, however, now involves her wrists, PIP joints, shoulders, knees, and lower back. She endorses associated joint swelling and morning stiffness and reports minimal improvement with Acetaminophen. Additional ROS positive for fatigue, dry mouth, and sore throat, and negative for fever, weight loss, night sweats, dry eyes, chest pain, or dyspnea. She denies prior pregnancy complications, blood clots, or family history of connective tissue disease. Exam significant for left thumb PIP synovitis and tenderness to palpation. No other apparent synovitis or palpable joint tenderness. Initial work up included CBC w/ diff, ANA, ESR/CRP, and CKP.

Work-up positive for elevated ESR/CRP and positive ANA, and patient was referred to rheumatology. Prior to rheumatology consult, patient was admitted for significant joint pains. Inpatient work up significant for ANA 1:640 homogenous speckles, positive anti-SS-A titer at 5.6, CCP positive at 197, and RF positive at 15. Remainder of rheumatologic work-up negative. She was diagnosed with primary Sjogren’s disease with positive CCP antibody and started on prednisone 40 mg daily with subsequent improvement. She was discharged with close outpatient rheumatology and OB follow up.

IMPACT/DISCUSSION: While musculoskeletal (MSK) symptoms are common in pregnancy due to normal physiologic changes, pregnant women are at increased risk of new onset (or worsening of pre-existing) autoimmune rheumatologic conditions. Providers must be aware of the most common non-autoimmune musculoskeletal problems and recognize when additional work up may be necessary. Common non-autoimmune MSK problems include diastasis of rectus abdominis, low back pain secondary to hyperlordosis and shifts in the body’s center of gravity, pelvic pain secondary to laxity of pelvic ligaments and widening of the symphysis pubis, and De Quervain’s tenosynovitis or carpal tunnel syndrome secondary to fluid retention and nerve entrapment. Healthy pregnant women may also develop isolated arthralgias and arthritis in the small joints of the hands, which often occurs during the third trimester and are typically not associated with positive ANA or RF. Additional work up for autoimmune rheumatologic conditions and referral to rheumatology is warranted when pregnant women present with signs or symptoms of inflammatory arthritis or extraarticular symptoms.

CONCLUSION: 1. Musculoskeletal problems/joint pains are common in pregnancy and are typically secondary to laxity of ligaments, shifts in the body’s center of gravity, or fluid retention and nerve entrapment.

2. Additional work up of joint pain and referral to rheumatology may be warranted if patient presents with signs or symptoms of inflammatory arthritis or extraarticular symptoms.

Innovation in Healthcare Delivery (IHD) - Ambulatory Medicine

A PILOT STUDY TO ASSESS THE FEASIBILITY OF A CHAPLAIN-DIRECTION INTERVENTION AIMED AT IMPROVING ADVANCED CARE PLANNING AT A PRIMARY CARE CLINIC

Katherine B. Daniel¹; Nia M. Mitchell¹; Katherine Henderson²; Elissa Nickolopoulos³; Patrick Hemming^4,5; Alex H. Cho^4,5; Jessica Ma^4,6; Nicole Dussault⁴. ¹School of Medicine, Duke University School of Medicine, Durham, NC; ²Chaplain Services and Education, Duke University Health System, Durham, NC; ³Case Management, Duke University Health System, Durham, NC; ⁴Department of Medicine, Duke University School of Medicine, Durham, NC; ⁵Duke Outpatient Clinic, Duke University Health System, Durham, NC; ⁶Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, NC. (Control ID #4033329)

STATEMENT OF PROBLEM/QUESTION: Is it feasible to implement a chaplain-directed intervention that facilitates advance care planning visits and documentation at a resident primary care clinic?

DESCRIPTION OF PROGRAM/INTERVENTION: Advance care planning (ACP) involves an individual’s health conditions, care options, and values, including at the end of life. Limited training and time hinder the ability of resident physicians to conduct ACP conversations in their primary care clinics, but clinical chaplains may help overcome these barriers. This project evaluates the feasibility of a chaplain-directed intervention to increase ACP visits and documentation between residents and their primary care patients.

This pilot study was conducted over 1 year at a resident outpatient clinic. A convenience sample of 200 patients identified by institutional algorithm as at high risk for hospitalization were randomized to intervention or control arms. Intervention consisted of chaplain review of the patient's chart, focusing on prior ACP documentation, to determine if they would benefit from additional ACP conversations. The chaplain then implemented targeted next steps such as contacting providers, talking to patients directly, or scheduling dedicated ACP visits. The chaplain kept thorough notes on her review process, communication, and scheduling efforts.

MEASURES OF SUCCESS: Primary outcomes assess the intervention’s feasibility. Measures include the number of patients successfully reviewed, time required for chaplain chart review, number of patients and providers contacted, rates of successful patient and provider engagement, and creation of standardized processes such as ACP scripts and documentation templates.

Secondary outcomes explore the intervention’s impact by comparing scheduled and attended ACP visits as well as ACP documentation, including ACP notes, advance directives, and healthcare agent forms, between study arms before and after the intervention.

FINDINGS TO DATE: Of the 100 intervention arm patients reviewed, the chaplain determined that 77 would benefit from additional ACP conversations. The average chaplain review time was 10 minutes (minimum 5, maximum 25). The average chaplain intervention time was 25 minutes (minimum 15, maximum 120). The chaplain contacted 56 providers with a 59% response rate and 12 patients with a 75% response rate. The chaplain requested 24 patient appointments, provided resources to 17 providers to guide ACP conversations, and coordinated interdisciplinary consultations for 20 patients. Two sets of call scripts were created (one for providers, one for scheduling staff), as well as an ACP note template and an ACP patient handout. Chart review analysis of secondary outcomes is underway.

KEY LESSONS FOR DISSEMINATION: Residents face many barriers to incorporating ACP into clinic workflow. A chaplain-directed ACP intervention is feasible and can promote increased patient-clinician coordination but requires time and support. This pilot study lays the groundwork for a larger, multi-center study to further evaluate the impact of chaplain intervention on ACP.

EXPLORING DISPARITIES IN COLORECTAL CANCER SCREENING COMPLETION RATE: A RETROSPECTIVE ANALYSIS BY AGE, ZIP CODE, AND CLINIC VARIATION IN A PRIMARY CARE SETTING

Mako Koseki, Ryan Fliehman, Rui Jiang. Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4053808)

STATEMENT OF PROBLEM/QUESTION: What demographic differences between those who completed screening vs not help us to design interventions to increase screening rates?

DESCRIPTION OF PROGRAM/INTERVENTION: It has been two years since United States Preventive Services Task Force (USPSTF) updated CRC screening recommendations to lower starting age of 50 to 45 given increasing incidence of colorectal cancer (CRC) in younger age. With support from information technology specialist, we conduct a needs assessment by creating a dashboard that would compare the screening completion rates our clinic and evaluate demographic differences of the completion rates.

MEASURES OF SUCCESS: We created a CRC screening dashboard that allows a clinician to easily maneuver filters to visualize EPIC patient data from our clinic. Initially, we used the Patient Health Main tables that are populated in the electronic medical report. This was then loaded into the Clarity Database (DB) for reporting purposes. Once the DB was validated, it was connected to Visual Analytic Tool called Tableu which allows creating charts, tables, and visualizations that matches our needs. We analyzed the population who completed CRC screening by age, zip code, modality, and sites using the Tableu.

FINDINGS TO DATE: Using the dashboard, a single-center retrospective analysis of patients in academic primary clinic was performed between 1/1/2023-6/30/2023. We are an urban clinic with 2 sites: site 1 with 41% commercial/42% Medicare/15% Medicaid, site 2 with 21% commercial/51% Medicare/27% Medicaid. 2876 patients between age 45-75 who were average risk for CRC visited our clinic, and 1858 patients (65%) had completed screening (67% in site 1, 62% in site 2), in which 443 patients used Cologuard (15%) while others used colonoscopy. When broken down by age, completion percentage was 39% for age 45-49, 56% for 50-54, 68% for 55-59, 69% for 60-64, 72% for 65-69, and 73% for 70-75. In specific, Cologuard use accounted for 36% in age 45-49 at site 1, and 45% at site 2. Zip code comparison of modality difference within the five counties in Mid-Atlantic Regions also showed similar percentages in each group, although had a gap between the sites in which site 2 used more Cologuard than site 1 in total.

KEY LESSONS FOR DISSEMINATION: CRC screening completion among individuals in age group 45-49 remained lower than other groups. In this age group though, the usage of Cologuard was higher when compared to other age groups. The site accepting primarily Medicare/Medicaid insurance had lower total completion rate but higher Cologuard use. The observed disparities between the two sites underscore health inequalities associated with insurance differences. Tableu datasets allows these conclusions to be visualized concisely with charts and tables, which can be used for education toward practioners to increase the awareness of the CRC screening and for further interventions to increase CRC screening completion rates.

IMPLEMENTING AN EDUCATIONAL VIDEO TO IMPROVE PATIENT ENGAGEMENT FOR VETERANS WITH TYPE 2 DIABETES MELLITUS

Howard Gordon^4,5; Pooja Solanki¹; Jessica Gardner¹; Naomi Ashley¹; Frances Weaver^2,3; Kevin Stroupe^2,3; Eleanor Rivera^6,1; Reside L. Jacob²; Richard L. Street⁷; Sudha Bhoopalam². ¹Research, Jesse Brown VA Chicago Healthcare System, Chicago, IL; ²Edward Hines Junior VA Hospital, Hines, IL; ³Loyola University Chicago, Chicago, IL; ⁴Jesse Brown VA Chicago Healthcare System, Chicago, IL; ⁵University of Illinois Chicago College of Medicine, Chicago, IL; ⁶University of Illinois Chicago, Chicago, IL; ⁷Texas A&M University System, College Station, TX. (Control ID #4064031)

STATEMENT OF PROBLEM/QUESTION: Although it is well established that patients who actively communicate during medical visits are more engaged in their care, more adherent to physicians’ recommendations, and have better health outcomes, there are few interventions used in clinical practice that are designed to improve patients communication in their medical encounters.

DESCRIPTION OF PROGRAM/INTERVENTION: The “Speak Up!” video is an educational intervention designed to promote patients use of active participatory communication behaviors in their medical encounters. This video intervention was previously tested in 3 different randomized controlled clinical trials and was shown to improve outcomes in patients with type 2 diabetes mellitus. We are conducting a pragmatic clinical trial testing effectiveness and implementation of the video intervention in outpatient clinics at six VA sites over 33 months using a stepped wedge design where sites begin implementation sequentially one site at a time in 3-month intervals. A stepped wedge design is advantageous to reduce project staff load and to learn successful strategies from earlier sites to implement in later sites. A total of 510 patients will be enrolled across six sites (85 at each). To be eligible, patients must have a diagnosis of T2D, take diabetes medication, have an A1c > 7.0, and visit their primary provider at least once a year. To date we have begun implementation at three sites and have developed an implementation glossary of several strategies used for implementation. We have conducted an initial set of qualitative interviews with patients who viewed the video and clinic staff implementing the video. Questions for patients assessed perceptions of how the video was offered and how viewing the video influenced their primary care visit. Questions for staff were based on organizational readiness for change and assessed the program within the framework of evidence, context, and facilitation.

MEASURES OF SUCCESS: (1) Partnering with clinic staff and identifying implementation strategies to establish the intervention video into clinic workflows. (2) Assessment of the proportions of enrolled patients who watch the video before the primary care visit.

FINDINGS TO DATE: In 192 patients, the fidelity of implementation was 76% across 3 sites with 11 clinics and 40 providers. We identified several barriers to implementation and 12 successful implementation strategies (e.g., align implementation and organizational goals, build a coalition, and capture/share local knowledge). Patient perceptions of the video were positive overall (e.g. "The video was like a course in assertiveness"). In general staff were supportive of implementation (e.g., "the whole program you initiated...is going to provide excellent care to our Veterans").

KEY LESSONS FOR DISSEMINATION: We were able to achieve good clinical adoption of the Speak Up! video across multiple primary care clinics despite variations in structure and context across clinics and several barriers to introducing a non-mandated program into the clinic workflow.

IMPROVING LUNG CANCER SCREENING RATES AT A LARGE ACADEMIC RESIDENCY CONTINUITY CLINIC

Aislinn Camoney¹; Rachel H. Kon²; Lauren Carbo³. ¹Internal Medicine, UVA Health, Charlottesville, VA; ²Medicine, University of Virginia School of Medicine, Charlottesville, VA; ³UVA Health, Charlottesville, VA. (Control ID #4064371)

STATEMENT OF PROBLEM/QUESTION: Lung cancer screening rates at our hospital had stagnated at 5% of eligible patients, the residency continuity clinic has unique challenges to increasing its screening rates.

DESCRIPTION OF PROGRAM/INTERVENTION: National lung cancer screening rates remain around 6% despite over a decade of guideline recommendations. Similarly, the well-resourced lung cancer screening center at our large Mid-Atlantic medical center is underutilized. Previously, institution policy required a central referral process with a shared-decision making visit in radiology rather than individual physicians ordering low dose CTs to ensure documentation compliance. To improve access for our large eligible patient population, the option for primary care providers to order screening was added but awareness of this and knowledge needed to meet insurance requirements was lacking. Our intervention focused on improving screening rates at our outpatient resident clinic with many rotating providers and complex patients. The barriers we identified included frequent resident turnover, inexperience with counseling and ordering screening, unreliable tobacco use history in EMR, and inadequate time in workflow. To address workflow and documentation knowledge, a new EMR orderset was developed that included eligibility criteria, appropriate ICD-10 codes, correct scan order, a shared decision tool, and templated shared decision-making documentation. We developed a new education session on lung cancer screening and delivered it during standard curricular time for residents and clinic preceptors. The session included the evidence supporting screening, shared decision-making tools, description of identified practice barriers, and demonstration of the new orderset.

MEASURES OF SUCCESS: Baseline screening rates across resident and attending practices were calculated from retrospective Epic EMR extraction tools for the period from July 2021 to July of 2023. Our primary measure is number of completed lung cancer screenings. Other outcomes include number of new orders for screening (not yet completed). We have preliminary 6 month post-intervention screening rates and will look again at 9 months and 1 year.

FINDINGS TO DATE: We compared the post intervention data of screening rates from July to mid-December 2023 with baseline data over the same six month time frame in previous years. Our clinic has a potential eligible population of 3047 current or former smokers. Preliminary data showed an increase from 139 screenings pre-intervention to 186 screenings post-intervention.

KEY LESSONS FOR DISSEMINATION: Our results show a promising trend in improving lung cancer screening in a large residency continuity clinic with many barriers by both improving knowledge and providing efficiency tools. Implementing a system that simplifies the ordering process appears to be an effective intervention, both for resident and attending clinics. Education sessions can help refresh residents as to the necessity and benefit of screening. Education will need to be repeated over time.

IMPROVING PATIENT EMPANELMENT IN RESIDENT PRIMARY CARE CLINIC

Samuel Trump¹; Seth Scheetz³; Julie Oyler². ¹Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ³Cardiology, Cleveland Clinic, Cleveland, OH. (Control ID #4064805)

STATEMENT OF PROBLEM/QUESTION: Resident physician primary care panels at an academic medical center have steadily increased in size, and this can have negative consequences for continuity of care and trainee experience.

DESCRIPTION OF PROGRAM/INTERVENTION: Empanelment is the process of assigning a patient to a primary care physician or care team. There is a lack of evidence to guide optimal panel sizes, but there are recognized downsides to oversized panels including decreased effectiveness and continuity of care.

Residents face specific scheduling challenges that limit ability to safely hold large panel sizes, including less time allotted to clinic due to inpatient service obligations and decreased efficiency within clinic as training physicians. These limitations deepen the negative effects of oversized panel sizes; resident clinics have lower rates of continuity than non-teaching sites given competing training requirements.

This is particularly problematic given that residents care for a larger proportion of outpatients from underserved backgrounds, and resident patients are less likely to achieve chronic disease and preventive screening outcome measures and have higher rates of ER visits and hospitalizations.

Previous resident empanelment in our clinic consisted of full panels being passed down between a graduating resident and an incoming PGY2 at the end of the academic year. Additionally, all resident classes had new patient openings which could grow their panel. Resident panels grew to between 103-177 active patients (active being defined as having been seen within the last two years) and 121-226 total patients.

Our intervention consisted of altering the empanelment process for residents in order to condense panel size via three mechanisms. First, PGY3s passed along 3/4 of their panel to an incoming PGY2 and the other 1/4 to an incoming PGY1. Second, PGY3s were asked to go through their panel prior to panel handoff and remove “inactive” patients. Third, new patient slots were removed from PGY2 and PGY3 schedules.

MEASURES OF SUCCESS: Primary measures include number of active and total patients on resident panels, standard variation of total panel size across residents, and number of residents with panel size greater than 120 total patients.

FINDINGS TO DATE: Mean number of total and active patients, respectively, on resident panels decreased from 129/99 in year 1, to 114/91 in year 2, to 105/85 in year 3. Standard deviation of resident panel size decreased from 61 to 47 to 45 over the above time increments. Number of residents with panel size over 120 total patients decreased from 64 to 45 to 26.

KEY LESSONS FOR DISSEMINATION: Residents in the primary care setting have limitations to the number of patients they can hold on their panels due to training constraints, and patient care may suffer if panel sizes are too large. We demonstrate methods to successfully condense resident panel sizes in a sustainable way in order to maximize continuity of care for patients and to provide a more fruitful and consistent primary care training experience for residents.

INTEGRATING ELECTRONIC HEALTH RECORD (EHR)-BASED RAPID DIETARY ASSESSMENT AND COUNSELING WITH EMBEDDED CLINICAL-DECISION SUPPORT FOR CARDIOVASCULAR DISEASE RISK REDUCTION

Allison Crawford, Peter Georginis, Andrew Moawad, Neda Laiteerapong. General Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4058113)

STATEMENT OF PROBLEM/QUESTION: Dietary factors strongly influence the risk of atherosclerotic cardiovascular disease, yet dietary screening and counseling are rarely provided by clinicians as part of standard ambulatory care despite the availability of evidence-based screening tools.

DESCRIPTION OF PROGRAM/INTERVENTION: The goal of the program was to increase evidence-based dietary screening and counseling to support reducing cardiovascular disease morbidity and mortality, which aligns with USPSTF guidelines and may reduce health disparities related to cardiovascular disease risk factors. A clinical decision support system for measuring dietary food frequency and increasing lifestyle interventions was implemented in the academic general internal medicine, cardiology, and nephrology clinics within an academic medical center in the Midwest. Specifically, a new best practice alert (BPA) was developed for adults with cardiovascular risk factors, which encouraged completion of the validated Starting the Conversation dietary questionnaire. This questionnaire was also available to patients to complete via the patient portal prior to clinical visits. The BPA also included a link to a new Smartset which included evidence-based practice recommendations based on the principles of Lifestyle Medicine. The Smartset includes patient education and resource materials for cardioprotective diets, stress management, physical activity, tobacco cessation, and healthy sleep, as well as medications for weight loss, laboratory tests, and referrals for behavioral counseling interventions.

MEASURES OF SUCCESS: Using Epic’s Slicer Dicer tool, we evaluated total times an action was taken based on the BPA firing across the following outpatient clinics: primary care, internal medicine/pediatrics, cardiology, nephrology and endocrinology. An action will be defined by a clinician providing or referring a patient for dietary counseling.

FINDINGS TO DATE: Measurements were taken from our soft launch date, September 13, 2023 to December 18, 2023. A total of 151 actions were taken by clinicians across that time frame. In addition, we also used the Slicer Dicer tool to evaluate the number of times dietary screening was completed either by clinicians or patients. The screening is stored as a flowsheet in Epic and using Slicer Dicer, we noted that dietary screening was performed 248 times between the aforementioned dates.

KEY LESSONS FOR DISSEMINATION: Adopting validated rapid dietary screening and clinical decision support tools in clinical practice through the EHR offers an opportunity to overcome current barriers to dietary assessment and counseling and challenge current standards to promote a culture of preventing chronic diseases within standard ambulatory visits as well as increased referrals to appropriate services to further address cardiovascular risk reduction.

MENISCAL INJURY SEEN ON POCUS BY PRIMARY CARE PROVIDERS CORRELATES WITH MRI FINDINGS

Isaac Holmes^1,2; Jennifer Dong³; Dana Waxenberg^1,2; Elizabeth Sinclair^1,2; Michael Janjigian^2,1. ¹Internal Medicine, New York City Health and Hospitals Bellevue, New York, NY; ²Medicine, New York University Grossman School of Medicine, New York, NY; ³Internal Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4064486)

STATEMENT OF PROBLEM/QUESTION: Diagnose meniscal injury by point-of-care ultrasound (POCUS) in a primary care clinic

DESCRIPTION OF PROGRAM/INTERVENTION: Patients with acute knee injury presenting to safety net institutions may not have rapid access to advanced imaging such as MRI. Establishing probable etiology and severity of injury is done by history and physical exam. The primary exam maneuver for diagnosis of meniscal injury is McMurray’s Test which has a highly variable positive likelihood ratio with poor intertester reliability. Ultrasound has been established as an acceptable modality for diagnosis of acute knee injury with high specificity but low sensitivity. Our clinic already possessed a dedicated cart-based ultrasound machine as well as several providers (physicians and physician assistants) well trained in POCUS. Providers were taught knee POCUS by subject matter experts through our internal POCUS training course. In our primary care and urgent care clinics, we applied POCUS examination in addition to history and physical exam to evaluate patients presenting with acute knee injury concerning for meniscal injury. Ultrasound clips were reviewed by local subject matter experts. Patients with evidence of meniscal injury on POCUS were referred for advanced imaging with MRI.

MEASURES OF SUCCESS: Success was measured as patients with meniscal injury seen on POCUS that was subsequently confirmed by MRI.

FINDINGS TO DATE: Eleven patients were identified as having meniscal injury on POCUS examination. Six out of these 11 completed the MRI (3 are pending MRI, 1 was canceled due to resolved symptoms, 1 patient was lost to follow up). Of the 6 MRI studies completed, all confirmed the diagnosis of a meniscal tear.

KEY LESSONS FOR DISSEMINATION: The presence of meniscal injury on POCUS was confirmed on MRI in all cases in this series to date. We demonstrate the ability of primary care physicians and physician assistants to accurately diagnose the presence of meniscal injury using POCUS. Specificity for meniscal tear in particular appears to be high given appropriate training and oversight. POCUS is a valuable tool for acute diagnostics in an urgent care or primary care setting. Adaptation of POCUS in primary and urgent care settings is likely to reduce the need for advanced imaging and specialty consultations. This is of particular value in resource limited settings such as safety net institutions and rural practices. Continued development of a POCUS curriculum especially targeted at providers practicing in these settings is likely to yield benefit to patients by decreased time to diagnosis and increased access to care.

OPTIMIZING CARE FOR THE WHOLE PERSON – AN INNOVATION TO PROMOTE A HOLISTIC APPROACH TO PATIENT CARE

Anna K. Shah¹; Paul O'Rourke²; Colleen Christmas³. ¹Department of Medicine, Johns Hopkins University, Baltimore, MD; ²Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD; ³Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #4064674)

STATEMENT OF PROBLEM/QUESTION: The electronic health record (EHR) is essential to modern day medicine but is often cited as a barrier in developing connections between patients and physicians.

DESCRIPTION OF PROGRAM/INTERVENTION: While medicine was founded on relationships between physicians and patients, modern medicine has many barriers which prevent patient-centered care. One barrier commonly identified is the electronic health record (EHR), which often causes physicians to spend more time documenting clinical encounters and creating problem lists of diagnoses rather than learning about their patients and focusing on the patient as a unique human being and identifying social determinants of health for that person.a,b,c These forces likely challenge forging deeper connections between physicians and their patients. These deep connections are what brought many to the medical profession and has been shown to mitigate burnout.d

We created a “Whole Person Care” EHR Smartphrase that is inserted into the "Assessment and Plan" portion of primary care clinic notes to prompt discussion of each individual patient’s goals, values and determinants of health. It is purposefully included in the assessment and plan portion of clinical notes for easy reference and to prompt tailoring the plan to these individualized factors. Our study was approved by our IRB and implemented at the Johns Hopkins Bayview Internal Medicine Residency in the outpatient primary care clinic.

MEASURES OF SUCCESS: Objective data was gathered of how many times the Smartphrase was used by resident physicians over our three-month study period. Residents were surveyed asking about their perception of ease and usefulness of the Smartphrase and asked items from the Work and Meaning Inventory Scale one month prior to and one month after the study period.

FINDINGS TO DATE: The study period is ongoing at the time of this submission so our data is preliminary however the study will be complete by December 31, 2023 so complete data will be available by the time of the 2024 SGIM Meeting. Data from the initial half of our study period showed that the Whole Person Care Smartphrase was utilized 18 times. Pre-surveys were also completed by 50% of all internal medicine residents. Full Smartphrase utilization data and pre- and post-survey data analysis will be available to present at the 2024 SGIM Meeting.

KEY LESSONS FOR DISSEMINATION: - The EHR may be used to promote rather than disrupt connections between patients and physicians and to facilitate whole person care.

- We plan to present data on the utilization and impact of this tool both on patient care plans and resident physicians' sense of meaning in their work.

TAKING OFF THE PRESSURE: IMPROVING HYPERTENSION MANAGEMENT AT A FEDERALLY QUALIFIED HEALTH CENTER

Claire Garpestad¹; Elizabeth Batista^2,1; Joseph Truglio^3,1; Matthew Weissman^4,2. ¹Internal Medicine - Pediatrics, The Mount Sinai Hospital, New York, NY; ²Internal Medicine-Pediatrics, Mount Sinai Health System, New York, NY; ³Internal Medicine, Pediatrics and Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY; ⁴Internal Medicine/Pediatrics, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4064311)

STATEMENT OF PROBLEM/QUESTION: Our project aimed to increase the percentage of FQHC patients aged 18-85 years old with hypertension who have BP <140/90 from a baseline of 61% to a goal of 67% within 1 year.

DESCRIPTION OF PROGRAM/INTERVENTION: The residents of an academic hospital’s Internal Medicine-Pediatrics (Med-Peds) Program care for patients of all ages at a Federally Qualified Health Center (FQHC), where many patients are un- or underinsured and undocumented. This FQHC sees about 13,000 patients per year and 22% have hypertension. Prior to this project, only 61% of adults with hypertension were at goal (BP less than 140/90 mmHg). Between July 2021-July 2022 we conducted a systematic quality improvement project to improve management of hypertension.

MEASURES OF SUCCESS: We conducted iterative assessments involving our FQHC team, patients and community members to uncover barriers to hypertension management including: lack of standardized workflow at BP follow-up visits, variation in documentation of BP goals and next steps in management, and underutilization of high-potency, long half-life, combination antihypertensives, especially for patients without insurance. After identifying barriers, creating process maps and undertaking several PDSA cycles, we were able to appreciate a steady increase in rates of hypertension control.

FINDINGS TO DATE: Initial PDSA cycles focused on improving the accuracy of blood pressure measurements and improving access to follow-up “blood-pressure checks" via nurse visits. We then created a standardized workflow in the electronic medical record (EMR) wherein residents documented antihypertensive regimen, current blood pressure and target, as well as anticipated next steps in the EMR “problem list,” readily accessible to any covering resident or nurse. This allowed for timely and effective adjustments in medication regimens during nurse follow-up visits. Lastly, we expanded the medication options on our 340b pharmacy partnership for patients without insurance to include combination and long-acting antihypertensives. Our interventions resulted in an increase in the percentage of patients with HTN at goal from 61% in June 2021 to 71% by June 2022, with continued improvement to 74% in June 2023 to present. Subgroup analysis showed no differences in BP control based on race, language or insurance status.

KEY LESSONS FOR DISSEMINATION: Several lessons and future directions emerged over the course of this project. Our work underscored the important role of clear and systematic EMR documentation and close follow-up in improving hypertension management. This is particularly true in resident-run clinics where one patient may be under the care of several providers. Further, our project revealed the importance of interprofessional collaboration by including patients, medical assistants, nursing, local pharmacies, and community members in order to better address complex problems with multiple barriers to success. Our residency program now includes patients in all aspects of QI projects, including selecting and defining metrics and process evaluation.

THE TRANSITION CARE TEAM: A MODEL FOR ACCEPTING COMPLEX PEDIATRIC YOUNG ADULT PATIENTS INTO AN ADULT HEALTH CARE SYSTEM

Niraj Sharma^1,2; Margaret Threadgill³. ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Pediatrics, Boston Children's Hospital, Boston, MA; ³Medicine-Pediatrics, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #4033152)

STATEMENT OF PROBLEM/QUESTION: Pediatric health systems have spent great efforts to prepare young adults with chronic conditions of childhood origin to transition to adult-centered care, but less work has been done by adult systems to successfully accept and retain these patients.

DESCRIPTION OF PROGRAM/INTERVENTION: The transition from pediatric to adult health care systems is fraught with barriers which often lead to “bounce-backs” to the pediatric system, postponement of transfer, increased ED utilization and inpatient hospitalizations, and decreased patient and provider satisfaction. Even when a transition has been prepared excellently by pediatrics, if the adult side is not optimized to accept these patients, the above enumerated barriers and poor outcomes remain looming large. The Transition Care Team (TCT) was developed to improve the acceptance of patients into the adult health care system. Within one large urban adult quaternary-care health system, the TCT (two Medicine-Pediatrics physicians and one care coordinator) and virtual transition process (VTP) were developed. The VTP includes: coordination with referring pediatric providers, virtual appointments with young adults with medical/social complexity and their families, addressing insurance issues, identifying an accepting PCP and communicating the transition plan, and ongoing availability/follow-up with all stakeholders.

MEASURES OF SUCCESS: Measures were divided into three areas. First, qualitative feedback was received to assess the patient/family and pediatric and adult provider experiences. Second, process measures, including the time to complete the transition process, were collected. Third, value to the adult healthcare system was calculated by measuring by quality (successful adult PCP appointment), revenues, and costs.

FINDINGS TO DATE: Over 18 months, 75 young adults were referred to the TCT, 33 (44%) required insurance change, and 63 (84%) completed transition to their new adult PCP with a mean turnaround time of 18 weeks. Qualitative feedback was collected from patients, families, pediatric providers, and adult providers. All endorsed positive experiences and increased confidence in the transition process. Value to the adult healthcare system was demonstrated by measuring quality and revenue generated with the TCT and securing ongoing financial support from the adult health care system.

KEY LESSONS FOR DISSEMINATION: Optimizing an adult healthcare system to accept complex transition patients is integral to successful transfer. Having a formal acceptance process for these patients improves patient/provider experience and confidence in the adult system and increases value for the adult quaternary-care health system it operates within.

Innovation in Healthcare Delivery (IHD) - Career Development, Professionalism, and Wellness

DEVELOPING AND EVALUATING A COACHING PROGRAM GENERAL MEDICINE JUNIOR FACULTY AND FELLOWS

Elizabeth P. Griffiths, Kendra A. Moore. Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4060384)

STATEMENT OF PROBLEM/QUESTION: Does a 6-session structured coaching program for general medicine junior faculty and fellows, particularly those from identity groups at higher risk for burnout and attrition, decrease burnout, increase self-efficacy, increase job satisfaction, and/or improve retention?

DESCRIPTION OF PROGRAM/INTERVENTION: We developed a 6-session coaching program serving 12 assistant- and associate-level general medicine faculty as well as general medicine fellows who see patients in an outpatient primary care practice at an academic medical center in the California-Hawaii region. Program participants received three months of every other week individual coaching sessions with a certified professional coach who is also general medicine faculty. Applications from faculty and fellows from identity groups at higher risk of burnout and attrition were prioritized, including women and physicians of color.

MEASURES OF SUCCESS: The program is being evaluated by measuring recruitment of faculty and fellows from groups at higher risk of burnout and retention through completion of all sessions. In addition, participants complete a pre- and post-intervention survey that measures burnout, self-efficacy, job satisfaction, and likelihood of remaining at the same academic medical center. Qualitative responses evaluate strengths and impact of the program as well as opportunities for improvement.

FINDINGS TO DATE: To date, all 12 available slots in the coaching program have been filled for past, current, or future cohorts. Five participants have completed the coaching program, all of whom identify as women of color and all of whom completed the full six sessions of coaching. When comparing pre- and post- surveys, all participants demonstrated an improvement in burnout as measured by the Maslach Burnout Inventory two-item scale. Two thirds of participants demonstrated an improvement in self-efficacy and job satisfaction. There was no demonstrated effect on likelihood to remain in their current job. All participants reported that they were very likely to recommend the coaching program to their colleagues and comments highlighted that coaching inspired a sense of empowerment and gave tools to address challenging situations that caused stress. As this intervention is ongoing, available data is limited (n=3); additional data will be forthcoming prior to the conference.

KEY LESSONS FOR DISSEMINATION: Interest in professional coaching by physicians most at risk for burnout is high, given our success in recruiting and retaining participants from these backgrounds. Preliminary data suggests that coaching is effective in impacting burnout, self-efficacy and job satisfaction. Given that coaching is still relatively new to most junior faculty and fellows, grant or institutional funding to allow them to try coaching before personally investing in it is important.

HUMANITY IN PRIMARY CARE: PROVIDER PERSPECTIVES ON DEDICATED ASYNCHRONOUS WORK TIME

Brittney R. Fraumeni, Lauren A. Drake, Robert Doolan, Mark Earnest, Gena Weir, Lisa M. Schilling. Department of General Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4060250)

STATEMENT OF PROBLEM/QUESTION: The cognitive and emotional intensity of practicing primary care and the ever-increasing amounts of asynchronous work are leading to provider burnout, attrition, and feeling undervalued.

DESCRIPTION OF PROGRAM/INTERVENTION: Primary care providers are tasked with increasing amounts of asynchronous clinical work without dedicated time for these responsibilities. This work originates from phone calls, patient and care team messages, and other “in-basket” tasks, such as review of self-ordered and specialist-ordered tests, prescription requests and refills, letters, referrals and durable medical equipment, and eConsult follow-up. Providers must often do asynchronous tasks outside of their clinic sessions – a practice that leads to provider burnout and attrition. We conducted a 12-month pilot with 47 providers working within 5 academic general internal medicine (GIM) practices in the Mountain West. The pilot trialed several models for integrating dedicated asynchronous work time into the clinical workday. The final model was approved by leadership.

MEASURES OF SUCCESS: Using baseline and post-pilot provider surveys, as well as post-pilot provider focus groups, we measured the pilot’s perceived impact on provider burnout, clinical career plans, clinical work, and clinical practice.

FINDINGS TO DATE: Pilot provider self-reported burnout decreased from baseline (3.5) to post-pilot (3.3).

Pilot provider plans to retain their clinical FTE increased from baseline (23%) to post-pilot (58%).

Clinical work was perceived as being positively impacted through accomplishing more during the clinical workday, providing better patient care, and being more intentional with clinical time than before the pilot.

Impact on clinical practice:

Clinical days feel more humane - “I mean, that sounds really basic, but sometimes before…I would actually have to ask myself ‘where in my day am I taking a bathroom break?’ And now I always know that it's going to be there.”

Sense of control in workday - “[Flexible asynchronous time] gives me a touch of autonomy for what happens during [my workday]…I think that makes me feel better and it's hard to express that differently.”

Feeling appreciated by leadership - “I think that it's important that [the operational leaders] understand it…I think that they really need to find a way to show us that they respect us and they value us… And I think just giving in for this little thing is at least something to show that they have the respect for what we do.”

Improved connection with peers - “It feels like there has never really been a change that's ever been presented to a bunch of primary care doctors where they're all agreed that it was a positive thing except for this.”

KEY LESSONS FOR DISSEMINATION: Dedicating clinical time for asynchronous responsibilities positively impacts provider burnout, clinical retention plans, and clinical practice.

Having flexibility with asynchronous work time adds a sense of humanity and autonomy to providers’ clinical days.

Leadership addressing provider concerns creates a sense of being valued and promotes improved relationships.

VA WRITES: WRITING THE WAY TO WELLNESS

Elizabeth Marhoffer^1,2; Anna Reisman^1,2; Pauline C. Halsey³. ¹General Internal Medicine, Yale University School of Medicine, New Haven, CT; ²VA Connecticut Healthcare System, West Haven, CT; ³VA Boston Health Care System West Roxbury Campus, West Roxbury, MA. (Control ID #4062324)

STATEMENT OF PROBLEM/QUESTION: Can online reflective writing workshops support employee wellness?

DESCRIPTION OF PROGRAM/INTERVENTION: Healthcare workers often face distress and risk developing burnout, with little time to process their experiences. This can lead to mental health strain and attrition. Prompted by COVID, workshop founders aimed to provide a safe space for VA employees to leverage writing as a means of reflection.

VA Writes is an online reflective writing workshop held weekly for eight weeks twice yearly. Participants are clinical and non-clinical VA employees from different sites. Each workshop is led by two facilitators and lasts one hour. A group discussion of a work of art (visual art, a literary excerpt, or a poem) is followed by a writing prompt and time for writing. Those who wish to read their writing aloud are invited to do so.

Participants learn of the program through presentations, email, intranet postings and word of mouth. Senior facilitators support facilitators-in-training during workshops.

MEASURES OF SUCCESS: Post-workshop surveys include Likert-type and open-ended questions. Increasing interest in the workshop and the opportunity to expand the number of sessions across additional VAs were considered further measures of success.

FINDINGS TO DATE: VA Writes began in 2021 with 14 participants and grew to 66 participants in concurrent meetings by fall 2023. An additional VA site and “booster” sessions for alumni were added. One hundred and eleven people have participated to date. Participants were 68% clinical and 32% non-clinical staff, including nurses, physicians, schedulers, physical therapists, assistants and others. The overall survey response rate was 80%. Ninety-eight percent of respondents strongly agreed with the statement “this workshop has provided me with a space to reflect.” Ninety-six percent strongly agreed that “this workshop has given me a safe community in which to create, share and talk.” No respondents felt neutrally or disagreed with these statements. All respondents said they would be interested in attending future sessions.

Comments from open-ended questions included the following:

“It is easy to say we value self-care, but when opportunities like this [are] encouraged by leadership, . . . it shows me that VA is actually committed to it.”

"While this isn't explicitly a DE+I activity, it is a stealthy one where staff from different disciplines and department share of themselves authentically and deeply."

“The best learning and growing experience of my [21-year] VA career.”

KEY LESSONS FOR DISSEMINATION: Reflective writing workshops can have a positive impact on healthcare workers’ sense of community, ability to communicate non-judgmentally, self-awareness and job satisfaction. These goals can be achieved in a short period of time in the virtual setting across multiple sites. New facilitators can be trained successfully during workshops.

Innovation in Healthcare Delivery (IHD) - Clinical Informatics and Health Information Technology

ACTIONABILITY OF CLINICIAN FEEDBACK FOR CLINICAL DECISION SUPPORT IMPROVEMENT

Allison J. Hare^1,2; Alan D. Brush¹; Craig B. Monsen¹. ¹Internal Medicine, Atrius Health, Bedford, NY; ²Department of Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4060359)

STATEMENT OF PROBLEM/QUESTION: New electronic health record (EHR) functionalities enable health systems to collect real-time feedback from clinicians on clinical decision support (CDS) alerts. The widespread adoption of this feature remains incomplete, however, limiting the realization of potential CDS improvements across organizations. A better understanding of the actionability of clinician feedback on CDS may demonstrate the utility of implementing this feature.

DESCRIPTION OF PROGRAM/INTERVENTION: In July 2022, our health system – a multispecialty outpatient medical group in New England – implemented end-user CDS feedback functionality into its EHR (Epic Systems Corporation, Verona, WI). Clinicians could provide real-time feedback through a Likert scale and written comments when responding to CDS alerts. Over the following 12 months, comments were systematically gathered and utilized to make improvements to CDS alerts.

MEASURES OF SUCCESS: Clinician feedback comments on CDS were reviewed within the context of their associated patient encounters and categorized into actionable and non-actionable feedback, including the identification of distinct themes of feedback in both categories.

FINDINGS TO DATE: Between July 19, 2022 and July 14, 2023, there were 3.81 million firings of 188 unique CDS alerts that displayed to clinicians across our organization. There were 249 comments entered by 70 unique clinicians on 81 unique alerts during the collection period. 115 (46.2%) comments were classified as actionable, and 134 (53.8%) comments were classified as non-actionable. There were 38 unique alerts with actionable feedback, which were improved accordingly. The most common themes of actionable feedback included unclear alert wording (11.2% comments), incorrect alert criteria (9.6% comments), and missing acknowledgement reasons (8.4% comments). Non-actionable feedback commonly centered on alert fatigue or frustration (32.1% comments), user misunderstanding of the alert’s intent or workflow (15.7% comments), and issues that were impossible to address (4.4% comments).

KEY LESSONS FOR DISSEMINATION: Nearly half of all clinician feedback comments on CDS proved to be actionable, predominantly addressing concerns related to unclear alert wording, incorrect alert criteria, and the absence of appropriate acknowledgement reasons. Additionally, the process of reviewing clinician feedback itself revealed various additional opportunities for improvement. Most non-actionable feedback seemed to stem from clinician alert fatigue or frustration. Our findings highlight that clinician feedback on CDS is often actionable and can enable targeted improvements in CDS.

ASSESSMENT OF A SPECIALTY ELECTRONIC CONSULT (E-CONSULT) REFERRING SYSTEM AT A SAFETY NET HEALTHCARE SYSTEM

Delia Shen, Emilie O'Neill, Kevin Chen, Sarah Rose Cass, Telecia Groomster, Hannah Jackson. Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY. (Control ID #4064329)

STATEMENT OF PROBLEM/QUESTION: E-consult utilization for specialty advice has been lower than expected and we sought to understand potential drivers of this.

DESCRIPTION OF PROGRAM/INTERVENTION: High quality specialty access is important for patients at safety net institutions. Current wait times for specialty appointments at our health system—a large, multi-specialty, multi-site, urban, safety net health system in the mid-Atlantic—average 60-200 days. In 2016, e-consults were implemented with specialists triaging all ambulatory referrals for potential e-consult. Specialists can respond with e-consult recommendations or request to schedule an appointment. From June-August 2023, 108,546 referrals were generated. However, few e-consults were completed (8.8%) and the vast majority of referrals were triaged to schedule appointment.

We hypothesize that higher rates of e-consult completion will improve timely access to specialty care. Our goals are to investigate current e-consult barriers, facilitators, and disparities in specialty access.

E-consult and referral tracking dashboards were created, which allows for site- and system-level visualization of referral volumes, outcomes, and specialty wait times. We are conducting stakeholder surveys with specialist and referring providers, starting with a urology department pilot to gather information on staffing models, education, e-consult content and appointment scheduling. Based on provider input, we will redesign the e-consult system to include a bifurcated referral system with e-consult referrals and standard appointment request referrals, enhanced clinical decision support, recommendations on staffing models and trainings for all providers.

MEASURES OF SUCCESS: Qualitative metrics include perceived experience with e-consult system, appropriateness of e-consult referral, clearness of e-consult clinical question, clearness of e-consult response, and helpfulness of e-consult response pre and post intervention.

Quantitative metrics include number of e-consults, number of ambulatory referrals, e-consult completion rate, average days from e-consult order to triage, average days from triage to schedule, and average days from order to appointment.

FINDINGS TO DATE: Urologist surveys show mostly positive experiences, with most providers enjoying the ability to triage referrals. Providers prefer scheduling appointments from e-consults due to lack of clarity and information provided. Most agreed there was insufficient provider training regarding the e-consult system and lack of guidance or standardization on staffing, reviewing, and responding to e-consults. Qualitative feedback from referring providers include lack of transparency on referral outcome timeline, lack of bidirectional conversation, and variable response quality.

KEY LESSONS FOR DISSEMINATION: Participants will learn how e-consult systems can improve access to specialty care, what limitations exist in creating an e-consult infrastructure, and new operations methods to improve e-consult systems.

DEATH BY A THOUSAND CLICKS: ASSESSING CLICKS BY PRIMARY CARE CLINICIANS IN THE ELECTRONIC HEALTH RECORD

Elisabeth Askin, Mitchell D. Feldman. Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4047190)

STATEMENT OF PROBLEM/QUESTION: According to Epic Systems, clicks generate much of the time clinicians spend in the Electronic Health Record (EHR). Yet, while clinicians often complain about excessive clicks, little research has examined their overall number, nor efforts to reduce them.

DESCRIPTION OF PROGRAM/INTERVENTION: We sought to: 1) tabulate clicks; 2) characterize them by type of task as well as by clinician characteristics such as gender and faculty level; and 3) design a pilot intervention to reduce unnecessary clicks specifically on orders.

Epic Systems houses metadata on clicks; we used this metadata to count total clicks and identified specific orders which could be simplified. We then used our institution's existing ticket-queue system to request changes to ordering tasks in the EHR. Our intervention aimed to reduce overall volume, reduce friction (i.e. most "annoying" clicks), and apply overall user-centered design of finding and selecting orders. Two examples are 1) defaulting “urine” as the specimen type for “urinalysis” orders, and 2) eliminating automated pop-ups when canceling orders.

This occurred in an outpatient general internal medicine practice with 53 clinical faculty physicians, 74 resident physicians, and 11 nurse practitioners, which is part of a large academic medical center.

MEASURES OF SUCCESS: We collected the number of clicks as well as the breakdown by type of task and clinician characteristics over the course of one month in 2022 and again in 2023, then normalized this data by eight hours of scheduled patient time. We also collected data on elements of success or failure for individual ticket-queue requests, as well as effort required to process.

FINDINGS TO DATE: At baseline, clinicians clicked a median of 5,830 times, normalized per eight hours of scheduled patient time. Note-writing, in-basket, clinical review, and ordering tasks generated 76% of total clicks. Clicks also varied by clinician characteristic, with men, residents, more junior faculty, and those with higher clinical responsibilities making more clicks.

Our interventions to reduce unnecessary clicks on ordering tasks did not reduce overall clicks, neither on ordering tasks alone nor on total tasks. In fact, clicks increased during the program, likely due to a large and unrelated EHR system upgrade in June 2023. Further, while some requested changes were successful (such as adding speed buttons to pap orders), many were not (such as those necessitating change to hard-coded EHR design or to orders used across settings). Finally, even successful changes often required a high level of effort, such as an exchange of thirty-eight emails before defaulting a dose for cyanocobalamin injections.

KEY LESSONS FOR DISSEMINATION: 1) Primary care clinicians make a large number of clicks in the EHR

2) Health institutions can collect data on the number of clicks their clinicians are making in the EHR

3) Existing systems for making changes in the EHR may be overly burdensome to clinicians, limiting their utility to improve user experience

EPIC WIN! HALF-DAY EMR CURRICULUM LEADS TO PERSISTENT IMPROVEMENT IN EMR TIME AND SKILLS

Hadas Reich^1,2; Meena Fatimi^1,2; John Martin^1,2; Carson Lee^1,2. ¹Internal Medicine, New York University, New York, NY; ²New York City Health and Hospitals Corporation, New York, NY. (Control ID #4064783)

STATEMENT OF PROBLEM/QUESTION: EMR use is a major source of burnout for staff and most trainings do not sufficiently address EMR use challenges.

DESCRIPTION OF PROGRAM/INTERVENTION: EMR use is known to contribute to staff burn out.Typical EMR trainings are virtual, static, and not tailored to individual user preferences, clinical role, or work site. While training is often provided for new users, ongoing training is seldom offered. Optimized EMR use, particularly in Epic, requires personalization, which depends on knowledge of the software and implementation time.

Gouverneur Health is a large, urban FQHC which uses Epic. Our multidisciplinary training was delivered to MD, NP, PA, clinical pharmacist, nurse, medical assistant, and clerical staff in the Department of Medicine. All had previously had standard Epic new user training.

The interactive, role-specific curriculum was designed to be high-yield, practical, and interactive, with real-time skill practice and time for guided personalization. All staff were excused from clinical duties to attend the half-day training.

MEASURES OF SUCCESS: Efficiency data for MD, NP, and PA users for the 6 months prior and the 6 months after the training were obtained using Epic tools, and compared using a paired t-test. Department-wide chronic disease metrics and patient volume were obtained as balancing measures.

All trainees answered a survey with 5-point Likert-scale questions assessing self-reported efficiency and confidence with Epic immediately pre and post, and three months post-training. Results were compared using a paired t-test.

FINDINGS TO DATE: We found a statistically significant decrease of 22 minutes per user per day in the mean number of minutes spent in Epic (118 to 96, p<.001), which persisted 6 months after the training.

Survey data showed a statistically significant improvement in self-reported comfort with using Epic. On a 5-point scale, the mean improvement across all questions was 0.7 (p=0.04). This improvement was seen in every role and persisted 3 months after training, though waned slightly with time.

Patient volume per day was unchanged, as were department chronic disease outcome measures.

KEY LESSONS FOR DISSEMINATION: Our training was unique in that it was developed locally to address departmental needs, and the trainers themselves were skilled peers from within the department. The in-person, real-time training allowed users from multiple disciplines to practice new skills with supervision and establish lasting peer support.

Our training led to a persistent decrease in minutes of EMR use and persistent improvements in self-reported Epic skills. The number of patients seen per day on average did not change, indicating the decreased EMR time was not due to decreased volume. Clinical outcomes were unchanged, indicating the decreased EMR time did not negatively impact care.

Reducing time spent in EMR and improving EMR skills may address burnout and improve efficiency. Departments should invest resources in having ongoing, dedicated trainings for staff and invest in local leaders with expertise in EMR use and curriculum development.

ESTABLISHING A CONSORTIUM TO ACCELERATE EVIDENCE-GENERATION AND IMPROVE QUALITY THROUGH VIRTUAL CARE TECHNOLOGIES IN THE VETERANS HEALTH ADMINISTRATION

Timothy P. Hogan^1,2; Leonie Heywork⁵; Nicholas McMahon¹; Navid Dardashti³; Cindie Slightam⁴; Nilesh Shah⁵; Donna Zulman⁴; Scott Sherman^3,6. ¹VA Bedford Healthcare System Center for Healthcare Organization and Implementation Research, Bedford, MA; ²O'Donnell School of Public Health University of Texas Southwestern Medical Center Dallas, TX, Dallas, TX; ³Health Services Research & Development, VA New York Harbor Healthcare System, New York, NY; ⁴Research, VA Palo Alto Health Care System, Menlo Park, CA; ⁵VHA Office of Connected Care, Washington, DC; ⁶NYU School of Medicine, VA New York Harbor HCS, New York, NY. (Control ID #4064531)

STATEMENT OF PROBLEM/QUESTION: The Veterans Health Administration (VHA) sees great potential in virtual care technologies like telehealth, mobile apps, and other patient-facing platforms, to enhance service delivery; however, the traditional research cycle is limited in its ability to produce rapid and actionable results that can support the use of virtual care in a learning healthcare system like VHA.

DESCRIPTION OF PROGRAM/INTERVENTION: In June 2020, VHA funded the Virtual Care CORE (VC-CORE), to facilitate research on the use of virtual care to enhance the accessibility, capacity and quality of VHA health care and Veteran experience. The VC-CORE reflects a partnership between VHA’s Health Services Research Service and Office of Connected Care, the entity responsible for VHA’s digital health strategy, and is organized around four impact goals: 1) Facilitate increased adoption and use of virtual care; 2) Foster research on the impact of virtual care; 3) Create a network of virtual care investigators aligned with the needs of VHA; and 4) Coordinate requests for applications focused on virtual care and synthesize evidence for reporting purposes in support of VHA.

MEASURES OF SUCCESS: The VC-CORE has a set of metrics, tracked by VHA, intended to gauge its impact on the healthcare system. These include: 1) the number of individual members and facilities that join its network; 2) the number of RFA’s focused on virtual care developed and released to the VHA research community; 3) total number of projects and total funding distributed through the VC-CORE in support of RFAs; and 5) Novel opportunities for early career researchers and trainees to launch work related to virtual care.

FINDINGS TO DATE: Since its inception, VHA’s VC-CORE network has grown to include 354 members located at nearly 40 VHA medical centers nationwide. Since 2020, 10 RFAs have been developed intended to address key VHA priorities. These RFAs have funded 46 unique projects, with total funding in excess of $10 million between fiscal years 2020-2024, including $2 million in the last year and anticipated in future years. Finally, the VC-CORE has established a novel Associate Investigator Program to distribute start-up funds to early career researchers and trainees, competitively selected as awardees based on their envisioned virtual care research trajectory.

KEY LESSONS FOR DISSEMINATION: Learning healthcare systems are committed to applying rigorous, evidence-based practices to promote innovation, quality, and safety in care. VHA’s novel CORE Program and it’s VC-CORE specifically, are exemplary initiatives that other organizations can model to speed the research-to-practice cycle for high-priority needs.

GENERATIVE AI IN PRIMARY CARE: LESSONS FROM AMBIENT LISTENING DOCUMENTATION AND DRAFTING PATIENT PORTAL REPLIES

Jacqueline G. You^1,2; Amanda J. Centi³; Emily Alsentzer²; David Y. Ting^4,3; Lydia C. Siegel^2,3; Elaine Goodman⁴; Sayon Dutta^5,3; Anne Stanislaus³; Dustin S. McEvoy³; Jackson Olin⁶; Rebecca G. Mishuris^2,3. ¹Pathology, Massachusetts General Hospital, Boston, MA; ²Medicine, Brigham and Women's Hospital, Boston, MA; ³Digital, Mass General Brigham Inc, Somerville, MA; ⁴Medicine, Massachusetts General Hospital, Boston, MA; ⁵Emergency Medicine, Massachusetts General Hospital, Boston, MA; ⁶Boston University, Boston, MA. (Control ID #4061910)

STATEMENT OF PROBLEM/QUESTION: How can generative artificial intelligence (generative AI) solutions address primary care documentation burden?

DESCRIPTION OF PROGRAM/INTERVENTION: Clinicians spend more time documenting than on face-to-face time with patients.¹ Primary care physicians are plagued with in-basket messages and electronic health record (EHR) work.² There is considerable potential for generative AI to positively impact clinical workflows by reducing the burden of notes and non-visit work.^3,4 Ambient listening documentation, which uses large language models (LLMs) to draft visit notes from recorded patient-clinician interactions, may be a lower-cost, more scalable scribing solution compared to in-person or virtual scribes, both of which improve documentation outcomes.^5,6,7 We are piloting this technology over 6-12 months with 400 physicians, physician assistants (PAs), and nurse practitioners (NPs) using two ambient listening documentation vendors integrated with our EHR (Epic). Separately, to address EHR inbox-related burden, we implemented OpenAI’s GPT-4 LLM in the EHR to draft replies to patient portal messages for nurses, physicians, PAs, and NPs. We honed LLM prompts to generate messages that would augment the care team’s reply generation and facilitate workflows for message categorization, while minimizing risk to the patient. In particular, we minimized medical advice given by GPT to align with institutional policy and incorporated a clinical symptom categorization framework to aid staff and nurses in message triage.

References available upon request.

MEASURES OF SUCCESS: For the ambient documentation pilot, metrics include time in notes, time to note completion, documentation time outside of work hours (“pajama time”), percentage of note generated by AI. For the in-basket pilot, metrics include message volume, edit distance (Levenshtein distance between generated drafts and finalized sent messages), user satisfaction scores, time spent drafting messages. For both pilots, we are measuring burnout and workload perception with clinician surveys.

FINDINGS TO DATE: Early feedback from the ambient documentation pilot shows decreased time documenting clinical notes for some users. Areas for improvement include need for EHR integration, better problem-oriented charting workflows, and overall tone. The full pilot will have midpoint results in April 2024. Early feedback from the in-basket pilot suggests draft replies are more accurate than anticipated, reduce time to response formulation, and facilitate more efficient workflows. Nurses perceive greater benefit than physicians. The pilot will conclude in February 2024. Themes in implementation include maintaining patient safety, maximizing trust and transparency in AI, user education, and understanding optimal user “phenotypes” for experiencing benefit from the technology.

KEY LESSONS FOR DISSEMINATION: Generative AI solutions like ambient listening and generated draft replies have the potential to transform primary care but require thoughtful implementation with transparency, meaningful metrics, and attention to user workflows.

MAKING SPECIALTY ACCESS TRANSPARENT: A DATA-DRIVEN APPROACH

Christine Zhang¹; Emilie O'Neill¹; Stasha O'Callaghan²; Telecia Groomster³; Sarah Rose Cass¹; Kevin Chen¹; Hannah B. Jackson¹. ¹Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY; ²New York City Health and Hospitals Corporation, New York, NY; ³Ambulatory Care Operations, New York City Health and Hospitals Corporation, New York, NY. (Control ID #4061928)

STATEMENT OF PROBLEM/QUESTION: In the outpatient specialty referral landscape, it is challenging to distil complex operational electronic medical record (EMR) data into actionable insights on clinic capacity, access, and timeliness of appointments generated by specialty referrals.

DESCRIPTION OF PROGRAM/INTERVENTION: Management of available specialty resources and timely access to specialty care are important aspects of providing high quality services in a large multi-specialty, multi-site medical system. Given the dynamic nature of supply and demand and known issues with wait times and access in some specialties and sites, there was a need to provide at-a-glance visibility into system-wide specialty resource allocation and utilization.

A set of measures were developed with stakeholders using referral and scheduling data pertaining to the availability, capacity and efficiency of outpatient clinical services offered throughout a large urban medical system in the Mid-Atlantic region: 1) capacity ratio (referral volume divided by available appointments), 2) scheduling rate (percent of referrals scheduled) and 3) timeliness of appointment (referral scheduled within appointment window, as per referral priority). Available clinical services across sites were mapped to specific data elements in the referral order pathway, in order to isolate appropriate referrals. Performance of each measure based on internal benchmarks were combined into an overall composite score, easier for front line providers to understand in real time, with three tiers (high, medium, low) and presented in a self-service dashboard (Figure 1).

MEASURES OF SUCCESS: Number of specialty clinics for which performance measures are continually assessed will be one of the primary ways to evaluate success. Ensuring consistent access and enabling the system to right fit specialty care within each sub-region serviced is one of the ultimate aims of these efforts.

FINDINGS TO DATE: Data on referrals ordered and appointments scheduled for patients were collected from the EMR for 95 distinct outpatient specialties across 11 acute medical centers, with adult and pediatric services identified separately. Most (51%) specialty clinics’ composite scores were within the lowest performance tier, while 13% of clinics were middle tier and 35% were within the highest performance tier.

KEY LESSONS FOR DISSEMINATION: To help address challenges faced around access to specialty care, information technology tools such as dashboards can condense operational data into actionable tools for providers and unveil opportunities for improved resource allocation.

QUALITATIVE PERSPECTIVES ON EPIC ALERTS AND CLINICAL DECISION SUPPORT

Afifah Khan, Jeffrey L. Schnipper. Division of General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #4063621)

STATEMENT OF PROBLEM/QUESTION: How do the stakeholders who govern, support, and receive electronic health record (EHR) best practice alerts (BPAs) feel about them and other forms of clinical decision support (CDS)?

DESCRIPTION OF PROGRAM/INTERVENTION: The EHR has many methods of CDS that are intended to improve provider workflow and help clinicians take better care of patients. Unfortunately, some methods of CDS have had opposite results and detract from patient-facing time and patient care. In particular, BPAs fire so frequently in the EHR that most are ignored, almost entirely defeating their purpose. This project involves semi-structured interviews with inpatient hospital medicine service end users at an academic medical center in New England, members of governance boards, and members of site-specific and system-wide information systems teams to qualitatively assess how BPAs could be changed to create more effective CDS. The goal of the study is to provide preliminary data to inform changes to CDS to be more relevant and effective for end users.

MEASURES OF SUCCESS: We are conducting thematic analysis of interview transcripts using the constant comparative method. Inductive and deductive coding are being used to identify themes and case characteristics, external and internal contexts, and characteristics of the individuals involved.

FINDINGS TO DATE: The initial findings have shown end users find specific BPA content categories helpful, for example many found sepsis BPAs to be unhelpful but drug-drug interaction and allergy BPAs to be helpful. Otherwise, many issues regarding usability center on context, such as the volume, timing, and interruptive nature of BPAs. Interviews with information systems teams who conduct monthly quality assurance (QA) reviews on BPAs reveal a focus on modifying content or retiring a few BPAs each month that have the lowest acceptance rates. At this medical center, the highest rates of BPA acceptance are generally 10-20% and the BPAs undergoing QA reviews are commonly accepted <10% of the time. After interviews with several key stakeholders, the governance process around retiring or modifying BPAs seems inadequate, as it is uncommon for governance groups, who are often involved in creating BPAs, to approve changing or eliminating BPAs.

KEY LESSONS FOR DISSEMINATION: The key lesson for dissemination is the utility of BPAs could be improved by changing their context as well as content, specifically optimizing their volume, timing, and interruptive nature. Low priority BPAs could also be changed to other forms of CDS. High priority BPAs may need additional quality improvement efforts to increase their acceptance rates.

STANDARDIZED VIRTUAL CLINIC SUPPORT IMPROVES EFFICIENCY AND ACCESS TO VIDEO VISITS

Joanna S. Cavalier^1,2; Donna Phinney²; Kelly Gagnon²; Jennifer Wilkins²; Matthew Roman²; Elisabeth Fassas¹; Reeti Gulati¹; Blake Cameron^1,2. ¹Department of Medicine, Duke University Health System, Durham, NC; ²Duke University Health System, Durham, NC. (Control ID #4056391)

STATEMENT OF PROBLEM/QUESTION: Because virtual visits involve different workflows than in-person visits, we analyzed whether a centralized virtual visit support team, staffed by nurses and medical assistants trained in standardized processes for virtual visit preparation, technical support, patient intake, and wrap-up tasks, would improve efficiency and access compared to usual virtual care.

DESCRIPTION OF PROGRAM/INTERVENTION: Virtual care remains a critical part of care delivery even post-COVID-19. Given unique workflows required for virtual visits, we hypothesized that a centralized support team for virtual care, as compared to usual virtual care supported by in-person clinic staff, would improve efficiency and access to care. This study evaluates the impact of a centralized virtual visit support program on operational and access metrics within an academic medical practice. The Duke Virtual Care Center (VCC) pilot program launched in 2022 to support virtual visits in 3 clinical specialties: dermatology, endocrinology, and gastroenterology. Participating providers scheduled virtual appointments in dedicated half-day sessions. VCC staff performed pre-visit intake tasks, ensured successful real-time audio/video connection, arranged video-based interpreter services, provided post-visit patient education, and coordinated post-visit laboratory, imaging and appointment scheduling as needed. Data were obtained from the electronic health record.

MEASURES OF SUCCESS: Number of virtual visits completed in VCC versus non-VCC

No-show rates

Video-to-telephone conversation rates

Duration of video visits

On-time start rates

Patient satisfaction

FINDINGS TO DATE: Between July 2022 and June 2023, there were 21,039 virtual visits in dermatology, endocrinology, and gastroenterology, of which 67.6% (n=14,221) were supported by the VCC and 32.4% (n=6,818) were not. Visits supported by the VCC had a lower no-show rate (7.0% vs. 13.8%), lower conversion from video to telephone visit (2.2% vs. 8.6%), greater eCheck-in completion (82.9% vs. 72.5%), higher on-time patient arrival (92.0% vs 85.0%), and higher on-time appointment start (85.1% vs. 37.6%). Net promoter scores related to VCC- and non-VCC-supported visits were comparable (+76), albeit measured only among patients who successfully completed virtual visits.

KEY LESSONS FOR DISSEMINATION: Virtual visit support provided by centralized staff improved clinic efficiency and access to video visits by reducing no-show rates, reducing video-to-phone abandonment, and promoting on-time appointments. Separating virtual and in-person visit tasks relieved providers and nursing staff from competing demands and facilitated development of specialized nursing expertise in supporting remote care. Further research is needed to evaluate the impact of such a support model on clinical outcomes, provider satisfaction, and cost of care.

STANDARDIZING VIRTUAL HEALTH WORKFLOWS TO IMPROVE ACCESS AND QUALITY OF CARE IN COMMUNITY HEALTH CENTERS

Arielle Elmaleh-Sachs^1,2; Maia Morse³; Doreen Colella¹; Elsa Buggs¹; Kerri Cuccurullo¹; Isaac Dapkins^1,2. ¹Family Health Centers, NYU Langone Health, New York, NY; ²Internal Medicine, NYU Langone Health, New York, NY; ³Primary Care Development Corporation, New York, NY. (Control ID #4064644)

STATEMENT OF PROBLEM/QUESTION: Providing high quality virtual health care requires different considerations and workflows than in person care.

DESCRIPTION OF PROGRAM/INTERVENTION: This project included a two-year evaluation of current practices for virtual outpatient care delivery in community health centers in the Mid-Atlantic region. Key informant interviews were held with representative staff members across the care team continuum, including nurses, front desk registration and dedicated virtual health staff within the health centers’ Internal Medicine, Pediatrics, OBGYN, Behavioral Health, Homeless Medicine, and School-based Health clinics. In addition, discussions with community-based organizations highlighted disparities in access to care due to digital health literacy, language barriers, as well as for patients with disabilities and older adults. Based on the themes identified, new workflows were developed to standardize virtual visits to improve throughput, align staff roles, and improve quality of care. This included pre-virtual visit screening for digital determinants of health such as access to technology and internet, tip sheets to guide patients in connecting to visits, and review of compliance standards. Checklists outlining best practices during the virtual visit, such as reviewing home monitoring device data, patient eligibility and visit documentation were developed to maximize visit interaction and streamline documentation. All virtual health related materials were used to develop and deploy a virtual health training for staff involved in the workflow.

MEASURES OF SUCCESS: Measures of success include improvement in staff survey responses after completing virtual health training and increased utilization of virtual health in select populations (patients experiencing homelessness, those with limited English proficiency, residents of public housing) at 6-month follow-up.

FINDINGS TO DATE: Focus groups identified several themes, including the following: 1) virtual health increases flexibility for providers and access for patients, 2) a working virtual care platform is in place with appropriate IT support, 3) there is site-based variation in workflow for discussing technological set up for appointments. Areas for growth included: 1) lack of clarity on role within virtual visits for some team members; 2) eligibility criteria for patients who can receive virtual health is not clearly defined, 3) technology is a barrier for many vulnerable populations served, 4) patient engagement has been inconsistent.

Pre-evaluation surveys for the virtual health training found that at baseline (n=76), 88% of participants had a good understanding of the appropriate uses of virtual health, which increased to 97% post-evaluation (n=116). Similarly, 70% reported understanding the billing and legal requirements for virtual health before the training, with an increase to 89% post-training.

KEY LESSONS FOR DISSEMINATION: Using an overarching lens to examine all components of successful virtual health delivery while understanding the needs of the population can increase overall access to care.

USING TEXT STRING SEARCHING AND CLINICAL DATA TO IDENTIFY MEDICATION DISCONTINUATIONS IN ELECTRONIC HEALTH RECORD DOCUMENTATION

Jennifer Barrow¹; Elizabeth Bayliss¹; Glenn K. Goodrich¹; Ariel Green²; Courtney Kraus¹; James Lagrotteria¹; Matthew Maciejewski³; Jonathan Norton²; Ted Palen¹; Valerie Paolino¹; Emily Reeve⁴; Orla Sheehan⁵; Linda Weffald¹; Cynthia Boyd². ¹Kaiser Permanente Colorado Institute for Health Research, Aurora, CO; ²Johns Hopkins University, Baltimore, MD; ³HSR&D, Durham VA Medical Center, Durham, NC; ⁴Monash University, Clayton, Victoria, Australia; ⁵Connolly Hospital Blanchardstown, Blanchardstown, Dublin, Ireland. (Control ID #4062587)

STATEMENT OF PROBLEM/QUESTION: To develop and validate a text string search tool to identify medication discontinuation that will be adaptable by others and applicable to text fields of interest.

DESCRIPTION OF PROGRAM/INTERVENTION: Using verbatim clinical documentation extracted from record reviews of older adults, we developed text strings suggesting a high likelihood of medication discontinuation for two different medication groups. We combined these text strings with electronic health record (EHR) data to create algorithms likely to identify likely medication discontinuations. Text strings and algorithms were developed specifically for each medication type to account for clinical documentation reflecting the indicated use.

MEASURES OF SUCCESS: Sensitivity and specificity in development and validation cohorts for each medication group.

FINDINGS TO DATE: We have developed algorithms combining pharmacy, medication order, and progress note text string data for oral diabetes medications and statins.

For oral diabetes drugs, the best performing algorithm had a sensitivity of 82% to 87% and specificity of 83% to 84% in identifying true discontinuations. Text strings alone had a sensitivity of 69% to 86% and specificity of 79% to 78% in validation and development cohorts.

For statins, the best performing algorithm had a sensitivity of 77% to 85% and a specificity of 79% to 86%. Text strings alone had a sensitivity of 44% to 60% and specificity of 90% to 90% in validation and development cohorts.

With the development of each text-based algorithm, we are exploring factors that affect differences in sensitivity and specificity of the algorithms by medication group. For example, treating all statins as interchangeable using dispensing data markedly improved algorithm performance as it accounted for frequent adjustments between statins made as part of treatment intensification.

KEY LESSONS FOR DISSEMINATION: Applying text string search methods combined with electronic clinical data can identify medication discontinuations at scale and help generate evidence to inform deprescribing.

VIRTUAL NURSING INTERVENTION IMPROVES HOSPITAL DISCHARGE EFFICIENCY WITH HIGH PATIENT SATISFACTION

Joanna S. Cavalier^1,2; Blake Cameron^1,2; Donna Phinney²; Kelly Gagnon²; Matthew Roman²; Kay S. Lytle². ¹Department of Medicine, Duke University Health System, Durham, NC; ²Duke University Health System, Durham, NC. (Control ID #4056355)

STATEMENT OF PROBLEM/QUESTION: Due to staffing shortages and mounting financial pressures for health systems, virtual nursing programs are being launched across the United States; however, limited research has been published on key success factors and outcomes.

DESCRIPTION OF PROGRAM/INTERVENTION: A virtual nursing (VN) pilot was designed to support inpatient nurses in the context of nursing shortages and high demands on nursing teams. The VN pilot aimed to increase efficiency of admission, discharge, and daily workflows while maintaining quality and patient satisfaction. A 9-month VN pilot occurred on 3 medical-surgical units across 3 hospitals in a large academic health system. Three other units with similar patient populations served as control units, without VN services. The virtual nurses, at the request of bedside nurses, aided in tasks related to admission, discharge, patient education, mentoring of learners, and rounding via iPad video calls. Data were exported from the electronic medical record or collected via patient surveys.

MEASURES OF SUCCESS: Number of virtual nursing requests placed

Number and % of virtual nursing tasks completed across 5 categories: admission, discharge, patient education, mentoring of learners, and rounding

Time from admission to completion of admission documentation

Time from discharge order to actual discharge

Patient satisfaction

FINDINGS TO DATE: The VN pilot assisted 1,993 patients with 4,014 tasks, the most common of which were patient education (1,393) and discharge (1,252). Admission documentation took an average of 31 hours in both pilot and control units. In pilot units, the average time from discharge order to actual discharge was 2.8 hours versus 5.7 hours in control units. Patients were satisfied with their VN experience, rating it 4.53/5.

KEY LESSONS FOR DISSEMINATION: A large VN pilot aided in efficiency of discharges while maintaining high patient satisfaction. Other health systems with staffing shortages interested in an intervention to improve the efficiency of the discharge process should consider a virtual nursing intervention. Key success factors include (1) seamless technical integration between virtual nurses, in-person nurses, and patients to facilitate “face-to-face” interaction, (2) ability to request VN support on-demand, particularly during the busiest hours for admission and discharge, and (3) support from senior leadership to invest in an innovative program that requires several months to demonstrate ROI. The value of a VN program should be measured in both efficiency of clinical tasks as well as satisfaction and retention of patients and nursing staff. Future directions include analyzing the impact on readmissions, length of stay, patient harms, and nurse satisfaction and retention, and program growth.

Innovation in Healthcare Delivery (IHD) - Geriatrics and Palliative Care

COMPARISON OF CONCURRENT CARE AND TRADITIONAL HOSPICE MODELS AT A REGIONAL VA

Jeremy Zhang¹; Ann Broderick²; Rachel A. Hadler³; William A. Zeitler⁴. ¹Internal Medicine, The University of Iowa Hospitals and Clinics Department of Internal Medicine, Iowa City, IA; ²Hospice and Palliative Care, Iowa City VA Medical Center, Iowa City, IA; ³Anesthesiology, Emory University, Atlanta, GA; ⁴Hematology, Oncology, and Blood and Marrow Transplantation, The University of Iowa Hospitals and Clinics Department of Internal Medicine, Iowa City, IA. (Control ID #4054495)

STATEMENT OF PROBLEM/QUESTION: What are the differences in baseline characteristics and outcomes of veterans receiving concurrent care and traditional hospice at the VA?

DESCRIPTION OF PROGRAM/INTERVENTION: As Americans live longer through social and medical advancements, access to palliative and hospice services for the aging population becomes increasingly essential. At its core, hospice care focuses on relieving symptoms and supporting patients with terminal illness and an estimated 6 months or less to live. The traditional hospice model as described in Medicare policy has numerous prerequisites and barriers. Notably, patients are often forced to make a difficult choice to stop disease-directed therapies in order to enroll. Poor provider understanding of hospice also contributes to the all-too-common scenario in where hospice is offered too late to make a meaningful impact for patients and their families. These issues were prominent in the VA population in 2006, when only 5% of eligible veterans were identified as having received hospice services.

Consequently, the VA Comprehensive End-of-Life Care Initiative in 2009 created the concurrent care hospice model where veterans no longer had to stop all disease-directed therapies to qualify. Initial national VA data in lung cancer suggested that concurrent care may be better than traditional hospice by decreasing aggressive treatments, ICU hospitalizations, and even medical costs. Our regional VA developed a Hospice Flag system that tagged patients in the electronic medical record who had either a concurrent or traditional hospice enrollment to inform health care providers. This project investigates how the concurrent care hospice model may help improve access to hospice care and patient-centered outcomes over traditional hospice by retrospectively reviewing all veterans with a new hospice flag from October 2017 to July 2021. Only patients with cancer as primary enrollment diagnosis were included as this was the largest cohort per national data (~30% of hospice patients).

MEASURES OF SUCCESS: Our primary aim was to establish correlation between hospice type and veterans’ ultimate location of passing (e.g. percentage at home versus hospice facility). Secondary measure included median length-of-stay (LOS) enrolled in hospice

FINDINGS TO DATE: 317 total veterans were enrolled in concurrent care hospice (96) and traditional hospice (221) from Oct 2017 to July 2021. 72% of veterans in concurrent care (69/96) passed away at home compared to only 57% in traditional hospice (125/221); the remaining were in either a hospice facility or hospital. Median LOS in hospice was 62 days for concurrent care and 26 days for traditional hospice

KEY LESSONS FOR DISSEMINATION: This project demonstrates that concurrent care hospice is significantly associated with veterans being able to pass away in their own home. Concurrent care was also correlated with longer median LOS in hospice, suggesting greater duration of support services provided to patients & families. The study's limitations include its retrospective nature and narrow focus on the cancer population

This abstract was accepted and previously presented at the 2024 ASCO Annual Meeting. All rights reserved.

ENHANCING COGNITIVE ASSESSMENT IN PRIMARY CARE: A QUALITY IMPROVEMENT PROJECT FOCUSED ON PRIMARY CARE PHYSICIAN ASSISTANTS

Michelle Berning¹; Teresa Zhang¹; Laura Frain²; Andrea W. Schwartz^2,3; Jerilene Tibayan⁴; Julia Loewenthal². ¹Department of Medicine, Brigham and Women's Hospital, Boston, MA; ²Division of Aging, Brigham and Women’s Hospital, Boston, MA; ³Geriatric Research Education and Clinical Center, VA Boston Health Care System Jamaica Plain Campus, Boston, MA; ⁴Institute for Healthcare Improvement, Boston, MA. (Control ID #4059489)

STATEMENT OF PROBLEM/QUESTION: Can implementation of an Epic SmartPhrase improve rates of cognitive assessment in older adults with memory concerns during a visit with a primary care physician assistant (PA)?

DESCRIPTION OF PROGRAM/INTERVENTION: Despite the growing prevalence of dementia in the US, about half of dementia cases are undiagnosed in primary care. To address this, we conducted a quality improvement (QI) project with the Institute for Healthcare Improvement aimed at increasing rates of cognitive assessment from 0 to 50% in adults aged 65+ with subjective or observed changes in memory or thinking during a visit with a PA.

This QI initiative was conducted at a large academic primary care clinic in New England serving > 21,000 patients (24% age 65+) with 7 PAs and 117 physicians (70 residents, 47 faculty). In early 2022, PAs requested education on cognitive impairment from the geriatrician in the clinic, as most do not receive formal geriatrics education. Based on PA experiences and feedback, our team (geriatrician, PA champion) developed an EHR SmartPhrase based on the Gerontological Society for America Kickstart, Assess, Evaluate, Refer (KAER) cognitive assessment toolkit.

MEASURES OF SUCCESS: The primary outcome was frequency of SmartPhrase use. We conducted Plan-Do-Study-Act (PDSA) cycles from 1/30/23-5/15/23. We also assessed confidence in managing memory concerns before and after an educational session. The study was exempt from review by the local IRB.

FINDINGS TO DATE: At baseline from 1/23-1/30/23, PAs saw 58 patients age 65+, 6 of whom (10.3%) expressed memory concerns. The SmartPhrase (PDSA #1) was introduced on 1/30/23. By week 3, the proportion of older patients reporting memory concerns who received cognitive assessment increased from 0% to 60%, dropping to 0% by week 5. In PDSA #2, we shortened the SmartPhrase name and provided universal access in Epic for all clinicians. Rates of cognitive assessment increased temporarily to 66% following this change. In PDSA #3, we held an educational session on cognitive impairment and the SmartPhrase, offering CME credits. Twenty two clinicians (6 PAs) attended. Confidence in assessing an older patient with memory concerns increased after the session (pre: 14% little confidence, 79% some, 7% high; post: 91% some, 9% high).

KEY LESSONS FOR DISSEMINATION: In this QI initiative, we successfully developed and integrated an Epic SmartPhrase into a primary care practice, resulting in enhanced rates of cognitive assessment and confidence of primary care PAs with diagnosis/management of cognitive concerns. A major strength of this study was the focus on PA clinicians who are increasingly utilized in primary care clinics but receive limited geriatrics training. Limitations included sustainability of the SmartPhrase, as reflected by the fluctuating frequency of SmartPhrase use. We learned the importance of engaging stakeholders and a champion to enhance accessibility and use of the SmartPhrase, in addition to pairing the tool with education. Next steps include refining the EHR tool and expanding CME efforts in our primary care system.

EVALUATING COGNITIVE IMPAIRMENT IN A LARGE HEALTH SYSTEM: OUTCOMES OF A NOVEL QUALITY IMPROVEMENT PROGRAM

Barak Gaster²; Monica Zigman Suchsland¹; Annette L. Fitzpatrick¹; Joshua M. Liao²; Basia Belza⁵; Amy P. Hsu²; Sarah McKiddy⁵; Benjamin S. Olivari³; Jaqueline Raetz⁴. ¹Family Medicine and Epidemiology, University of Washington, Seattle, WA; ²Medicine, University of Washington, Seattle, WA; ³Centers for Disease Control and Prevention, Atlanta, GA; ⁴Family Medicine, University of Washington, Seattle, WA; ⁵School of Nursing, University of Washington, Seattle, WA. (Control ID #4019197)

STATEMENT OF PROBLEM/QUESTION: The prevalence of Alzheimer’s disease and related disorders (ADRD) is rising, and primary care providers (PCPs) will increasingly play a role in its detection, but PCPs lack an efficient framework for evaluating cognitive concerns.

DESCRIPTION OF PROGRAM/INTERVENTION: We developed an evidence-based workflow for primary care, implemented as a web-based training which was combined with tools which were integrated into the electronic health record (EHR). These tools provided a clear path for participants to use the training in their clinics. The training also included a structured framework for counseling newly diagnosed patients using clear and compassionate language. The workflow was a model of best practices which was adapted from the Gerontological Society of America’s KAER (Kickstart, Assess, Evaluate, Refer) Toolkit. We implemented the program across a network of 14 community-based primary care clinics affiliated with a large health system.

MEASURES OF SUCCESS: Three outcome measures were assessed: 1) a comparison of the number of cognitive assessments that PCPs entered into the EHR pre- and post-training; 2) a comparison of the number of patients newly diagnosed with cognitive impairment pre- and post-training; and 3) changes in confidence and attitudes of PCPs in identifying and managing dementia, as measured by a validated survey tool: the General Practitioner’s Attitudes and Confidence Scale for Dementia (GPACS-D).

FINDINGS TO DATE: Across the 14 clinics, the mean number of cognitive assessments entered into the EHR increased from 5.2 per month before the training to 21.2 after the training (p<0.01). The mean number of patients newly diagnosed with mild cognitive impairment increased from 23.5 per month before the training to 32.2 after the training (p=0.03). Fifty PCPs completed the GPACS-D survey before and after the training. They reported a significant improvement in their confidence and attitudes toward identifying and managing dementia, demonstrated by a mean total score increase from 3.33 to 4.09 (p<0.01).

KEY LESSONS FOR DISSEMINATION: An evidence-based system of PCP training, combined with EHR tools for PCPs to use in cognitive evaluation, increased cognitive testing and the identification of mild cognitive impairment among patients in a 14-clinic community-based primary care network. The tools and training were designed to be concise and easy to replicate in other health systems, without requiring systems to hire new staff or build new services. All materials developed, including video recordings of the trainings and templates of the EHR tools, are freely available to all clinics who would like to adapt this workflow. As a result, the project is easy to implement and has clear reproducible outcomes. It is applicable for use in a wide range of primary care settings to improve cognitive evaluation by PCPs and enhance care for persons living with ADRD.

IMPLEMENTING 5MS CONSULT TO IMPROVE AGE-FRIENDLY CARE FOR HOSPITALIZED OLDER ADULTS

Grace I. Chen, Maristela Garcia. Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4063367)

STATEMENT OF PROBLEM/QUESTION: Hospitalized older patients frequently have multimorbidity that require consideration of age-friendly principles not typically considered in medical management to optimize care delivery.

DESCRIPTION OF PROGRAM/INTERVENTION: We implemented a dedicated consult service on hospitalized older patients in a large academic hospital focused on the 5Ms of age-friendly care: what matters; mind; mobility; medications and multi-complexity. Providers performing the consults are a team composed of a geriatrician and a nurse practitioner (NPs). NPs primarily work as acute care providers on the hospitalist service and had not previously practiced with a dedicated geriatrics perspective. For the first year of implementation, 9 NPs were trained by geriatrics faculty on the 5Ms principles. As the health system is transitioning to a full-risk model with its Medicare Advantage (MA) managed care patients starting 1/1/2024, the initial cohort identified for 5Ms consultations were referred by the health system medical group utilization management (UM) team on hospitalized MA patients identified as high utilizers of health system resources. Identified 5Ms principles for each patient were utilized by inpatient team members and UM to transition care to outpatient care team.

MEASURES OF SUCCESS: ● Current: Comfort level of non-geriatricians on using 5Ms principles for hospitalized older patients and use of information by UM

● Future: Decrease in healthcare utilization by MA patients and dissemination of age-friendly care to all clinical settings via 5Ms consults

FINDINGS TO DATE: Findings are from surveys administered to the NPs and UM Medical Director 11 months after implementation of 5Ms consult service.

After 5Ms, 8 of 9 NPs changed approach to patient care. Specifically, more awareness about ageism, importance of function and mobility, and how what matters and multi-complexity need to be addressed in context of social drivers of health.

Prior to 5Ms, 2 of 9 NPs considered what mattered in caring for older patients. After 5Ms, 8 of 9 consider what matters in caring for older patients. 6 of 9 NPs have changed their approach to how they discuss plan of care and discharge planning with hospitalized older patients.

Health systems need to have ability to address the social drivers of health along the care continuum to optimize patient care, especially in full-risk settings.

Provided critical information to UM not typically available in medical assessment of patient’s active issues.

KEY LESSONS FOR DISSEMINATION: Increase geriatrics workforce by training non-geriatrician providers to incorporate 5Ms in care of older patients.

Need venue (e.g. electronic medical record system) for information obtained from the comprehensive 5Ms consult to be accessible to all as foundation of care approach

Need communication amongst providers across the care continuum to approach care in alignment and follow up on outstanding items.

Health system needs to have ability to connect patients/families to identified resources to address psychosocal barriers to care optimization.

IMPLEMENTING A MULTIDISCIPLINARY GERIATRICS CO-MANAGEMENT MODEL IN AN URBAN COMMUNITY HEALTH CENTER

Carolina Fonseca Valencia¹; Talya Salant²; Jeremy Whyman¹. ¹Gerontology, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4062635)

STATEMENT OF PROBLEM/QUESTION: Can a geriatrician embedded in a primary care team function to improve the care of complex socioeconomically disadvantaged (SEcD) older adults?

DESCRIPTION OF PROGRAM/INTERVENTION: Older adults with lower educational achievement and socioeconomic status represent a diverse and complex group with high levels of intertwined socioeconomic stressors, low health literacy, and chronic medical conditions. Due to this complexity, the diagnosis and management of geriatric syndromes (including but not limited to frailty, cognitive impairment, gait and balance issues and polypharmacy) can go undetected or be delayed resulting in preventable costs, morbidity, and mortality.

Geriatric co-management care is characterized by collaborative care provided to patients with geriatrician and non-geriatrician clinical staff working together to detect, prevent, and manage geriatric syndromes. This model of care, that utilizes the comprehensive geriatrics assessment (CGA) as primary tool, is beneficial for the care of complex, socioeconomically disadvantaged (SEcD) older adults. Although multiple studies of geriatric co-management among surgical specialties in hospitalized patients have demonstrated its benefit in reducing in-hospital mortality, length of stay and post-operative complications, less is known about the impact of this model in community health settings that focus on caring for vulnerable SEcD older adults.

To lessen healthcare inequities and understand the impact that specialized geriatrics care has in the health management of vulnerable SEcD older adults, we have implemented a geriatric co-management model in an urban community health center. Our intent is to enhance early diagnosis and management of geriatric syndromes and to support the primary care team.

MEASURES OF SUCCESS: Demonstrate the feasibility of implementation by number of CGAs completed successfully.

Define specific characteristics of older adults evaluated by the geriatric-primary care co-management model by using demographic data, and information about their overall health and health care utilization.

Describe the prevalence of geriatric syndromes and the impact they have on the overall health of the patients.

FINDINGS TO DATE: In a 12-month period we have completed a today of 65 CGAs on patients between the ages of 53-95 years. Most of the patients evaluated have been women (66%) who are non-English speaking (65%), with Cape Verdean Creole and Spanish being the most prevalent languages. Overall, these patients have been noted to be at least moderately frail with an average frailty index of 0.421. The most common geriatric syndromes encountered include cognitive impairment (MCI and dementia), polypharmacy, and gait disturbances.

KEY LESSONS FOR DISSEMINATION: It is feasible to implement a geriatrics-primary care co-management model in an urban community health center, utilizing resources available within the health center. This care model aid PCPs in careing for vulnerable SEcD older adults by supporting early diagnosis and intervention on complex geriatrics syndromes and their complications.

QUALITY SUGGESTIONS FOR ADVANCE CARE PLANNING: ELECTRONIC MEDICAL RECORD REMINDERS TO ENCOURAGE MEDICAL DURABLE POWER OF ATTORNEY COMPLETION

Christine Haynes, Robin Yasui, Delia Harr, Meghann Lang, Daniel Kortsch. Denver Health, Denver, CO. (Control ID #4047263)

STATEMENT OF PROBLEM/QUESTION: Effective strategies to support advance care planning (ACP), especially for patients with advanced illness, often require a significant investment of time and resources, and are difficult to sustain.

DESCRIPTION OF PROGRAM/INTERVENTION: Many patients with advanced illness have not had advance care planning (ACP) discussions. While many interventions exist to support these patients, they are often resource-intensive. We prioritized completion of a Medical Durable Power of Attorney (MPDOA), which offers patients the right to choose their own healthcare decision maker. Only 11.4% of patients over 65 and 16.6% of patients identified as high healthcare utilizers had an MDPOA on file at our large safety net healthcare system. Additionally, there were disparities based on race/ethnicity, language, and payor source. We utilized provider nudges called Quality Suggestions (QS) within the electronic medical record (EMR) to help improve MDPOA completion. These auto-generated texts are embedded in ambulatory primary care provider (PCP) note templates and offer patient-specific interventions based on >100 quality metrics. They are designed as a clinical nudge, not a required step, that provides voluntary clinical decision support. In November 2022 we introduced a QS for MDPOA completion for patients with a high annual mortality risk, defined by an EMR autogenerated end-of-life care (EOLC) index. These scores are derived from diagnoses, medications, and other variables and correlate with one-year mortality based on an Epic foundation machine learning model. When patients with an EOLC index that represented the sickest 1.3% of ambulatory patients saw a PCP and did not already have an MDPOA on file, a QS recommended MDPOA completion.

MEASURES OF SUCCESS: We measured how often this QS was shown, how many of those patients had MDPOAs on file six months later (further stratified by age, sex, race/ethnicity, language, and payor source), and compared it to the overall MDPOA completion rate in our healthcare system.

FINDINGS TO DATE: From November 2022 through October 2023, a QS recommended MDPOA completion a total of 5282 times. Among these patients, 10% had an MDPOA on file six months later. As a comparator group, only 0.3% of patients with a lower EOLC index who saw a PCP over the same time frame (and 2.2% of our highest healthcare utilization patients) had subsequent MDPOAs on file. Improvements were seen across various demographic subgroups. Improvements were most pronounced in patients without health insurance; the smallest impact was seen in patients who spoke a language other than English or Spanish.

KEY LESSONS FOR DISSEMINATION: This EMR-based nudge offers a straightforward reminder to providers to consider MDPOA completion for patients with a high annual mortality risk. It required minimal resources to implement and maintain, and while only a soft reminder, was able to contribute to successful MDPOA completion in 10% of targeted patients. This offers individual healthcare systems an opportunity for a tailored ACP intervention for patients with serious illness.

Innovation in Healthcare Delivery (IHD) - Healthcare Delivery and Redesign

ACCESS TO SAFE CONTRACEPTION IN THE PRIMARY CARE SETTING - A POPULATION HEALTH APPROACH

Rubaina Zaman¹; Kelly Graham²; Laura Desrochers²; Anthony Ishak^1,3; Caroline A. Letendre¹. ¹General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ³Massachusetts General Hospital, Boston, MA. (Control ID #4060189)

STATEMENT OF PROBLEM/QUESTION: Incidence of cardiovascular risk factors that pose potential risk for exposure to systemic hormonal contraception are on the rise in younger patients. This epidemiological shift, along with increase in maternal age, has led to a rise in the complexity and overall risk of the population seeking contraception. Developing a population health-based approach embedded in primary care to risk-stratify patients may improve access to safe and effective contraception in a complex and aging population.

DESCRIPTION OF PROGRAM/INTERVENTION: Within our large academic primary care clinic comprised of ~40,000 patients in the greater Boston area, we designed the following interventions:

(1) Develop a contraceptive registry to identify patients meeting Medical Eligibility Criteria (MEC) categories III and IV (for whom combined hormonal contraceptives/CHCs) are considered unsafe)

(2) Implement an outreach campaign to enable contraception counseling for patients identified within these risk categories

(3) Implement a primary care-embedded family planning clinic that provides lower-risk alternatives (long-acting reversible contraception/LARC) for all patients, including those at high risk

MEASURES OF SUCCESS: Primary Outcome: Change in # patients on a CHC with MEC III/IV conditions

Secondary Outcomes:

1. Medical and social factors associated with being prescribed a CHC with a MEC III/IV contraindication

2. Rates of different MEC III/IV contraindications in the population

Implementation outcomes:

1. % High-risk patients who received outreach, completed counseling, and were scheduled for a LARC placement

2. Time to next LARC appointment

FINDINGS TO DATE: Among 2,225 patients with active CHC prescriptions, 552 (24.6%) met class III or IV MEC. These patients were significantly more likely to be older (OR 1.04; CI 1.02-1.05) and to have been hospitalized in the previous year (OR 3.35; CI 2.35-4.77). Asian race was associated with decreased odds (OR 0.69; CI 0.52-0.91) and Black race with increased odds (OR 1.37; CI 1.04-1.79) of MEC III or IV contraindications compared to White patients. Migraine with aura and hypertension were the two most common class III or IV MECs identified in this group of patients (36% and 15%, respectively).

A total of 243 patients were outreached (52% of patients meeting inclusion criteria). 44 LARC procedures and 32 counseling visits were completed, and 9 patients received additional hypertension management by a clinical pharmacist. Contraception counseling visits resulted in CHC discontinuation in 50% of patients and LARC uptake in 30% of patients. IUD procedures tripled and ENG-implants doubled per month during the study period. Time to next LARC appointment dropped from 14 to 6 days.

KEY LESSONS FOR DISSEMINATION: 1. Embedding a comprehensive family planning clinic within a primary care practice promotes both value-based and equitable access to safe contraception.

2. There is a significant relationship between race and inappropriate CHC prescribing, indicating additional factors related to health equity contributing to unsafe prescribing.

A NOVEL APPROACH TO TRAVEL CONSULTATIONS IN A PRIMARY CARE SETTING BY USING ASYNCHRONOUS EVISITS TO OPTIMIZE PATIENT AND PROVIDER EXPERIENCE

Louise King¹; Christine Gladman². ¹Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC; ²Medicine, University of North Carolina, Chapel Hill, NC. (Control ID #4065058)

STATEMENT OF PROBLEM/QUESTION: Primary care patients seeking advice before international travel need a convenient and less expensive method to get a travel medicine consultation, and providers need a structured format to respond to travel advice questions posed by patients.

DESCRIPTION OF PROGRAM/INTERVENTION: Our primary care clinic, in an academic setting in the Southern region, created asynchronous evisits for travel consultation. Our clinic patients were able to use their patient portal system to have an evisit, which entailed filling out a travel questionnaire asking the details of patients’ trip, their vaccination status, and any concerns they had. A practitioner with experience in travel medicine and certified to prescribe yellow fever vaccines responded within 3 business days. Appropriate medications and vaccines were prescribed, and patients were instructed to make a nurse visit appointment at our clinic for vaccine administration. Providers were encouraged to refer their patients for these evisits when they were approached by their patients for travel advice, either at in-person visits or via electronic messaging.

MEASURES OF SUCCESS: Measures of success include the number of travel evisits performed, the numbers of vaccines prescribed, the numbers of antimalarials prescribed, the cost savings for the patients, and the ease for the provider to answer the evisits.

FINDINGS TO DATE: We have done 26 travel consultation evisits over an eleven-month period, which was equal to the number of in-person travel visits during the same period. A total of 35 vaccines were prescribed, and 21 patients received antimalarial medication. Seven visits required further messaging by the provider or the patient. One visit was converted into an in-person visit. The average amount of time spent on the visits was 16 minutes. Twenty-three of the evisits were charged at $75 and 3 higher complexity visits were charged at $95. The average cost for an in-person travel consultation at our office had previously been $123, and was $147 at other local travel clinics.

KEY LESSONS FOR DISSEMINATION: Asynchronous evisits for travel consultation offer an effective way of providing travel advice for patients. The decreased administration costs and time required can be passed on to the patients in terms of cost savings and thus create a more equitable system for giving travel advice. The amount of time spent by the provider on the evisit is not burdensome and can provide a needed resource for primary care providers when they are asked for travel advice by their patients. Next steps will be surveying patient and provider satisfaction with the evisits, and consideration of offering the evisits to a broader patient base.

A PRIMARY CARE-PARTNERED “FAST-TRACK” GENETIC COUNSELING SERVICE

Olivia Benson, Anna Verwillow, Kristen Shannon, Suzanne Brodney, Katherine Gallagher, Heidi L. Rehm, Jennifer Haas, Leland Hull. Massachusetts General Hospital, Boston, MA. (Control ID #4026263)

STATEMENT OF PROBLEM/QUESTION: Innovative, team-based solutions are needed to meet the increasing demand for preventive genetic testing.

DESCRIPTION OF PROGRAM/INTERVENTION: The Massachusetts General Hospital Preventive Genetic Counseling Service (PGCS), embedded in the Division of General Internal Medicine, offers virtually coordinated genetic counseling to facilitate 1) hereditary breast cancer genetic susceptibility testing, 2) preconception carrier screening, and 3) assistance with interpretation and triage of direct-to-consumer genetic testing.

Patients are referred to the genetic counseling service by their primary care clinician (PCC) for one of these indications. A genetic counseling assistant collects the family and personal medical history needed for risk assessment before the visit using a prespecified questionnaire via secure messaging or telephone. During a 30-minute virtual visit, a genetic counselor provides pre-test counseling about the risks, benefits, and limitations of genetic testing. Informed consent for testing is obtained. The PCC signs the genetic test order, but the PGCS team handles all testing processes, including returning results. PCCs are copied on all communications. If a patient warrants further assessment by a subspecialist after their appointment, the referral to the indicated specialty is prepared for PCC to cosign; all other patients return to their PCC for follow-up and continued preventive care.

MEASURES OF SUCCESS: Measures assessed include visit volume (goal to reach 7 visits/4-hour sessions over the first six months), time from referral to appointment (goal <4 weeks), and subspecialty physician visits saved (goal of >50% of patients returning to PCC to preserve subspecialist access for most complex cases).

FINDINGS TO DATE: From February through June 2023, pilot visits were scheduled intermittently to test the model with a senior GC. In July 2023, a 25% effort GC was hired to see patients one day/week. As of October 25, 2023, 63 patients have been referred to the service, and 42 patients (66.7%) were seen in a median of 19 days (IQR 2-32.5) after a referral was placed. Most patients were seen for a family history of breast cancer (N=37). Of these, 33 had genetic testing; no pathogenic variants were found. Patients with a calculated lifetime breast cancer risk >20% per Tyrer-Cuzick score (17 of 37, 46%) were offered a follow-up personalized risk assessment with a breast specialist; the remaining 54% returned to the care of their PCC.

KEY LESSONS FOR DISSEMINATION: We describe a new approach to providing flexible genetic counseling support to primary care clinicians. Next steps include expanding and increasing volume, proactively offloading specialty clinic waitlists so they can focus on more complex genetics cases, providing passive education of PCCs about genetic testing processes, and collecting survey and qualitative data from interested parties. Long-term goals include using a population health approach to reach patients who would benefit from a genetics assessment and adding additional genetic counseling foci in response to the needs of PCCs.

A QUESTION LISTING PROGRAM TO SUPPORT PATIENTS BEFORE MEDICAL VISITS

Jai K. Khurana^1,2; Karina J. Mahida^1,2; Brittney Mancini¹; Felisha Marques¹; Karen Sepucha¹; Leigh Simmons^3,1. ¹Health Decision Sciences Center, Massachusetts General Hospital, Boston, MA; ²Harvard University, Cambridge, MA; ³Medicine, Mass General Brigham Inc, Boston, MA. (Control ID #4043250)

STATEMENT OF PROBLEM/QUESTION: We evaluated the implementation of a program where volunteers conduct pre-visit calls to patients to help them prepare for medical visits by creating a Question List to organize questions and concerns.

DESCRIPTION OF PROGRAM/INTERVENTION: Medical visits can evoke feelings of stress and intimidation for patients. This can result in patients missing key details and questions going unanswered. We developed an outpatient Question Listing program at a New England academic medical center to address this problem. Prior research shows that Question Lists can address patient concerns by promoting higher self-efficacy, lowering anxiety, and encouraging patients to ask more questions. Volunteers, who are undergraduate pre-medical students or clinical research coordinators, undergo a comprehensive 8-week training with online modules and simulated patient interactions before conducting patient calls. Volunteers call patients 1-3 weeks prior to their appointment. During the conversation, patients discuss their questions and concerns while volunteers actively use prompts to help patients reflect. Volunteers send a one-page summary of the Question Listing to patients and clinicians within 24 hours. Research Electronic Data Capture is utilized for patient tracking and consent documentation.

MEASURES OF SUCCESS: We recorded key metrics by clinic such as the number of patients called, the number reached, and the uptake rate of the Question Listing service. Preliminary evaluation also includes informal interviews and surveys with providers, volunteers, and patients. Future evaluations will include qualitative and quantitative measures of satisfaction from providers, volunteers, and patients.

FINDINGS TO DATE: We report results from the first 20 months of implementation. 18 volunteers prepared 76 Question Lists with adult primary care and urogynecology patients between January 2022 and August 2023. We reached 52% (342/657) of primary care patients and 22/55 (40%) of urogynecology patients by phone. Of those reached, 20% (69/342) of primary care patients and 7/22 (32%) of urogynecology patients had Question Lists completed. Informal feedback from patients and clinicians finds that the service clarifies patient priorities, saves time during the visit, helps patients identify new questions, and organizes patients’ concerns.

KEY LESSONS FOR DISSEMINATION: Question Listing services can be delivered with trained non-clinical volunteers in primary care and urogynecology clinics. A barrier to widespread use of these services is difficulty reaching patients by phone. Demand for the service was higher in specialty settings compared to primary care, though there was interest in both clinics. We aim to expand services to additional specialty clinics as we anticipate greater patient demand. We encourage developing similar programs to assess patient information needs and support patients.

ASSESSING HEALTH BEHAVIORS AMONG ELDERLY CLIENTS WITH HYPERTENSION AT AN URBAN COMMUNITY CENTER IN QUEENS, NEW YORK – BUILDING A COMMUNITY-BASED INTERVENTION PROGRAM

Natalia Hernandez¹; Ray Chester S. Ambida¹; Sharon Johnson¹; Matthew Leiman¹; Mariecel Pilapil²; Alice Fornari¹; Daniel J. Coletti³. ¹Internal Medicine, Northwell Health, New Hyde Park, NY; ²Medicine and Pediatrics, Northwell Health, New Hyde Park, NY; ³Medicine, Northwell Health, Great Neck, NY. (Control ID #4060778)

STATEMENT OF PROBLEM/QUESTION: Hypertension is a leading preventable cause of cardiovascular disease in the US. Queens is a very diverse county with hypertension disproportionally affecting minorities. The objective of this study is to identify the factors that affect blood pressure (BP) control among senior adults at a community center in Queens, NY and develop interventions to help them achieve better blood pressure control.

DESCRIPTION OF PROGRAM/INTERVENTION: Through a partnership between the Northwell ENHANCE community health Track and the Queens Community House in Forest Hills, NY, resident physicians assessed health related behaviors among community members 65 years of age and older with or without self reported history of hypertension. Our goal was to identify factors that negatively affect BP control and develop community-based interventions to improve knowledge and health related self-efficacy for hypertension. BP monitoring was offered once a week using the guidelines set by the NYSDH. Data was collected through a survey which included demographics, history of hypertension, ability to correctly identify a normal BP range and knowledge of lifestyle modifications associated with better BP control. Based on the findings, a project would be implemented for the community, which aims to improve knowledge and practices on blood pressure control.

MEASURES OF SUCCESS: Improve blood pressure reads in 5 to 10% of the clients, either with or without self reported history of HTN, after education sessions are held at the community house.

FINDINGS TO DATE: Data was collected from a total of 41 older adults, 46% (n=19) had a self-reported history of hypertension. Among those with history of hypertension 47% (n=9) of them had BP readings in the hypertensive range (BP130-139/80-89 mmHg or above) and were not able to correctly identify a normal BP range. Also, 42% (n=8) were not able to identify low salt intake or exercise as lifestyle modification strategy for BP control.

On the other hand, out of the 22 older adults without self-reported history of hypertension, 36% (n=8) were found to have BP readings in the hypertensive range and were not able to correctly identify a normal BP range. Also 36 % (n=8) were not able to identify low salt intake or exercise as lifestyle modification strategies for hypertension control.

KEY LESSONS FOR DISSEMINATION: Poor health literacy about HTN correlates with higher BP measurements among those with and without a diagnosis of HTN. Similarly, lack of knowledge regarding the appropriate lifestyle modifications recommended by the American Heart Association, associates with higher BP readings across both groups. These findings highlight the importance of community-based interventions that aim at educating at-risk populations in blood pressure control.

A TRANSITIONAL CARE MANAGEMENT PROGRAM FOR MEDICARE PATIENTS AT A SAFETY NET HOSPITAL

Ana Sofia Warner^1,2; Erin Nahrgang³; Christine Pace^3,2; Ellen Coletti³; John Goldie³; Dellara Terry¹; Namala Sam³; Li-Yun Wu³; Gregory T. Tomilonus³; Stephanie Pagliuca⁴. ¹Value Based Care, Boston Medical Center, Boston, MA; ²General Internal Medicine, Boston University, Boston, MA; ³Boston Medical Center, Boston, MA; ⁴Geriatrics, Boston Medical Center, Boston, MA. (Control ID #4064076)

STATEMENT OF PROBLEM/QUESTION: From 2019-2021 our hospital’s 30-day readmissions rate increased among patients insured by Medicare, negatively impacting both our patients and our hospital’s quality performance.

DESCRIPTION OF PROGRAM/INTERVENTION: In May 2022 we launched a transitional care management program aimed at reducing 30-day readmissions among patients with Medicare at our academic, safety net medical center. Our program is based on the Transitional Care Management program that was designed by Naylor and colleagues. Patients are eligible for the program if they are admitted to the hospital, are 65 or older, are insured by Medicare, and have a moderate to high readmission risk as determined by our hospital’s proprietary algorithm. Our team includes 2 nurse practitioner (NP) and community wellness advocate (CWA) dyads, a nurse manager and a CWA whose role is exclusively patient outreach and enrollment. Our enrollment CWA meets eligible patients while they are admitted to the hospital, explains our program, obtains consent, and, when possible, coordinates with family members. An NP conducts a home visit within 72 hours of the patient arriving home from the hospital or post-acute care facility. Our team conducts weekly rounds to review all enrolled patients with the physician directors of the program. Patients are enrolled for 30-60 days, during which time they receive weekly outreach and often additional home visits. During the initial home visit the NP completes an assessment of the patient, follows up on any post-discharge items in the discharge summary and with the CWA, screens for SDOH needs and makes sure the patient has any needed follow-up appointments. Our team is able to provide transportation to appointments while patients are enrolled in our program. We also refer patients to community resources such as elder services and meal support programs as necessary.

MEASURES OF SUCCESS: - 30-day readmission rate for patients enrolled in our program compared to a risk-score-adjusted benchmark

- Improvement in the hospital’s Medicare hospital-wide readmission metric to below the national mean

- Successful enrollment in longitudinal programs for eligible patients

FINDINGS TO DATE: From May 2022 to September 2023, 977 patients were outreached, 310 were enrolled, and 150 completed our program. Patients who completed our intervention had a readmission rate of 16.7% compared to a risk-score-adjusted benchmark of 18.2%. The greatest readmission reduction has been among our highest-risk cohort whose readmission rate was reduced from 35.7% to 18.8%.

KEY LESSONS FOR DISSEMINATION: A transitional care management program that incorporates home visits can successfully reduce 30-day readmissions among Medicare patients and improve performance on CMS quality metrics at a safety net hospital.

A TWO-WAY TEXTING INITIATIVE TO IMPROVE EQUITY AMONG PATIENTS WITH POORLY CONTROLLED HYPERTENSION

Maelys Amat¹; Katherine M. Tighe²; Philip Wilson¹; Elisabeth Russo²; Molly Wallace²; Naing Aung^3,1; Leonor Fernandez⁴; Jonathan Li⁴. ¹Internal Medicine, Beth Israel Deaconess Medical Center, Somerville, MA; ²Population Health, Beth Israel Deaconess Medical Center, Boston, MA; ³Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ⁴Medicine, Beth Israel Deaconess Medical Center, Waban, MA. (Control ID #4063809)

STATEMENT OF PROBLEM/QUESTION: Despite hypertension being a chronic condition for which the treatment largely hinges on the collection of blood pressure (BP) readings both in-office and at home, our clinic noted low rates of home blood pressure measurements for all patients and disparities in hypertension control affecting our most underserved patients.

DESCRIPTION OF PROGRAM/INTERVENTION: At our large academic medical center-based primary care clinic, we noted significant disparities in hypertension control, with our most underserved patients being least likely to have adequate BP control. In light of this, we hoped to see if dispensing free blood pressure cuffs to encourage home BP monitoring would help improve hypertension control for this cohort of patients. We first identified our most underserved patients with hypertension, using the proxy of Medicaid health insurance, and dispensed blood pressure cuffs to them at no cost. We then utilized a HIPAA secure two-way texting platform to encourage patients to collect home blood pressures and communicated with them to review recent readings. Our primary care clinic-based population health team assisted in communicating with patients and documenting the BPs in the electronic health record (EHR) for clinicians to review during visits, thereby optimizing the opportunity to improve BP control through self-monitoring of blood pressure (SMBP).

MEASURES OF SUCCESS: Through the implementation of this program, we aimed to increase our overall hypertension control rate from 69% to 75% within 1 year of implementation. For process measures, we also collected data on the percent of patients who were given a blood pressure cuff who responded to text messages, and the percent of patient who replied with a home blood pressure reading.

FINDINGS TO DATE: Of the 199 patients who received a free blood pressure cuff, 116 have received outreach to date. Of the 116 patients who received outreach, 53 (45%) were greater than 65 years of age, 66 (57%) were female, 26 (22%) had limited English proficiency, 17 (15%) identified as Hispanic and 66 (57%) identified as Black/African American. The mean blood pressure in this cohort prior to outreach was 140.9 systolic over 82.0 diastolic. Preliminary data shows a mean difference of -1.4 in systolic blood pressure and of -3.3 in diastolic blood pressure in this patient cohort following text messaging outreach.

KEY LESSONS FOR DISSEMINATION: Early data from our intervention highlights two-way text messaging as a tool that may be used to involve underserved patients with poorly controlled hypertension in their care, thereby improving hypertension control.

BACK TO THE (NOT SO) BASICS: AN AI-DRIVEN APPROACH TO ENGAGING PRIMARY CARE CLINICIANS (PCC) IN PREVENTIVE CARE FOR FAMILIAL HYPERCHOLESTEROLEMIA (FH)

Samir C. Faruque^1,2; Kain Kim¹; David Kulp¹; Shivani Lam¹; Laurence Sperling¹; Danny J. Eapen¹. ¹Internal Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA; ²Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #4059984)

STATEMENT OF PROBLEM/QUESTION: Up to 80% of people in the US living with FH, a potentially life-threatening and under-recognized genetic condition, are undiagnosed and under-treated. This is a population at risk for preventable premature heart and vascular disease.

DESCRIPTION OF PROGRAM/INTERVENTION: The FIND FH^® machine learning algorithm (MLA) has been deployed at several academic institutions to identify individuals with undiagnosed FH based on electronic medical record (EMR) data. However, prior studies have not developed an implementation framework to integrate the algorithm into clinical care with the aim of empowering PCCs. We assessed existing PCC attitudes and familiarity with FH at a single, large academic medical center, as well as barriers to PCC engagement to inform future quality improvement initiatives.

MEASURES OF SUCCESS: A survey was developed for PCCs quantifying baseline knowledge of FH and its disease burden, available diagnostics and therapeutics in FH screening and management, in addition to subjective PCC experiences/practice patterns in treating FH patients. The survey was administered prior to implementation of a novel outpatient EMR clinical decision support tool that enhances the expeditious detection, management, and referral of patients with a family history and/or laboratory measures concerning for potential FH. A workflow was implemented to notify and engage patients identified by the FIND FH^® MLA and their corresponding PCCs.

FINDINGS TO DATE: 70 PCCs consented to the baseline survey with a 79% (n=55) completion rate. PCCs reported a mean of 2.86 patients (SD=4.55) under their care currently diagnosed with FH, but only 40% of these PCCs recommended routine screening of children and first-degree relatives. 53% were aware of the existence of preventive cardiology and lipid specialist services at their institution. 87% identified PCCs as most effective for early detection of FH, but 47% had low-to-average scores on both objective and subjective measures of FH awareness. 25 PCCs whose patients had been flagged by the FIND FH^® MLA were contacted iteratively through the EMR with a 56% response rate. 100% chose to defer care to an outpatient preventive cardiologist over pursuing workup in the primary care setting.

KEY LESSONS FOR DISSEMINATION: Our data demonstrates high PCC interest in FH management; however, all responders deferred next steps to specialist care. This suggests a gap in clinical decision support for PCCs. Future investigation will quantify impact on PCC practice including prescribing behavior, cardiac testing utilization, and referral patterns. Implementation of a novel EMR tool and educational initiative consisting of webinars and clinician-to-clinician telemedicine are planned. Empowering clinicians on the front line of patient care in identifying and treating people living with FH serves as a key strategy to addressing this under-diagnosed and under-treated population. Systems-based approaches to addressing these aims include leveraging EMR-based clinical decision support models and cross-disciplinary partnerships with medical specialists.

BOOSTING RURAL WOMEN VETERANS’ ACCESS TO CARE

Mariam Jacob¹; Jenny K. Cohen^1,2; Tara Stacker¹; Kara Zamora^1,2; Jennifer Childers³; Mayan Bomsztyk^1,3. ¹General Internal Medicine, San Francisco VA Health Care System, San Francisco, CA; ²University of California San Francisco School of Medicine, San Francisco, CA; ³VISN 21 VA Sierra Pacific Network, Pleasant Hill, CA. (Control ID #4062417)

STATEMENT OF PROBLEM/QUESTION: We targeted one VA Health Care System (VAHCS) which is home to 12,139 enrolled Veterans, 31% of whom live in rural areas and 23% are women. Even though women make up a sizable Veteran population, concerns persist that women Veterans are not receiving timely, accessible, high-quality, health services, and prior data show that rural women Veterans face numerous health disparities due to poor access to care.

DESCRIPTION OF PROGRAM/INTERVENTION: To improve access for rural women and transgender Veterans, we created the “Boost Team,” a multidisciplinary telehealth outreach service that links Veterans in one VAHCS to Veterans Health Administration (VHA) services. A nurse practitioner (NP) conducts outreach calls to women and transgender Veterans assigned to this VAHCS and whose addresses are geographically closest to one of the VAHCS’s four rural outpatient clinics. Calls started in September 2022 and are ongoing. During the calls, the NP reviews the Veteran’s electronic health records (EHR) to identify care gaps, uses motivational interviewing to elicit wellness goals, and provides real-time clinical care. To ensure robust and high-quality services and scale Boost, we are conducting a program evaluation including chart review to understand how outreach impacts future engagement in care and the Patient Empowerment, Engagement, Activation Survey (PEEAS), a validated survey tool, to understand how outreach impacts self-efficacy. Veterans who received an outreach call from the Boost NP and received care were invited to take the PEEAS 4-6 weeks after the Boost call.

MEASURES OF SUCCESS: Calls are documented in the EHR, workload credits allocated, and patients did not have a co-pay for the phone encounter. We tracked call attempts, referrals, and labs ordered, and administered patient satisfaction surveys following successful calls. Datasets are stored on a secure VA server.

FINDINGS TO DATE: 9/19/2022 and 12/01/2023, the Boost NP called 586 rural cisgender women and transgender Veterans and spoke with 330 of them. All Veterans who were successfully reached had at least one care need resolved during the call. Most commonly needed services were care coordination/referrals (specialty and primary care). Between April 2023 and July 2023, 33 Veterans participated in the PEEAS. Veterans reported on average 85% agreement or strong agreement in the engagement and activation domains. Chart review is ongoing.

KEY LESSONS FOR DISSEMINATION: VA clinician-led outreach efforts positively impact rural women and transgender Veterans’ engagement in care. Outreach and program evaluation remain ongoing, and we are also piloting related projects based on feedback from Veterans who receive outreach. These auxiliary projects include a national and local peer-facilitated virtual cancer support groups, prenatal care packages, and population health outreach efforts (mammography and toxic exposure screening).

BRIDGING DISPARITIES IN PRECISION CANCER PREVENTION THROUGH UNIVERSAL HEREDITARY CANCER SCREENING AT A FEDERALLY QUALIFIED HEALTH CENTER (FQHC)

Neha Awati¹; Vivian Pan²; Pamela Ganschow¹. ¹Internal Medicine, University of Illinois System, Urbana, IL; ²Cancer Center, University of Illinois Chicago, Chicago, IL. (Control ID #4064948)

STATEMENT OF PROBLEM/QUESTION: Utilization of precision cancer prevention services in primary care is low, and racial disparities exist.

DESCRIPTION OF PROGRAM/INTERVENTION: The MiFamCan Project endeavors to address significant racial, ethnic, and socio-economic disparities in identifying patients at high risk for cancer based on their family history. Research consistently reveals lower utilization of evidence-based cancer prevention services, such as genetic testing, for individuals at risk for hereditary cancer. MiFamCan aims to bridge this gap by implementing universal hereditary cancer screening across a system of Federally Qualified Health Centers.

In-clinic navigators administered an electronic risk assessment tool to all adult patients presenting for a routine primary care visit. Assessments took place after clinic staff roomed the patient but before the provider began the visit and included a health literacy screen to identify patients who required assistance. The tool collected cancer family history and identified patients who met National Comprehensive Cancer Network (NCCN) criteria for genetic testing for hereditary cancer syndromes (e.g., BRCA and Lynch). Navigators then notified providers via secure chat messages in the electronic medical record, and providers placed referrals for patients interested in genetic counseling.

MEASURES OF SUCCESS: Quantitative measures:

- # screened in primary care

- # eligible and referred for genetic counseling

- patient demographics

Qualitative measures:

- semi-structured patient and provider interviews to assess acceptability and feasibility of universal hereditary cancer screening in primary care

FINDINGS TO DATE: From January to December 2023, the MiFamCan Project screened 1216 patients for hereditary cancer risk in 2 primary care clinics. Over 75% of the patients identified as Black (43%) or Hispanic (32%), and 16% were identified as having low health literacy. Of those screened, 242 (20%) patients were eligible and 167 (69%) were referred for genetic counseling. Genetic counseling saw a 3-fold increase in referrals for high-risk cancer services from these 2 clinics in the 6 months before and after implementation. Staff and clinician feedback was gathered to optimize clinical workflow. Provider interviews elicited concerns for feasibility of implementation; however, educational initiatives and tailored workflow enhanced provider acceptability and confidence with implementing universal hereditary cancer risk assessment in primary care. Patient interviews showed positive experiences with MiFamCan and interest in precision cancer prevention in primary care.

KEY LESSONS FOR DISSEMINATION: Precision medicine holds the promise of improving patient care through individualized treatment and disease prevention, yet the adoption of precision cancer prevention initiatives, such as hereditary cancer risk assessment and genetic testing, remains limited. Successful integration of these initiatives into the primary care setting is vital for reaching at-risk populations.

CAN THE UTILIZATION OF GENERATIVE AI CONTRIBUTE TO COST MANAGEMENT WITHIN THE FRAMEWORK OF THE AMERICAN HEALTHCARE MODEL?

Maria Zahid Yusuf¹; Mesrop Aleksanyan¹; Wanda Saleh¹; Nejla Findik Kaya¹; AliAsghar Diwan²; Arslan A. Cheema¹; Ashkan Eighaei Sedeh¹. ¹Internal Medicine, Capital Health Regional Medical Center, Trenton, NJ; ²Emergency Medicine, Capital Health, Trenton, NJ. (Control ID #4044811)

STATEMENT OF PROBLEM/QUESTION: The annual US healthcare expenditure reached 4.3 trillion dollars in 2021, approximating $12,900 per capita. Despite this, the US has surpassed by other countries in healthcare outcomes, ranking at the 11^th position. Thus, it is critical to re-assess the current healthcare delivery model to optimize healthcare spending.

DESCRIPTION OF PROGRAM/INTERVENTION: The use of generative AI, particularly ChatGPT, continues to attract significant attention in the healthcare sector. This powerful tool, however, needs further evaluation for its potential role in healthcare management and in optimizing expenditure. This study aims to evaluate the novelty and effectiveness of the recommendations generated by ChatGPT for reducing healthcare delivery costs in the US.

MEASURES OF SUCCESS: This non-human subject study was initiated with 3 study staff independently running the following prompt through ChatGPT: “What are the current strengths and weaknesses of the American healthcare delivery model?” A cross-reference of the proposed strengths and weaknesses with the existing literature was performed to authenticate response validity. High cost was selected as the primary drawback for further analysis of the proposed weaknesses. ChatGPT was asked to offer solutions to reduce costs by utilizing the proposed strengths, using the following prompt: “Propose innovative ways that an increased emphasis on "insert strength here" can reduce healthcare delivery costs in the US.” The generated recommendations were again cross-referenced with the literature to assess for novelty. A novel recommendation was one with no current studied implementation. Novel recommendations were evaluated for practicality and categorized into practical or impractical. If a recommendation was already in practice, the scale of the cross-referenced study was assessed. Effectiveness was classed as indeterminate if a recommendation was backed up by a single-center study, while those backed up by multi-center studies were categorized as effective or ineffective. An effective recommendation was one with an evidence-based impact on reducing healthcare costs.

FINDINGS TO DATE: Four questions on hypothetical solutions to lower healthcare delivery costs were generated, and prompts were inputted into ChatGPT, resulting in 20 recommendations. Upon reviewing the literature, 20 % (4/20) of the proposed suggestions were classed as novel, of which 100% (4/4) were deemed practical. Furthermore, 80% (16/20) of recommendations were identified to be already in use, of which large multicenter studies were available for 68.8% (11/16), with 72.7% (8/11) of these recommendations being effective vs 27.3% (3/11) ineffective in reducing healthcare delivery costs. Only small-scale single-center studies were available for the remaining 31.2% (5/16) of recommendations that were already in use, and their effectiveness was classed as indeterminate.

KEY LESSONS FOR DISSEMINATION: ChatGPT has the potential to contribute to healthcare management by providing innovative and evidence-based solutions to address the escalating healthcare costs.

CLOSING THE GAPS IN PAPS: REDUCING DISPARITIES IN CERVICAL CANCER SCREENING

Akemi L. Brown, Mike K. Cheng. Division of General Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4064118)

STATEMENT OF PROBLEM/QUESTION: Patients on UCSF resident primary care panels had lower cervical cancer screening rates compared to faculty panels (60.7% vs. 65.4%) as of October 2022 with Spanish-speaking patients having the lowest rates (52.9% vs. 75.6%).

DESCRIPTION OF PROGRAM/INTERVENTION: Our resident-driven project occurred in 2022-23 at UCSF's Division of General Internal Medicine Clinics where residents and faculty have primary care panels. Utilizing Lean, we performed a root cause analysis identifying barriers to cervical cancer screening in resident clinics and particularly for Spanish-speaking patients. Types of barriers included: (1) Process (providers struggle to generate a list of patients due for screening, unreconciled outside records, patient reminders sent in English language only), (2) Environmental/Contextual (limited appointment times especially if need language interpretation), and (3) Provider (avoidance of Pap smears by inexperienced providers, patient preference for female-identifying providers). We developed four interventions: (1) Leadership buy-in for extended visit times for Pap smears, (2) provider outreach using Epic population health tools to identify patients due for Pap smears with instructions for reconciling outside records, (3) patient outreach messages in English and carefully translated into Spanish, and (4) partnership with nurse practitioners to increase access for Pap smear visits.

MEASURES OF SUCCESS: We measured number of resident providers, total patients reached, and Spanish-speaking patients reached via the interventions. We then measured percentage of all patients and Spanish-speaking patients on resident panels who were up-to-date on cervical cancer screening post-interventions compared to those on faculty panels.

FINDINGS TO DATE: The interventions reached 72 residents, 826 total patients on resident panels, and 12 Spanish-speaking patients. After the interventions, up-to-date cervical cancer screening increased from 60.7% to 70.7% for all patients and 52.9% to 70% for Spanish-speaking patients on resident panels from Oct 2022 to May 2023. The relative difference in screening between resident and faculty panels decreased among all patients from 4.7% to 4.0% less among resident panels and among Spanish-speaking patients from 22.7% less in resident panels to 3.7% more in resident panels.

KEY LESSONS FOR DISSEMINATION: Our resident-driven project successful decreased disparities in cervical cancer screening between patients on resident panels compared to faculty panels, particularly among Spanish-speakers. Our project showed the utility of Epic population health tools for identifying disparities among patient care (e.g. by provider type, by language) and simplifying targeted outreach to patients affected by these disparities. We learned the value of partnering with interpreter services to account for nuanced cultural differences when translating into other languages. Lastly, utilizing a root cause analysis approach was helpful to identify barriers to Pap smear screening to make a compelling case to gain buy-in from leadership.

CREATING REPRODUCTIVE EXAMS AND SERVICES (CARES) FOR PEOPLE WITH DIFFERENT ABILITIES IN PRIMARY CARE

Jennifer LeC. RISN, Rowan University, Glassboro, NJ. (Control ID #4065066)

STATEMENT OF PROBLEM/QUESTION: People with intellectual, developmental (IDD) and physical disabilities do not have the same access to routine reproductive health services, such as cervical and breast cancer screenings, sexuality education or opportunities to make informed decisions about contraception and family planning. People with IDD also have a higher likelihood of experiencing sexual abuse.

DESCRIPTION OF PROGRAM/INTERVENTION: In this session, we have created educational materials to promote best practices and provide culturally competent, gender-inclusive reproductive healthcare to patients with IDD and physical disability. We will review the barriers to healthcare for this vulnerable population. We will introduce the CARES Manual which includes flyers for educating primary care physicians and their patients about accessing reproductive healthcare. The manual includes tools for understanding who should be screened for cervical and breast cancer, how to screen for abuse, how to collect sensitive information about sexuality and sexual history and creating a more accessible and inclusive environment for people with intellectual, developmental and physical disabilities.

MEASURES OF SUCCESS: Improved access to reproductive and gynecological care for people with IDD and physical disabilities will show increased gap closure for cervical cancer and breast cancer screenings for this population. Feedback from patients about their experience with receiving care after education and development and utilization a treatment plan that is individualized.

FINDINGS TO DATE: Successful experiences of people with IDD getting cervical and breast cancer screenings with positive feedback about their experience. We have several clinical cases to demonstrate and articulate positive experiences.

KEY LESSONS FOR DISSEMINATION: Primary Care Physicians will be able to access the CARES manual and flyers to display in their offices to educate their patiets about asking for support for reproductive and gynecologic care.

DEVELOPMENT OF A HOSPITALIST-RUN SHORT-STAY UNIT TO IMPROVE THROUGHPUT

Jung M. Park. Medicine, Emory University, Atlanta, GA. (Control ID #4057554)

STATEMENT OF PROBLEM/QUESTION: Traditional emergency department (ED)-run clinical decision/observation units encounter patient intake challenges due to the growing complexity of comorbidities and socioeconomic factors, prompting the need for a more flexible and inclusive approach to enhance patient intake and throughput management within the healthcare setting.

DESCRIPTION OF PROGRAM/INTERVENTION: We created a hospitalist-run short-stay Inpatient Observation Unit (IOU) in October 2022 at a large academic medical center to decompress the ED and improve patient throughput. The IOU is a closed 10-bed telemetry-/intermediate care capable unit, adjacent to the ED, staffed by 1 hospitalist and 1 Advanced Practice Provider (APP). The ED calls the IOU hospitalist directly for possible admission, who determines patient selection and admission by judging whether the patient can be discharged within 48 hours and an internal tip sheet with exclusion criteria. Patients are assigned “inpatient” or “observation” status, depending on medical necessity. The IOU assigns necessary testing priority to patients and facilitates patient progression.

MEASURES OF SUCCESS: ED throughput improvement is assessed by comparing IOU vs non-IOU medicine patients’ median time from admission order placement to the patient leaving ED/checking into a unit. Patient progression improvement is measured by comparing length of stay (LOS) of common primary diagnoses among IOU vs non-IOU medicine patients. We assessed utilization of inpatient vs observation status pre and post IOU implementation.

FINDINGS TO DATE: Preliminary data from November 2022 to October 2023 show a median time from admission order to ED exit of 207 minutes for IOU patients vs 720 minutes for medicine patients, a 71.25% efficiency gain. When comparing LOS of common primary diagnoses among IOU patients vs non-IOU patients admitted with the same primary diagnosis, “syncope and collapse” LOS for IOU patients is 1.97 days vs non-IOU patients’ 2.92 days; “acute kidney failure” LOS for IOU patients is 1.40 vs 3.80 for non-IOU patients; “hypertensive heart disease with heart failure (HF)” for IOU patients is 2.12 vs 4.33 for non-IOU patients; and “hypertensive heart and chronic kidney disease (CKD) with HF and stage 1 through stage 4 CKD” for IOU patients is 2.25 vs 4.79 for non-IOU patients.

The IOU increased utilization for observation status patients by ~19%: the mean number of patients in observation status was 108 before IOU implementation (January-September 2022) and 133 after (November 2022-October 2023).

KEY LESSONS FOR DISSEMINATION: The hospitalist-run short-stay IOU captures improves ED throughput and patient progression via more inclusive/flexible admission criteria. This accommodates a broader range of patient conditions, optimizes resource utilization, alleviates ED congestion, and improves overall hospital efficiency. Interdisciplinary collaboration among hospitalists, emergency physicians, and other healthcare professionals is also key in ensuring this model is successful, given patients’ diverse acuity levels and complex comorbidities.

DOCTOR, THE PATIENT IS READY: ENHANCING THE CHECK-IN AND ROOMING PROCESS AT A PRIMARY CARE OFFICE.

Sara Gianfagna, Melissa Mroz. Internal Medicine, University of Rochester Medical Center, Rochester, NY. (Control ID #4031053)

STATEMENT OF PROBLEM/QUESTION: Inefficiencies in the check-in and rooming process led to longer patient wait times and decreased staff satisfaction.

DESCRIPTION OF PROGRAM/INTERVENTION: The check-in and rooming process at a Mid-Atlantic academic outpatient primary care office was studied. Providers included attendings, residents and advance practice providers, providing care for about 2,600 patients per month. In March 2023, the average patient wait time to be ready for the provider was 8 minutes, n=2,682. Additionally, 11% of patients were waiting 21 minutes or more to be ready for their provider, n=2,686.

Inefficiencies were observed in the rooming process including printing encounter stickers with demographics, alerting patient care technicians (PCTs) of patient arrival, and notifying providers patients were ready.

The process changes were: 1) removing stickers at check-in, transitioning to an entirely electronic rooming process 2) assigning PCTs to specific providers rather than working in a rotating fashion.

A smaller subgroup was used for an initial pilot, including 2 PCTs and 10-20 providers, depending on the day. After 2 months of initial success, it was expanded clinic wide, to 6 PCTs and all 117 providers.

From March until August 2023, data was collected in the form of wait times. This was obtained through the electronic record at the time of check-in (at or after the time of the scheduled visit), until marked as “waiting” for the provider, signifying patients had vitals completed and were ready to be seen by the provider. The times did not account for extra time waiting if providers were running late for appointments.

After the process change, providers and staff were given a survey to get data on satisfaction.

MEASURES OF SUCCESS: 1. Comparing rooming times before and after

2. Surveying staff satisfaction

FINDINGS TO DATE: Wait times overall decreased. The average wait times for March, June, July and August 2023 were: 8 minutes (n=2,686), 5.6 minutes (n=2,472), 5 minutes (n=2,241), and 4.3 minutes (n=2,566), respectively. 11% waited 21 minutes or more in March 2023 (n=2,686), which decreased to 5% in August 2023 (n=2,566).

94% of those surveyed (n=29) were “satisfied” or “very satisfied” with the changes, citing improved wait times and team member communication. 93% surveyed (n=28) felt the process was “somewhat” or “significantly faster,” and 7% felt it was “somewhat slower.”

66% of those surveyed liked being entirely electronic, while 34% wished stickers remained. Reasons cited were delays in printing stickers for labeling specimens, and the lack of a patient identifier and not seeing the vitals before entering the room, which were historically written on the sticker.

Survey feedback on areas for improvement included increasing the number of PCTs and training all PCTs in phlebotomy to aid in efficiency and lab completion.

KEY LESSONS FOR DISSEMINATION: Changing the rooming process decreased wait times and increased satisfaction. Efficiency and communication improved and the number of opportunities for human error and HIPPA violations decreased.

ELEVATING THE ROLE OF THE GENERAL INTERNIST IN PRIMARY CARE

Sabrina Felson^1,2; Craig T. Tenner^1,2; Katherine Laurenzano³; Scott Sherman^1,2. ¹Medicine, VA New York Harbor Healthcare System, New York, NY; ²DGIMCI, New York University, New York, NY; ³Central Office of Primary Care, Veterans Health Administration, Washington, DC. (Control ID #4064619)

STATEMENT OF PROBLEM/QUESTION: As primary care is being increasingly delivered by advanced practice providers (APPs), internists must differentiate a unique skill set.

DESCRIPTION OF PROGRAM/INTERVENTION: Medical trainees are increasingly less likely to choose a career in primary care, making it harder to find a primary care doctor.

While most proposed solutions focus on the need to offload tasks from overburdened physicians, the onloading of meaningful responsibilities to increase provider satisfaction is equally important. Just doing less of what we do now will not entice medical graduates into primary care.

To enhance our professional scope, we propose incorporating technologies like POCUS and AI, as well as deepening our dexterity with panel management and team leadership. Physicians should focus on patients with complex medical needs and facilitate interdisciplinary medical communication between our subspecialists. APPs, while independently managing a panel, might consult the team physician for diagnostic or management challenges before referring for subspecialty care. The more unique proficiencies the general internist can offer, the more expansive and satisfying the professional identity.

Since 2010, the VA has led the country in team-based primary care delivery through its medical home model called Patient Aligned Care Teams (PACT). While the VA’s original PACT model stipulated a physician lead each team, APPs presently oversee 31% of teams across the enterprise. Grappling with this widening physician shortage, the Central Office of Primary Care piloted three PACT modernization pilots. Each model aimed to extend the reach of the physician—the limited resource—by adding additional panels managed by an APP. They deferred addressing the division of labor between APP and MD on the team.

We plan to use a variation on one of the PACT modernization pilots as a venue to explore clinical and delivery innovations and technology advances with specific attention to physician exclusive responsibilities. The VA’s already functional team-based medical home allows us to provide primary care to veterans that satisfies VA standards, while we explore patient and provider-driven changes in a medical home dedicated to advancing primary care. Our priority is to reinvigorate the primary care internist with a sense of competence, intellectual satisfaction, and meaningful service.

MEASURES OF SUCCESS: Apply VA panel management tools to IM-PACT (Internal Medicine PACT). Provider surveys and work week mapping.

FINDINGS TO DATE: Preliminary results from the VA's PACT modernization project

Current ratio of patients cared for by APPs and MDs in PACT

VA Central Office of Primary Care and NYU DGIMCI are interested in IM-PACT

KEY LESSONS FOR DISSEMINATION: Instead of focus only on removing responsibilities, we should selectively add to what internists can uniquely offer. Let’s elevate our professional identity.

Primary Care innovation requires a flexibility that the VA is uniquely situated to provide by virtue of its size, capitated payment structure, integrated subspecialities, and strong commitment to primary care.

ENHANCING DELIVERY OF EVIDENCE-BASED OBESITY CARE IN A LARGE ACADEMIC PRIMARY CARE PRACTICE WITH A GLUCAGON-LIKE PEPTIDE 1 AGONIST (GLP-1) WEIGHT MANAGEMENT PATHWAY

Alexa M. Triot¹; Cancan Zhang¹; Naing Aung¹; Kelly Graham². ¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4054681)

STATEMENT OF PROBLEM/QUESTION: In our large academic primary care practice with 37,291 patients, obesity poses a significant health challenge, affecting 32.3% (12,050 patients) who have a BMI ≥30. This group faces higher rates of comorbidities such as type 2 diabetes, hypertension, and fatty liver/NASH. This group also has higher rates of patients who identify as black, have public insurance and have low social support. The need for effective obesity management is paramount, given its associated morbidity and mortality. However, the utilization of GLP-1 agonists (GLP-1s), which are effective and safe for treating obesity, is limited by barriers including resource-intensive initiation and frequent visits.

DESCRIPTION OF PROGRAM/INTERVENTION: To tackle these challenges, we conducted a comprehensive needs assessment and developed the GLP-1 Weight Management Pathway. This innovative intervention, customized for our diverse practice that includes 60 faculty members, 110 internal medicine residents, around 50 medical students, and nurse practitioners, was trialed in our medical student-faculty clinic. It focuses on streamlined GLP-1 initiation and titration, aiming to enhance prescribing efficiency and improve patient health outcomes. The pathway was designed to be integrated seamlessly into our existing healthcare framework, providing a structured approach to weight management.

MEASURES OF SUCCESS: We evaluated the success of our intervention using several metrics: the number of GLP-1 prescriptions issued, provider comfort and knowledge in discussing weight management, and patient engagement in the pathway. We also aimed to overcome stigma and other barriers to weight loss conversations among providers, a crucial aspect for the successful implementation of the pathway.

FINDINGS TO DATE: Among our obese patient cohort, only 1,547 (12.8%) had been prescribed GLP-1s. While 68.2% of providers felt comfortable discussing weight loss, just 47% were discussing pharmacotherapy options. Our pilot program referred 35 patients, with 17 participating in the pathway. To date, 65% of these participants (11 of 17) continue on GLP-1 therapy for an average duration of 28.7 weeks. These patients achieved a mean weight loss of 11.9 lbs, with an average total body weight loss of 5.5%.The 6 patients who discontinued GLP-1 therapy did so due to insurance coverage and/or medication shortages.

KEY LESSONS FOR DISSEMINATION: The needs assessment and pathway findings underscore the necessity for a multimodal approach to GLP-1 prescribing, which includes addressing provider knowledge and comfort, managing the time-intensive aspects of medication initiation, and addressing prescribing barriers such as the requirement for prior authorization. The pathway showed promise in patient engagement and significant weight loss outcomes. Its integration into a student-faculty clinic enhanced patient care and enriched the educational experience for medical trainees. The adaptability and scalability of our pathway for broader application in primary care settings provide valuable insights for future obesity management models.

EXAMINING VACCINE HESITANCY TRENDS IN AN UNDERSERVED POPULATION AT A STUDENT-RUN FREE CLINIC

Hasti Nema, John Pum, Cameron Bear, Dhiraj Tadikamalla. Department of Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4049837)

STATEMENT OF PROBLEM/QUESTION: In 2019, the World Health Organization (WHO) included “vaccine hesitancy” and “a global influenza pandemic” among the top ten threats to global health. Since the start of the COVID-19 pandemic, the expedited approval of the novel mRNA vaccine and the misinformation surrounding its safety and efficacy have exacerbated these threats, contributing to widespread vaccination hesitancy. This rise in the COVID-19 vaccine distrust has consequently led to further hesitancy among other immunizations, specifically the influenza vaccine. A post-COVID systematic review of vaccine hesitancy found that only 69% of individuals were accepting of the influenza vaccine. Those who declined noted reasons including vaccine distrust, safety concerns, and doubts about the effectiveness.

DESCRIPTION OF PROGRAM/INTERVENTION: This study investigates whether a parallel trend exists regarding influenza vaccination within a Student-Run Free Clinic (SRFC) in midtown Detroit, focusing on an underserved population disproportionately affected by the pandemic. Patients included were individuals 18 or older who received the influenza vaccine at Cass Clinic from 2013 to 2022. Data collected through optional pre-vaccination surveys involved 248 individuals divided into "pre-COVID" (2012-2019, n=193) and "post-COVID" (2020-2022, n=55) groups.

MEASURES OF SUCCESS: Surveys were conducted to understand patient decision-making factors and how SRFCs are bridging the gap in providing vaccination care. Data included the following: demographic information (age, race, sex, employment, and health insurance), as well as whether they had previously received the vaccine, how often they received it, if they would have gotten the vaccine at a different location, whether they thought it was valuable, if they had concerns about the vaccine, and whether those concerns affected their decision to receive the vaccine. T-tests and z-tests were used for statistical analysis, with significance set at p < 0.05.

FINDINGS TO DATE: Within pre-COVID years, 42.55% (CI 41.29% +/- 7.82%) of patients receiving flu vaccination had concerns and 15.09% (CI 17.37% +/- 11.29%) of patients had concerns post-COVID, which demonstrates a significant decrease in vaccine concerns among the Cass patients (p=0.00019, <0.05). Furthermore, within pre-COVID years, the mean percentage of patients reporting no concerns was 57.55% (CI 58.71% +/- 7.82%) whereas post-COVID, the mean was 84.91% (CI 79.60% +/- 9.78%).

KEY LESSONS FOR DISSEMINATION: Contrary to the global trend, Cass Clinic observed a noteworthy reduction in vaccine hesitancy post-COVID, highlighting the distinctive role of SRFCs in fostering vaccination adherence, especially among vulnerable and underserved populations that were hit the hardest by the recent pandemic. This unexpected divergence prompts further investigation into the clinic's effective strategies, contributing valuable insights to public health efforts aiming to promote vaccination in marginalized communities and bridging the gap in the quality of healthcare and the vaccine education the patients receive.

EXPANDING INTERNIST-LED TREATMENT ACCESS FOR HOSPITALIZED ADULTS WITH OPIOID USE DISORDER IN TEXAS

Christopher Moriates¹; Alanna Boulton²; Richard Bottner³; John Weems^2,4; Nicholaus Christian⁵; Taylor Bazajou⁶; Carma Deem Bolton⁶; Karns-Wright E. Tara⁶; Holly J Lanham Lanham⁷; Erin Finley⁷; Jennifer Potter⁶. ¹Medicine, University of California Los Angeles, Los Angeles, CA; ²Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ³Colorado Hospital Association, Greenwood Village, CO; ⁴Addiction Medicine, CommUnityCare, Austin, TX; ⁵Office of the Clinical Director, National Institute on Drug Abuse, Gaithersburg, MD; ⁶Be Well Texas, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ⁷The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4015867)

STATEMENT OF PROBLEM/QUESTION: Approximately 20% of hospitalized patients have substance use disorder (SUD). Despite being safe and effective, pharmacotherapies for SUD are underutilized in hospitals, especially in Texas, due to lack of training, structures, and organizational cultures to support evidence-based care.

DESCRIPTION OF PROGRAM/INTERVENTION: In 2017, we launched the first hospital-based opioid use disorder (OUD) treatment program at an academic safety-net hospital in Austin, Texas which leveraged an internist-led multidisciplinary team to screen and treat OUD as part of standard of care. Based on initial success, we obtained funding from Texas Health & Human Services to spread the model to other hospitals in Texas through the Support Hospital Opioid Use Disorder Treatment (SHOUT) Texas program. Our implementation approach combined training, tailoring, and technical assistance following the Replicating Effective Programs (REP) strategy with statewide Telementoring delivered via Project ECHO.

MEASURES OF SUCCESS: To evaluate the spread and adoption of the SHOUT Texas model to four diverse sites using an integrated REP-ECHO implementation approach we measured 1) number of participating hospitals, 2) number of patients screened for OUD, 3) number of patients started on medications for OUD, and 3) number of patients discharged with coordinated outpatient care. Additionally, qualitative interviews were conducted with eight key stakeholders at expansion sites to identify strengths and weaknesses of the implementation strategy and supports and barriers to successful program implementation.

FINDINGS TO DATE: From 2020 to 2023 at the original hospital site, 644 patients were screened for OUD, 439 (68%) were started on buprenorphine therapy, and 375 (85%) of those patients were discharged with coordinated outpatient care. In 2022, the SHOUT Texas program was spread to and adopted in three diverse Texas hospital sites, who have screened an additional 7149 patients for OUD, started 3065 (42%) of them on buprenorphine, and discharged 795 (26%) of those with coordinated care.

Insights from data analyses and stakeholder interviews inform future adjustments for sustainability and further growth and are described in the Key Lessons for Dissemination section.

KEY LESSONS FOR DISSEMINATION: Internists and internist-lead teams can promote an increase in screening at treatment of OUD for hospitalized patients even in the absence of existing structural support or clinicians with addiction-specific expertise.

Implementation of the SHOUT Texas model across diverse hospital settings using REP and Project ECHO resulted in significant provider engagement and rapid increase in the number of patients initiating OUD treatment during hospitalization.

Participants identified prepared training resources, in-person launches, relative ease of roll-out, and collaboration with other Addiction Medicine physicians as supportive of SHOUT program implementation. Barriers included challenges in identifying outpatient follow-up for patients, aligning with local pharmacy and medication policies, and nursing education.

FEASIBILITY OF INTEGRATING PRIMARY CARE SERVICES INTO A SUBSPECIALTY PSYCHIATRY CLINIC

Amber K. Brown Keebler. Internal Medicine, University of Nebraska Medical Center, Omaha, NE. (Control ID #4065001)

STATEMENT OF PROBLEM/QUESTION: Patients with psychotic disorders often access and receive inadequate primary healthcare services.

DESCRIPTION OF PROGRAM/INTERVENTION: Primary care services were integrated into an existing academic subspecialty team-based psychosis clinic that included disciplines of psychiatry, psychology, social work, and nursing. Patients receiving these services were given the option to either establish or switch their primary care services to that provided in this integrated setting. Goals of the program include increased primary care encounters for patients, increase preventative services, increase cardiovascular risk assessment and implementation of primary prevention, effective collaboration of a multi-disciplinary team, and strengthen relationships bewteen psychiatry and internal medicine specialties.

MEASURES OF SUCCESS: Numbers of patient encounters per year are measured to determine continuing feasibility of patient participation and qualitative evaluation of provider satisfaction (both psychiatry and primary care) by verbal feedback. Future measures will include patient engagement, completion of preventative services (screenings, immunizations, and cardiovascular risk assessments), objective collaborative practice assessments, as well as healthcare utilization (ED Visits and Hospitalizations).

FINDINGS TO DATE: To date, patient volume has increased from 24 encounters in 2021, to 116 encounters in 2022, to 236 encounters in 2023. Clinic time allocated for primary care services has increased from 6 hours per month (two afternoon sessions) to 24 hours per month (four afternoon sessions). Provider response has been overwhelmingly positive and has resulted in continued growth of the integrated primary care service as evidenced by ongoing referrals for patients to establish primary care in this model. Provider comments include improved satisfaction in team communication, coordination of patient care, increased quality of care, and strengthened relationships with other providers.

KEY LESSONS FOR DISSEMINATION: Integration of primary care services in an academic subspecialty clinic is feasible based on these early findings.

FROM BUSTLE TO BRILLIANCE: TRANSFORMING ONE OF THE BUSIEST NON-ACADEMIC HOSPITALS INTO AN ACADEMIC CENTER AND ITS IMPACT ON QUALITY OF CARE

Joshua Tsai, Daniela Carralero-Somoza, Juan C. Rivera Martinez, Vivek I. Patel, Luis Daniel Lugo Rosado. Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4064882)

STATEMENT OF PROBLEM/QUESTION: Is there a successful approach to effectively transition a non-teaching hospital into an academic center that prioritizes the quality of patient care and resident education?

DESCRIPTION OF PROGRAM/INTERVENTION: Implementing a geolocation system in a busy hospital is crucial for integrating new resident physicians, centralizing patient care, and allocating specific wards for resident-led care. This model, led by new resident physicians, not only enhances multidisciplinary collaboration across hospital departments but also optimizes communication and streamlines transitions of care. Three inpatient teaching teams care for assigned “geolocated” units. A dedicated admitting resident team refines patient care management, ensuring timely admissions without disrupting inpatient workflows.

MEASURES OF SUCCESS: The research aimed to evaluate the efficacy of the recently implemented geolocation program through the analysis of several key variables. Specifically, the Length of Stay (LOS) in the geolocated unit was scrutinized over two distinct periods: January to June (before the introduction of the geolocation system) and July to November (following the implementation).

FINDINGS TO DATE: The research evaluates the geolocation program's efficacy, focusing on Length of Stay (LOS). Analysis over two periods shows the LOS decreasing from 5.32 to 4.5 days post-implementation. Floors lacking resident care had an average LOS of 5.3 and 5.15 days.

Findings suggest a positive impact of geolocation on LOS, correlating with resident presence. Additional data on adjusted LOS, severity of illness, and mortality risk await analysis.

KEY LESSONS FOR DISSEMINATION: Enhanced training experience via centralization fosters a cohesive care environment, emphasizing teamwork, familiarity, and rapid response. By confining care to a designated area, residents efficiently manage their patient’s needs, collaborate seamlessly with ancillary staff, respond to codes, and cultivate deeper patient-physician relationships. Moreover, residents provide quicker interventions and coordinated approaches for patient management.

This model underscores the importance of proximity, communication, and collaborative care in optimizing patient outcomes and resident training experience. Monitoring geolocated areas can provide valuable data on patient interactions, helping in future planning and resource allocation.

Beyond the observed advantages of enhanced centralized geolocations, there exists a broader spectrum of metrics warranting exploration. Factors such as rapid response rates, adverse effects mitigation, and readmission statistics present areas ripe for further quantitative investigation. Downstream organizational benefits including multidisciplinary continuity, camaraderie, and inter-team culture can also be explored qualitatively. Such insights could provide invaluable guidance for the adoption and refinement of this model across diverse residency programs to elevate the standard of care.

IDENTIFYING AND ADDRESSING CARDIOVASCULAR DISEASE RISK IN A RESOURCE-LIMITED AREA: A PILOT APPROACH USING A NON-LABORATORY TOOL AND COMMUNITY HEALTH CARE WORKERS

Sai Santhosha Mrudula Alla¹; Muneesh Seepana²; Sai Sri Hari Paruchuri³; Deekshitha Alla¹; Dhruv J. Shah⁴; Anju Pradeep⁵; Pahel Agarwal⁶; Khushboodeep Kaur^7,8; Moksh Sanjay Khetan⁹; Antony Joseph Pathinangil¹⁰; Vagdevi Moparthi³. ¹Department of General Medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India; ²Department of General Medicine, Guntur Medical College, Guntur, Andhra Pradesh, India; ³Department of General Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, India; ⁴MCPHS University, Boston, MA; ⁵Department of General Medicine, Kasturba Medical College Manipal, Manipal, Karnataka, India; ⁶Department of General Medicine, Bhaskar Medical College and Bhaskar General Hospital, Hyderabad, Telangana, India; ⁷Baba Farid University of Health Sciences, Faridkot, Punjab, India; ⁸Government medical college, Amritsar, Amritsar, Punjab, India; ⁹Vedantaa Institute of Medical Sciences, Dahanu, Maharashtra, India; ¹⁰Department of General Medicine, MGM Medical College, Navi Mumbai, Maharashtra, India. (Control ID #4038829)

STATEMENT OF PROBLEM/QUESTION: With an epidemiological transition in developing nations, there has been an increasing prevalence of non-communicable diseases (NCD) that have even infiltrated rural communities (RC). These NCD, especially cardiovascular diseases (CVD), remain undetected in the rural masses, causing high mortality. The limited availability of trained healthcare professionals, poor health equipment in rural settings, and sparse transportation connectivity deprive rural masses of access to proper screening services. Moreover, the added burden of low socioeconomic status, and underdeveloped healthcare infrastructure further hamper rural healthcare services. Thus, a comprehensive understanding and addressing of the risk factors of CVD are imperative for effectively managing its impact on public health in RC.

DESCRIPTION OF PROGRAM/INTERVENTION: We created a low-cost, non-invasive tool for rural CVD risk screening using WHO Society of Hypertension charts. This tool estimates 10-year CVD risk based on age, sex, blood pressure, BMI, smoking, tobacco chewing, alcoholism, and DM. In a South Asian rural health center, community health workers used the chart in outpatient settings. Patient age and systolic blood pressure determine risk on the chart, visually represented by a color scheme (dark green to red). The intersecting cell value indicates expected 10-year CVD risk. High-risk participants were referred to tertiary hospitals for further evaluation. Community health workers provided counseling on lifestyle modifications, addressing smoking, alcohol, hypertension, diabetes, exercise, and diet.

MEASURES OF SUCCESS: - We evaluated the study population for CVD risk factors and categorized them based on 10-year CVD risk.

- This non-invasive screening tool proves to be an efficient, safe, cost-effective, and patient-friendly diagnostic method that can be used in rural communities with minimal training.

- The tool aids in the early detection of CVD, enabling timely intervention and treatment, potentially enhancing patient outcomes.

- This tool has been instrumental in counselling individuals with high and moderate risk of CVD.

FINDINGS TO DATE: The project screened about 350 individuals, in the age group of 40-70 years from September 2023 to November 2023. Till date 3.44% of individuals had a high CVD risk, i.e. 20% to 30% risk of developing CVD in the next 10 years. 19.54% had a moderate CVD risk, i.e. 10% to 20% risk of developing CVD.

KEY LESSONS FOR DISSEMINATION: The tool is a cost-effective, simple, and handy measure that evaluates 10-year risk for major cardiovascular outcomes. It can be used in heterogeneous settings and also help categorize populations into different CVD risk categories. This categorization helps in providing more care and counselling to high-risk populations. This helps in preventing both fatal and non-fatal CVDs at the primary care level in resource-limited areas. The tool proves to help implement timely preventive measures to improve the life expectancy, and quality of life of the risk groups, and reduce the burden on the health system

IMPLEMENTATION OF AN AUTOMATED PRE-VISIT PLANNING TOOL IN AN ACADEMIC INTERNAL MEDICINE PRACTICE

John C. Matulis. Community Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4065258)

STATEMENT OF PROBLEM/QUESTION: Contemporary primary care practices are tasked with delivering a multitude of preventive services in addition to acute and chronic disease management. Without a structured process of pre-visit planning, which is traditionally time and labor intensive, important concerns are often unaddressed during chaotic office visits.

DESCRIPTION OF PROGRAM/INTERVENTION: At Mayo Clinic, Rochester, MN a novel Electronic Health Record (EHR) tool has been designed and implemented within our Internal Medicine practice to close overdue care gaps, prior to a scheduled patient appointment. The EHR tool can automatically accomplish the following without care team member involvement: communicate identified care gaps, place relevant orders, and instruct patients to self-schedule tests prior to an upcoming preventive health office visit. An agenda of the patient's most pressing concerns is also solicited and submitted to the care team to review prior to the appointment. This tool allows for all identified preventive services to be reliably scheduled and completed prior to the physician appointment. This automated approach to pre-visit planning has the potential to increase the value of the office visit, reduce physician in-basket burden and associated asynchronous patient communication while allowing more time during the visit to discuss patient specific health concerns, and to address social determinants of health.

MEASURES OF SUCCESS: 1. Patient and physician acceptability- survey regarding the value add, ease of use, and any unintended increase in workload and fragmentation from both patient and physician perspective.

2. Completion rate of recommended preventive health services and chronic disease surveillance prior to the scheduled appointment.

2. Rate of completion of Medicare Annual wellness visits prior to regularly scheduled patient office vistis.

FINDINGS TO DATE: The EHR innovation wa designed and tested in the Fall of 2023, and with some modifications has been implemented into the practice. Assessments of patient and care team acceptability, preventive service completion rate, and patient and physician perspectives on time available in the visit will be forthcoming in Q4 2023 and q1 2024.

KEY LESSONS FOR DISSEMINATION: We anticipate that our results will show that this novel electronic solution is scalable to other organizations and settings. In this presentation, we plan to provide valuable information on the importance of developing a system of pre-visit planning, our process of iteratively developing and refining this electronic tool and pearls for implementation of novel electronic tools into a busy and complex academic primary care practice.

IMPLEMENTATION OF LIFESTYLE PROGRAM TO IMPROVE THE ADHERENCE AND EFFECTIVENESS OF GLP-1 MEDICATIONS FOR WEIGHT LOSS

Eun Ji Kim^1,2; Milton Martinez²; Hallie Bleau²; Daniel Riebling²; Anne Flynn²; Zenobia Brown². ¹Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; ²Health Solutions, Northwell Health, Manhasset, NY. (Control ID #4064553)

STATEMENT OF PROBLEM/QUESTION: Obesity is a common medical condition that affects 40% of Americans, affecting 93 million Americans. Obesity is associated with an increased risk of type 2 diabetes, obstructive sleep apnea, osteoarthritis, fatty liver disease, polycystic ovarian syndrome, and cancer. The medical costs attributable to obesity are about $1,900 annually per person, amounting to $149.4 billion at the national level in preventable or modifiable healthcare spending.

Glucagon-like peptide-1 receptor agonists (GLP-1) medications are effective in sustained, clinically relevant weight loss among patients with obesity. In clinical trials examining the efficacy of these medications, patients made intensive lifestyle changes while taking the medication. As a health system, we have seen a significant increase in the use of these GLP-1 medications among employee health beneficiaries. Our conversation with providers suggested that many patients on GLP-1 medications were taking medications without any lifestyle changes. Therefore, we implemented a prior authorization process to ensure patients on GLP-1 are also making lifestyle changes to maximize the benefit of the medication.

DESCRIPTION OF PROGRAM/INTERVENTION: During the prior authorization process, patients were assessed for clinical criteria and were in a lifestyle program. Lifestyle program was defined as any program that provided education about nutrition, exercise, and behavioral changes. For patients not in another lifestyle program, we offered a lifestyle program. During the initial assessment, patients were asked about their weight journey, goals, and barriers. They were required to attend at least one class monthly, in one of 6 pillars of lifestyle medicine, and report their weight at least once monthly. Patients were followed up every 2 weeks for the first three months and every month afterward to assess barriers and facilitators using motivational interviewing.

MEASURES OF SUCCESS: The primary outcome of interest is the change in the percentage of patients with sustained weight loss of 5% of body weight before and after the implementation of the prior authorization. We are also interested in the number of patients enrolled in lifestyle programs and patients no longer being on the medication after the implementation of the prior authorization (potential cost saving).

FINDINGS TO DATE: To date, 924 employee health beneficiaries have been referred to the lifestyle program. 160 patients were already in another lifestyle program and 592 patients were enrolled in the lifestyle program. There were 109 patients who were not approved for these medications because they did not meet clinical criteria, were non-adherent with their medications, or showed no weight loss taking the medication.

KEY LESSONS FOR DISSEMINATION: Many patients who were prescribed GLP-1 medications for weight loss were not in any lifestyle change program. Instead of not covering GLP-1 medications due to the high costs, the implementation of a prior authorization that ensures patients make lifestyle changes can enhance the benefit of the medication.

IMPLEMENTING AN AMBULATORY SAFETY NET (ASN) TO CLOSE THE LOOP FOR PATIENTS AT RISK FOR COLORECTAL CANCER (CRC)

Nicole Napier, Stephanie Shapiro, Cecilia W. Stuopis, Michele David. MIT Health, Massachusetts Institute of Technology, Cambridge, MA. (Control ID #4026977)

STATEMENT OF PROBLEM/QUESTION: Patients at high-risk for CRC commonly fall behind in their CRC screening due to a lack of processes/systems to close the loop on follow up.

DESCRIPTION OF PROGRAM/INTERVENTION: Colorectal cancer (CRC) is the fourth leading cause of cancer-related deaths in the United States. During the COVID-19 pandemic, most routine colonoscopy procedures were canceled and high-risk patients were bridged with stool-based tests or no screening at all. As a result, high risk patients became overdue for their recommended CRC screening. Our organization, a university affiliated ambulatory practice, does not have a gastroenterology department. As a result, our patients have the option to schedule their colonoscopies at several external facilities. Consequently, no streamlined process existed to ensure patients scheduled or/completed their recommended colonoscopy. When colonoscopy was completed, reports that relayed colonoscopy findings and follow up recommendations were not consistently received nor acted upon. There are many contributing factors for patients falling behind on their CRC screening including miscommunication regarding recall date, lack of standardized tracking of call back recommendations as well as patient related barriers (fear of procedure/procedure prep, transportation, identifying a procedure companion, etc.). In order to address these issues, we designed an ASN program to help close the loop on overdue high-risk CRC screening and follow up. This ASN consists of a population health nurse who performs comprehensive chart reviews of patients who are high-risk to identify gaps in recommended care. Once patients are confirmed to be overdue for colonoscopy, they are managed by a patient navigator (PN) team to help perform outreach and assess/eliminate barriers that contribute to their overdue status. The PNs utilize a registry to track all outreach attempts and colonoscopy status as patients move through the program.

MEASURES OF SUCCESS: Measures of success include an increase of at least 10% for ASN individuals in a scheduled or completed status. In addition, we strive for an increase of at least 50% for ASN individuals who have a recommendation recall date set appropriately in the electronic health record (EHR).

FINDINGS TO DATE: Since implementation, the proportion of high-risk patients overdue for colonoscopy has decreased from 17% to 5%. In addition, the recording of recommended recall dates in the EHR has increased from 30% to >95%.

KEY LESSONS FOR DISSEMINATION: When implementing an ASN, it is important to create a registry that easily allows for tracking of patients and aids in the reporting of metrics. One must be able to build an automated process. Using a discrete EHR field to document the colonoscopy recall date allows us to identify patients who quality for the ASN program. Also, having a dedicated team to perform patient outreach, track colonoscopy reports and set the recall date; removes this workload from the primary care team. This allows for buy-in from the primary care team and allows them to focus on other health care items.

IMPLEMENTING A PATIENT-CENTERED HOME-BASED PRIMARY CARE (HBPC) PROGRAM IN THE SAFETY NET

Emily Wistar¹; Agatha Okobi¹; Kamel M. Awayda²; Anne Rosenthal¹; Leigh Kimberg¹. ¹General Internal Medicine, University of California San Francisco, San Francisco, CA; ²School of Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4064123)

STATEMENT OF PROBLEM/QUESTION: Homebound adults, especially people from marginalized and under-resourced communities, are poorly served by the office-based primary care system.

DESCRIPTION OF PROGRAM/INTERVENTION: Homebound adults are a growing, high-needs, high-cost population. Being homebound is an independent risk factor for mortality. Structural racism and poverty impact personal mobility, access to safe, timely transportation, and home environments with few stairs or consistently functioning elevators. At our urban academic safety net clinic, we did not have infrastructure to address inequitable access to primary care for homebound patients. We are engaged in a year-long pilot to inform the launch of a HBPC program by:

- Performing a PCP needs assessment survey

- Developing a standard workflow for home visits, including care guidelines, a provider toolkit, a standard EMR template, and electronic referral process

- Creating a detailed registry of homebound patients

- Cultivating relationships with community-based organizations (CBOs) serving homebound patients to link our patients more effectively to these resources

- Piloting a HBPC program with select patients to test the workflows and solicit input and feedback on the program’s development from patient participants

MEASURES OF SUCCESS: We are performing a process and feasibility evaluation to be assessed through these measures:

- infrastructure process metrics (patient registry, referral system, key stakeholder interviews, clinical guidelines, standard procedure guide, mapping of useful community-based resources)

- clinical care process metrics (patients seen, referrals to other home health services, number of successful CBO referrals)

- patient input into design of program (qualitative interviews)

- patient and provider satisfaction

FINDINGS TO DATE: - Needs Assessment: surveyed 33 clinic PCPs who identified severe illness, unmet caregiving needs, and built environment/transportation barriers as the main reasons their patients need HBPC.

- Initial patient visits: revealed previously unknown barriers to accessing clinic-based primary care, multiple unmet medical and social needs, and a high level of interest in HBPC

KEY LESSONS FOR DISSEMINATION: Inequitable access to primary care can be addressed through HBPC. We will develop a toolkit to assist others in starting a HBPC program.

IMPROVING ACCESS TO DIABETIC EYE SCREENINGS IN RURAL COMMUNITIES VIA “POP-UP EYE CLINICS”

Pratyusha Nunna¹; Brooke Donaher²; talia gearinger²; melody coller¹; rajeev ramchandran². ¹Internal Medicine, University of Rochester Medical Center, Rochester, NY; ²Ophthalmology, University of Rochester David and Ilene Flaum Eye Institute, Rochester, NY. (Control ID #4063424)

STATEMENT OF PROBLEM/QUESTION: Preventing blindness due to Diabetic Retinopathy by regular diabetic eye exams

DESCRIPTION OF PROGRAM/INTERVENTION: Diabetic retinopathy (DR) has become the leading cause of legal blindness with an estimated 9.6 million people in the United States with DR, of which 1.84 million are living with vision-threatening DR.

There is a higher prevalence of DR in rural communities compared to urban due to limited access to healthcare, long travel distances, cost and burden of diabetes management. Early diagnosis and treatment decrease the risk of associated vision loss by more than 90%. However only 60% of diabetic patients receive yearly eye exams.

In an attempt to overcome the geographic barrier, we collaborated with the ophthalmology department to pilot a “pop-up eye clinic” at rural primary care clinics (PCC) where an optometrist provides dilated eye exams.

MEASURES OF SUCCESS: Two rural PCCs were identified that were 20 miles from a university eye center, had low HEDIS scores (52% and 56% in 2021) and enough space for eye examinations and storage of equipment. Diabetic patients of the respective PCC who have not had a diabetic eye exam in more than a year were reached out by the PCC clinical coordinator to schedule dilated eye exams at the pop up eye clinic. Four half day sessions at rural PCC 1 from July-August 2022 and two full day session at rural PCC 2 in May-June of 2023 were conducted.

FINDINGS TO DATE: A total of 43 patients were scheduled with 81.4% (n=35) show rate. Demographic data shows median age of 62 years with 51% male, 49% female, 76.7% Caucasian, 16.2% African American and rest 4.6% other (non-Hispanic).

44.1% (n=12) of the scheduled patients were dependent on insulin and 18.6% (n=8) of patients had uncontrolled diabetes with A1c>9. Diabetic nephropathy was recorded in 6.9% (n=3) and 11.6% (n=5) had uncontrolled hypertension with BP>140/90 based on average of the last 3 visits.

There was 1 patient found to have a new diagnosis of mild non proliferative DR of both eyes without macular edema and 5 follow up patients with stable DR.

The average distance to PCC is 9 miles with the average distance to the closest tertiary university center being 20 miles and to the nearest eye clinic is 7.5 miles.

KEY LESSONS FOR DISSEMINATION: This pilot pop up eye clinic showed a significant improvement in diabetic eye screenings. Notable benefits include the proximity of access to specialized care in the comfort of PCC and personalized diabetic eye health education with warm hand offs to PCP.

The major drawback was limited availability of appointment slots. There were also administrative challenges with scheduling, additional work for on-site staff, insurance (medical vs vision coverage) and space availability within the PCC.

Overall, this pilot proved to be a success with a plan to continue the pop-up eye clinics once a month from March to June every year. There is scope to start a similar project in other rural PCCs and even urban PCCs in the future. At the end of the day the pop-up eye clinics may still be a temporary fix to a long-term problem.

IMPROVING EQUITY AMONG PATIENTS WITH POORLY CONTROLLED TYPE 2 DIABETES THROUGH A 2-WAY TEXT MESSAGING INITIATIVE

Philip Wilson¹; Katherine M. Tighe⁴; Naing Aung³; Leonor Fernandez²; Jonathan Li²; Maelys Amat¹. ¹Internal Medicine, Beth Israel Deaconess Medical Center, Somerville, MA; ²Medicine, Beth Israel Deaconess Medical Center, Waban, MA; ³Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ⁴Population Health, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4064226)

STATEMENT OF PROBLEM/QUESTION: Our primary care clinic identified disparities in diabetes control, with Black/African American and Hispanic patients having significantly lower rates of glycemic control (as defined by A1c <9.0%) when compared with white patients.

DESCRIPTION OF PROGRAM/INTERVENTION: We hypothesized that the observed racial disparities in diabetes control were strongly influenced by structural barriers to care, including the ease of communication with clinicians, and designed an intervention to assess whether targeting a novel method of direct communication (two-way text messaging) could aid in reducing disparities among this group of patients. The text messaging communication focused on care coordination and health education.

Our cohort consisted of 389 patients whose last measured A1c was ≥9.0% and who self-identified as Black/African American and/or Hispanic (based on registration data), identified from an overall clinic population of 40,000 patients. At the time of submission, 93 of these patients had received initial outreach via text message, and 32 patients had consented to participate in the intervention.

MEASURES OF SUCCESS: The primary objective was to evaluate whether participation in the two-way texting program improved A1c levels within the cohort of participants. We additionally collected several process measures, including the rate of patient participation in the texting program and the total number of text messages sent to each participant, as a proxy for engagement with the program.

FINDINGS TO DATE: Of the 93 patients who received initial outreach, 32 patients consented to participate yielding a 34% participation rate, compared to a 10-20% average for phone call-based population health initiatives. At the time of submission, the mean number of text messages per participant was 15.25 (range 3-47) and a total of 488 text messages were sent through the program. Among the 32 participants enrolled, 69% have had A1c measurement since the initiation of outreach. To date, the mean A1C in the intervention cohort has decreased from 10.8% to 10.2%. Notably, when dividing patients into quartiles based on engagement with the program (as measured by number of text messages), the first quartile (highest engagement) had a mean drop in A1C from 10.7 % to 9.3%, and the bottom quartile (lowest engagement) had a change in A1C from 10.5% to 10.6%.

KEY LESSONS FOR DISSEMINATION: Participation in a two-way text messaging program improves glycemic control among Black and Hispanic patients with poorly controlled diabetes. Early findings also show that increased engagement in the intervention is associated with a higher degree of A1c reduction. Reductions in A1c occurred in a sub-population of patients previously not highly connected with care.

IMPROVING HYPERTENSION CARE THROUGH A NOVEL MEDICAL ASSISTANT BLOOD PRESSURE CHECK VISIT

Sana Tehal¹; Jesse Rokicki-Parashar¹; Yingjie Weng²; Anuradha Phadke³. ¹PRIMARY CARE AND POPULATION HEALTH, Stanford University, Stanford, CA; ²MED/QUANTITATIVE SCIENCES UNIT, Stanford University, Stanford, CA; ³Medicine, Stanford University School if Medicine, Palo Alto , CA. (Control ID #4063972)

STATEMENT OF PROBLEM/QUESTION: A multidisciplinary team within our academic medical center primary care group sought to determine if a novel medical assistant blood pressure check visit could improve hypertension care given access constraints and an increase in telehealth utilization.

DESCRIPTION OF PROGRAM/INTERVENTION: The visit consists of an unattended automated office blood pressure (AOBP) check where a patient rests alone in a room for 5 minutes and then has three unattended BP checks one minute apart. Thereafter, a medical assistant re-enters the room, records the average of these three readings, and checks accuracy of home BP machine for patients presenting with personal devices. Medical assistants consult an electronic medical record note template to provide protocolized follow-up instructions based on AOBP values.

The improvement team trained medical assistants across five clinics on this visit and encouraged providers and staff to refer patients to these visits in a variety of clinical scenarios (e.g. following med titration, after telehealth visit, or in case of suspected white coat values.) Additionally, population health coordinators referred patients to these visits when doing hypertension-focused outreach.

MEASURES OF SUCCESS: We tracked visit utilization using an electronic medical record report. Additionally, we conducted retrospective chart reviews focused on documented blood pressure value reduction associated with the visit, rate of home blood pressure machine accuracy check, and clinical follow-up actions for patients with elevated readings.

FINDINGS TO DATE: Our clinics conducted 862 AOBP visits in 2 years.

In chart reviews of 104 of these visits we found:

-Patients had a mean age 62 years, 56% male, 53% with hypertension, and 26% with diabetes. 53% of patients with hypertension had a last blood pressure value prior to AOBP visit >=140/90.

-Among (n=67) patients with hypertension and a last recorded BP of ≥ 130/80 mmHg, mean pre-visit BP was systolic BP 147 (95% CI [127,167]), diastolic BP 91 (95% CI [77,103]) and mean AOBP was systolic BP 134 (95% CI [105,163]), diastolic BP 84 (95% CI [70,98]). This reflected a reduction in 13 mm Hg systolic BP points and 6 mm Hg diastolic BP points associated with AOBP visits.

-Over half (55%) had a home BP cuff accuracy check done during their visit.

-Among the 33 patients with mean AOBP ≥140 mmHg systolic, most had follow-up (visit or home BP reporting) within 3 months but 8/33 (27%) had no documented follow-up within 3 months.

KEY LESSONS FOR DISSEMINATION: Medical assistant blood pressure check visits are now a commonly utilized approach within our practices, provide high-quality blood pressure measurement, and ensure home blood pressure machine accuracy for our patients. Lower readings obtained during these visits have contributed to our medical group’s top decile hypertension control quality performance. Through chart reviews, we have found the need to further focus on follow-up processes for patients with high AOBP readings.

IMPROVING THE SCREENING AND DIAGNOSIS OF OBSTRUCTIVE SLEEP APNEA IN INDIVIDUALS WITH HYPERTENSION: A PRIMARY CARE CLINIC-BASED QUALITY IMPROVEMENT PROJECT

Ashwin Pillai^1,2; Zidan Saleh^1,2; Kaitlyn Gooding^1,2; Lara Melo Soares Pinho De Carvalho^1,2; Chef Stan Macaraeg^1,2; Sumarah Curry^1,2; Cunegundo Vergara^1,2. ¹Medicine, UConn Health, Farmington, CT; ²Hartford Hospital, Hartford, CT. (Control ID #4064084)

STATEMENT OF PROBLEM/QUESTION: In the context of a known dose-response relationship between untreated Obstructive Sleep Apnea (OSA) and elevated blood pressure, we conducted a Quality Improvement(QI) project to identify the most effective intervention to improve screening for OSA and increase appropriate polysomnography referrals in a hypertensive cohort.

DESCRIPTION OF PROGRAM/INTERVENTION: The quality improvement project was conducted at the outpatient primary care clinic of an academic center in New England. All providers received specific education about the overlap between hypertension, obesity, and OSA and the benefits of treating OSA. The interventions trialed were distinct reminder systems for providers to screen eligible patients with a STOP-BANG score and place polysomnography referrals, when appropriate. Intervention-1: weekly email reminders to providers. Intervention-2: personalized reminders to providers about eligible patients, pre-screened by the QI team, sent 1 day before the encounter. Providers who received neither intervention served as controls.

MEASURES OF SUCCESS: Rates of STOP-BANG screening and polysomnography referrals for eligible patients.

FINDINGS TO DATE: Our QI team screened 770 medically under-represented patients - 67% Latinx, 19% Black. 43% were non-English speakers. 51% had Medicaid, 32% Medicare, and 7% were uninsured. 74 patients were eligible. We tracked rates of STOP-BANG screening and polysomnography referrals. Each intervention ran for four weeks respectively. Intervention 2 emerged as statistically superior. STOP-BANG screening was performed for 22.2% of eligible control group patients, 15.3% of Intervention-1 Group patients and 58.3% of Intervention-2 Group(p=0.01). Intervention-2 was exclusively implemented over the next month to confirm sustainability. During the month-long maintenance phase, the screening rate sustained at 100% in the Intervention-2 Group, averaging 70.6% in aggregate for the cumulative 8-week duration. For patients who received a STOP BANG screen, referral rates were statistically comparable across all three groups (controls vs Intervention-1 vs Intervention-2: 100% vs 100% vs 83% respectively, p>0.05).

The results of this study served as the basis for creating a Best Practice Advisory in the Electronic Medical Record System that has been implemented across a large healthcare network in New England.

KEY LESSONS FOR DISSEMINATION: 1. Commonly encountered conditions are often undertreated and need to be consciously addressed to promote patient wellness and prevent downstream illness through early risk factor modification.

2. Behavioral change to improve the quality of care can be most effectively and sustainably induced by a combination of stakeholder education and system modification to provide timely and situationally appropriate reminders.

3. Electronic medical record systems can be leveraged to bring about large-scale systemic change through Best Practice Advisories.

INCREASE IN BILLING OF EVALUATION AND MANAGEMENT SERVICES DURING PREVENTIVE HEALTH VISITS THROUGH CLAIMS AUDIT, DATA VISUALIZATION, AND FEEDBACK TO OUTLIERS IN AN ACADEMIC INTERNAL MEDICINE PRACTICE.

Jodi M. Grandominico-Bradford¹; Neeraj H. Tayal²; Daniel E. Jonas¹; Thomas Brancazio³. ¹Internal Medicine, The Ohio State University, Columbus, OH; ²Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ³Information Technology, The Ohio State University, Columbus, OH. (Control ID #4061987)

STATEMENT OF PROBLEM/QUESTION: During preventive health visits, patients frequently bring problems outside the scope of these visits requiring evaluation and management services.

DESCRIPTION OF PROGRAM/INTERVENTION: Preventive health visits provide opportunities for care gap closure for preventive services, are reimbursed at higher rates than evaluation and management (E/M) visits, and are tied to attribution in value-based contracts. Patient concerns arise during preventive visits that may require medical evaluation and management. Preventive visits are scheduled for longer blocks of time than return visits and may negatively impact access for chronic health conditions. Utilizing this time to address concerns is sometimes necessary and efficient. Preventive services may be covered by a patient’s insurance plan fully. Because patients expect no out of pocket costs for these visits, the E/M work done during these visits may be undocumented and underbilled by primary care physicians. This leads to inappropriate medical documentation and loss of revenue potential. We used all payer claims data from seven primary care practices with 84 faculty in an academic general internal medicine division in the Midwest. Through a data visualization tool, called Qlik Sense©, we assessed the percentage of preventive visits billed concurrently with modifier 25 and an E/M code on the same date of service. The median percentage at baseline for faculty billing an E/M service in addition to a preventive service was 33.3% of the time. In May 2023, education was provided to faculty on appropriate use of modifer 25 to bill an E/M service in addition to a preventive visit when medically necessary. 22 faculty outliers with the lowest percentage use of modifier 25 to bill an E/M service with a preventive service were notified of their performance. Risks and benefits of behavior change were outlined including potential increase in wRVUs, revenue, and importance of medicolegal documentation. To assist, an educational billing and coding video was provided on use of modifier 25.

MEASURES OF SUCCESS: Percentage of outliers changing their behavior, percentage of preventive visits coded concurrently with modifier 25 and E/M codes, projected revenue, projected wRVU per faculty member

FINDINGS TO DATE: After intervention, 21/22 (95.4%) of the outliers changed their behavior. Post intervention, this cohort increased E/M billing with a preventive service, averaging 33.6% of their preventive visits (an absolute increase of 20% compared to their baseline average of 13.6%). Based on this intervention, projected revenue generated for 12 months for this fiscal year is an additional $232,416. Average additional projected wRVU generated per faculty member over 12months is 297.49.

KEY LESSONS FOR DISSEMINATION: Use of a claims audit, data visualization, and feedback to outliers assists with identifying opportunities for billing and coding efficiency for primary care physicians. Targeted outreach to outliers can improve physician practice patterns, increase revenue, and wRVU generation which may incentivize behavior change.

INSULIN TITRATION FOR TYPE II DIABETIC PRIMARY CARE PATIENTS USING PHARMACISTS

Aparna Sarin¹; Barbara Simon²; Megana Murugesh³; Alisha Goyal⁴; Emily Scopelliti⁵; Michael Kelly⁵. ¹Internal Medicine, Thomas Jefferson University, Philadelphia, PA; ²Endocrinology, Thomas Jefferson University Hospital, Philadelphia, PA; ³Internal Medicine, Thomas Jefferson University, Philadelphia, PA; ⁴Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA; ⁵Pharmacy, Thomas Jefferson University, Philadelphia, PA. (Control ID #4063853)

STATEMENT OF PROBLEM/QUESTION: Can insulin titration with pharmacists, done outside of PCP visits, help patients reach goal blood glucose levels sooner, and increase physician satisfaction?

DESCRIPTION OF PROGRAM/INTERVENTION: Approximately, 90% of patients with type 2 diabetes (T2DM) are treated by primary care providers (PCPs) and with a growing aging population, the demand for PCPs to provide care to diabetics is only expected to further increase. Despite novel therapies in T2DM, insulin remains a mainstay in those unable to afford, tolerate, or achieve glycemic control with their current regimens. At our academic primary care clinic, we tried a novel approach to insulin titration, using pharmacists, who are co-located within our practice. We created a referral process where PCPs could refer patients with hemoglobin A1c (HgA1c) >9%, requiring insulin initiation/titration to our pharmacists. Our pharmacists then made out-reach calls to set up telephonic or in-person visits to assess their blood glucose (BG) control. Patients were trained on how to measure, how often, and to log their values. They were educated on normal ranges as well as hyper and hypoglycemia. The pharmacists utilized preexisting insulin algorithms and did a minimum of 3 titrations.

MEASURES OF SUCCESS: We tracked: BG control at the beginning and the end of titration period, HgA1c at the beginning and at the end (if available, done at follow up visit with PCP), change in insulin dosing, and # of visits and minutes per titration, when able. Our secondary outcome is PCP satisfaction that will be measured through a survey in April 2024.

FINDINGS TO DATE: Enrollment began June 2023 and is expected to continue till April 2024. So far, we have performed titrations for approximately 38 patients, some of which are currently ongoing. On brief review, the data so far shows: that on enrollment, our patients had BG ranges averaging 80-379, and A1cs of 8.2-18.5. Upon completion, although some data is still pending, we saw BG ranges of 80-223 and A1cs of 6.6-10.7 so far. We saw an average increase in insulin dosing of 4-20 units. These titrations have required on average 2-7 calls/visits and 20-115 minutes of the pharmacists time. We will be tracking the patients A1cs at their follow up PCP visits and will be surveying PCP satisfaction with the program closer to the end date.

KEY LESSONS FOR DISSEMINATION: We propose that insulin titration, can be successfully managed in a team-based approach, further strengthening the relationships between pharmacists and PCPs are partners in providing care. Inter-visit titration performed by pharmacists (with the potential of also training other team members like RNs) with existing titration algorithms can ensure efficacious and timely insulin adjustments to get patients to goal as well as reinforce safety with insulin dosing. We hope this data can advocate the need for similar programs in primary care clinics given the burden of time to perform these titrations safely and in a timely manner.

INTEGRATING DIABETIC EYE SCREENING INTERVENTION WITH TELERETINAL EXAMS (EYESITE) IN PRIMARY CARE: A CASE STUDY IN AI, QI, AND IMP SCI

Marguerite Balasta¹; Lama Al-Aswad²; Sarah Boise³; Gaibriel De Guzman⁴; Gillian Lautenbach¹; Corinne Rhodes¹. ¹Department of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ²Ophthalmology, University of Pennsylvania, Philadelphia, PA; ³Penn Medicine, Philadelphia, PA; ⁴General Internal Medicine, Penn Medicine, Philadelphia, PA. (Control ID #4065021)

STATEMENT OF PROBLEM/QUESTION: Diabetic eye disease is a leading cause of blindness in the United States and strategic implementation of evidence-based artificial intelligence (AI) technologies can reduce gaps and access to preventive screening.

DESCRIPTION OF PROGRAM/INTERVENTION: An estimated 9.6 million US adults have diabetic retinopathy (DR) and is one of the leading causes of blindness in this country. DR is a progressive illness that requires early detection and treatment. Our team recognized a gap in DR screening in the primary care clinics at our academic institution with 39.9% of diabetic patients having a documented exam in the electronic health record (EHR). Patient barriers to screening include poor access to specialty care, time, cost, and insufficient patient knowledge or awareness. Despite evidence that primary care can improve screening rates, health system and provider barriers include lack of skilled human resources, infrastructure of retinal imaging, and cost of services. When teleretinal cameras are utilized to screen for DR in primary care, the most common ones currentlyy in use require asynchronous reading by an off-site ophthalmologist. Our population health team developed a program of integrating AI-based cameras into primary care clinics at our health system which addresses these barriers and facilitates patient referrals to specialty care for positive results.

MEASURES OF SUCCESS: We will present an implementation science (IS) approach using a framework called the Consolidated Framework for Implementation Research (CFIR) 2.0 as a comprehensive tool to describe socioecological factors influencing implementation including stakeholders and characteristics of the intervention. Quality improvement (QI) processes are used in this model to drive and evaluate the process of implementation. Proposed process and outcome successes include acceptability, feasibility, screening rates, and referrals to specialty care.

FINDINGS TO DATE: We will describe a previous effort to use non-AI based cameras into primary care at our academic institution which did not successfully integrate. Technologies and climate of diagnostic tools in healthcare have since evolved. Using lessons learned, our team developed an implementation strategy identifying multi- and cross-disciplinary stakeholders in operations, clinical care, and population health within internal medicine and ophthalmology.

KEY LESSONS FOR DISSEMINATION: AI-based teleretinal cameras can be used as a case study for understanding potential use of AI in primary care to enhance diagnostics, developing an implementation framework for this innovative interventions, and driving success using QI processes.

IT TAKES A TEAM: BUILDING SYSTEMS TO SUPPORT COMPREHENSIVE ADVANCE CARE PLANNING IN PRIMARY CARE

Brittany Chatterton¹; Cynthia G. Matsumoto²; Connor Reilly²; Reshma Gupta¹; Nathan Fairman³. ¹Internal Medicine, UC Davis Health, Sacramento, CA; ²Office of Population Health and Accountable Care, UC Davis Health, Sacramento, CA; ³Psychiatry and Behavioral Health, UC Davis Health, Sacramento, CA. (Control ID #4064604)

STATEMENT OF PROBLEM/QUESTION: We recognized the need within our health system to increase engagement of primary care patients in advance care planning (ACP) and create a framework to bolster diverse relationships among clinical and non-clinical staff to implement a health system-wide ACP intervention.

DESCRIPTION OF PROGRAM/INTERVENTION: At a single academic center in the California-Hawaii region, components of our ACP interventions included (1) a framework to integrate diverse relationships and co-create programs across the health system, (2) novel methods to generate patient registries including mandatory surprise questions and age requirements, and (3) electronic health records (EHR) changes to facilitate ACP discussions for primary care clinicians (PCCs). EHR modifications included automated prompts for PCCs, new ACP documentation templates and workflows, and enhancements to improve access to ACP information in the EHR. Interdisciplinary collaboration was created with a unique team of dedicated ACP social workers who clinicians can refer to for assistance with ACP. A tracking and referral system was developed to improve continuity of ACP communication across patient transitions from hospital to clinic. Education regarding ACP was provided for PCCs.

MEASURES OF SUCCESS: We measure completion of ACP documentation - completion of POLST forms, identification of surrogate decision maker(s), completion of an advance care directive paperwork - among primary care patients seen within our primary care clinic network. We collected feedback from practicing PCCs on implementation of the interventions.

FINDINGS TO DATE: Our study population (n= 34,260) was primary care patients aged ≥65 yrs old seen within our health system. In the 12 months prior to implementation there was an average monthly ACP completion of 0.6% (range 0.4%-0.9%) for individuals in our cohort. After the start of our interventions, the study cohort’s monthly completion increased to an average of 9.4% (range 0.8%-23.6%) in the first 12 months and 11.1% (range 9.5%-12.1%) for the subsequent 8 months. In total during the 20 months since the intervention started, our study cohort more than tripled (36.4%) in ACP completion.

KEY LESSONS FOR DISSEMINATION: Colleagues from information technology, social work, primary and specialty care, inpatient care, nursing, and operations were all necessary partners to create a sustainable system wide approach to ACP. Having a framework to build robust relationships and this multidisciplinary design team to refine the interventions was key to our success.

MEASURING THE IMPACT OF TEAM-BASED IN-BASKET TRIAGE PROGRAM ON PHYSICIAN ELECTRONIC HEALTH RECORD BURDEN

Sophie Chrisomalis¹; Celestine He²; Abigail Chen¹; Jessica Backman²; Chi Chan²; Jonathan Ripp²; Lauren Peccoralo¹. ¹Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4062201)

STATEMENT OF PROBLEM/QUESTION: How can we improve electronic health record (EHR) burden on ambulatory physicians by optimizing In-Basket message workflows?

DESCRIPTION OF PROGRAM/INTERVENTION: Research has found that receiving more in-basket messages per day was associated with a higher probability of burnout in physicians and that physicians spend twice the amount of time on clerical tasks than direct patient care. We implemented a pilot In-Basket program in which support staff were trained to review In-Basket messages utilizing Epic pools to decrease one aspect of this clerical burden. Messages were received by staff members and then sorted into three types: (1) administrative, staff managed, (2) simple medical questions, sent to a nurse or physician, and (3) complex medical questions, appointment scheduled.

MEASURES OF SUCCESS: We conducted a retrospective case control study where we compared data from 36 physicians whose practices underwent the intervention and 42 physicians who worked in similar settings in the same health system that didn't. We collected the following monthly metrics for the 5 months before and after the intervention month: proficiency score (Epic generated efficiency score), number of in-basket messages received by provider per month, seconds per completed message, time spent in in-basket, and ‘pajama time’ (time in minutes a provider spent charting activities outside scheduled work hours). Separate repeated measures analyses of variance (ANOVA) were conducted on each of the outcome variables of interest. The within-subjects factor was Time (1-5 months post-intervention) and the between-subjects factor was Group (control vs intervention). Analyses were adjusted for the mean of the values across the 5 pre-intervention timepoints and the mean number of appointments per month across the 5 post-intervention timepoints.

FINDINGS TO DATE: There was a significant group by time interaction for the outcome variable “pajama time” F(3.49, 233.96, p=0.03). Posthoc tests revealed that in the intervention group, pajama time minutes decreased at month 4 (adjusted mean [MOU1] [SD]=47.0 [4.2]) when compared to month 1 (55.0 [3.7]), p=.034, whereas in the control group pajama time minutes increased at month 4 (64.1 [4.0]) compared to month 2 (54.7 [3.6]), p=.042 (Figure [CC2] [MOU3] [PL4] 1). All other variables did not show any significant differences in outcomes between groups or any group by time interaction.

KEY LESSONS FOR DISSEMINATION: In the first 5 months following the institution of a team-based In-Basket pilot program, while there was no decrease in patient messages to the physicians or in time spent on messages, there was an overall decrease in time spent on the EHR after hours. This study is limited by the 5 months of pre and post data in a small group of physicians and we are currently evaluating the impact of this program on a larger group of physicians over a longer time frame. Ultimately, a team-based EHR in-basket triage protocol may be one way to decrease physician time in the EHR and overall clerical burden that, in turn, may reduce clinician burnout.

MOBILE INTEGRATED HEALTHCARE: AN ALTERNATIVE TO ACUTE ED AND HOSPITAL CARE FOR VULNERABLE DUALLY-ELIGIBLE INDIVIDUALS IN MASSACHUSETTS

Dan Henderson. Commonwealth Care Alliance Inc, Boston, MA. (Control ID #4064631)

STATEMENT OF PROBLEM/QUESTION: Can mobile integrated healthcare (MIH) improve heatlhcare value through prevention of high-cost acute care?

DESCRIPTION OF PROGRAM/INTERVENTION: In 2014, Commonwealth Care Alliance (CCA), a Boston-based payor-provider organization serving primarily dually-eligible individuals, piloted a mobile urgent care service staffed by paramedics and remote physicians. The pilot sought to offer patients an alternative to care in emergency departments. Co-produced with and informed by feedback from CCA's members -- a large share of whom are affected by complex health and social challenges -- the service was designed to offer a a superior experience funded by the anticipated savings from avoided higher-cost care. Now in it's tenth year, instED has iteratively refined its operations through over 30,000 in-home urgent care visits.

MEASURES OF SUCCESS: The primary measures of success for instED are the ability to safely avoid the need for ED visits (defined as the percentage of patients who remain hospital-free 3 days after a visit) and the ability to provide a superior patient experience (defined as net promoter score). Internal measures include safety, (defined as 30-day mortality, which remains lower than ED or hospital figures), equity (defined as visit rates stratified by CMS RELD data), and estimated economic savings to customers due to avoided care.

FINDINGS TO DATE: Over 30,000 visits, instED prevented 19,200 ED visits, and achieved Net Promoter Scores of 92-95%.

Additionally, a quasi-experimental difference-in-difference analysis identified a 1.12% reduction (95% CI -1.6% to -0.6%, p<0.000) in ED utilization. This corresponded to a relative effectiveness of 64.8% per visit in preventing a subsequent ED encounter. With regard to equity, the effect in preventing ED visits was greater along certain charcteristics, including race, ethniticy, language, and gender, as well as the presences of frailty, physical disabilities, severe persistent mental illness (SPMI) and age. (Data available but omitted here due to character limit).

KEY LESSONS FOR DISSEMINATION: As an innovation in care delivery designed to provide vulnerable individuals with an alternative to high-cost acute care, mobile integrated healthcare has demonstrated results that should encourage care delivery organizations, policy makers, providers, and patients, to consider applying the model to appropriate popluations and needs.

Key lessons include:

1. The suitability of this model for many urgent or acute health needs, particularly infections and flares of chronic conditions, such as CHF, COPD, diabetes, chronic kidney disease, dementia, and frailty.

2. The particular benefits for individuals with difficulty accessing care when needed (including due to disabilities, lack of access, lack of trust in health care, among others) and at increased risk of admission from the ED due to medical or social complexity.

3. The challenges to expansion and maturity of this model, particulary around measuring and improving quality and safety.

NYC STREET MEDICINE: THE LARGEST US PUBLIC HOSPITAL SYSTEM GROWS THE LARGEST US STREET MEDICINE PROGRAM, AND YOU CAN TOO!

James Grigg^1,2; Andy Cook³; Yinan Lan^3,2. ¹New York City Health and Hospitals Bellevue, New York, NY; ²New York University Grossman School of Medicine, New York, NY; ³New York City Health and Hospitals Corporation, New York, NY. (Control ID #4064679)

STATEMENT OF PROBLEM/QUESTION: People experiencing homelessness often receive fragmented care or may not be engaged in care. How can a large public system engage and deliver effective, integrated, longitudinal care to community members who are unhoused or unsheltered?

DESCRIPTION OF PROGRAM/INTERVENTION: 4,000 people experience unsheltered homelessness daily in NYC. To better address these patients’ needs, NYC H+H, the nation’s largest municipal healthcare organization, developed the SHOW program. SHOW vans provide primary care, harm reduction, connections to substance use treatment, housing resources, behavioral health services, and material goods to individuals who are unsheltered—where they live in the community, via diverse roving teams. The outreach teams include physicians, nursing, community health workers, behavioral health staff and peer counselors—who specifically bring lived experience to the work.

The 20 SHOW internists also deliver care in Primary Care Safety Net (PCSN) Clinics, serving people experiencing homelessness. This dual assignment allows for self-referral, SHOW to PCSN, leveraging relationships developed on the street. Rather than volunteering or finding time outside of full-time work (common in street medicine), physician clinical sessions are assigned and reimbursed like other ambulatory care clinic sessions.

MEASURES OF SUCCESS: The SHOW program has core mission-oriented goals, all tied to measures of success:

-Meet patients where they are

-Address health+social needs via multidisciplinary team

-Build trust, long-term relationships

-Connect patients to PCSN, housing resources, and social services

FINDINGS TO DATE: During the year 2023, SHOW units demonstrated successful outreach, establishing care with 955 individuals who may not otherwise access care. These engagements led to 283 linkages to PCSN and 109 linkages to substance use and behavioral health treatment.

KEY LESSONS FOR DISSEMINATION: -Street medicine can successfully engage individuals who are street homeless and provide wrap-around services in a large healthcare system

-Treating provider time as any other clinical assignment is important for capacity building and integration of care into large systems

-Physician self-referral from the street to homeless care clinic helps with continuity of care

-The team is paramount; street medicine is most effective when delivered by a team of diverse professionals whose own wellbeing is supported by the organization

OPTIMIZING VTE CLINICAL DECISION SUPPORT TOOLS BY TARGETING FIRST-CONTACT PROVIDERS AND ATTENDING PHYSICIANS REDUCES ALERT FATIGUE

Nathan Klapheke¹; Holly Krelle²; Sarah Tsuruo²; William C. King²; Kyra L. Rosen². ¹MCIT, New York University, New York, NY; ²Population Health, NYU Langone Health, New York, NY. (Control ID #4064693)

STATEMENT OF PROBLEM/QUESTION: To use a rapid randomized test to improve best practice notifications for pharmacologic VTE prophylaxis ordering in an inpatient care setting.

DESCRIPTION OF PROGRAM/INTERVENTION: Unnecessary and poorly targeted interruptive clinical decision support tools contribute to alert fatigue in inpatient settings. A large academic health system tested targeting of an interruptive best practice advisory for inpatient pharmacologic VTE prophylaxis through a single round of a rapid randomized controlled trial. This VTE prophylaxis alert was problematic; it was our 3rd most firing alert, firing over 5 times per-patient per-encounter and was over-ridden more than 90% of the time.

We conducted one round of testing consisting of two updates to the interruptive inpatient pharmacologic VTE prophylaxis best practice advisory. The first update simplified and grouped similar alert acknowledgement reasons, reducing the total number from twelve to eight. The second update of the alert reduced the receiving population from all clinicians opening the patient’s chart to the patient’s first-contact provider or the patient’s attending physician. Patients were randomized in a 1:1 ratio to the control and intervention groups based on odd or even unique patient contact serial-numbers.

MEASURES OF SUCCESS: Primary outcomes were timely VTE ordering rate and alerts fired per patient encounter. Comparisons between the control and intervention were made with Chi squared tests, with statistical significance being set at p = 0.05.

FINDINGS TO DATE: After targeting the BPA to the patient’s first-contact provider and the patient’s attending, average firings of the alert dropped from 1.4 firings per encounter in the control, to 0.8 firings in the intervention group (p < 0.001).

VTE prophylaxis ordering within 24-hours of admission to inpatient care remained similar at 81.1% in the control to 81.4% in the intervention group (p = 0.70).

KEY LESSONS FOR DISSEMINATION: Targeting a patient’s first-contact provider and attending physician instead of all clinicians who may have contact with a patient can reduce alert fatigue while maintaining the same standard of VTE prophylaxis ordering. This method of direct targeting could also be applied to other alerts and other care teams assigned to specific patients during inpatient care stays.

PHARMACIST-LED COLLABORATIVE MANAGEMENT TO IMPROVE ACCESS TO ANTI-OBESITY MEDICATION IN PRIMARY CARE

Amy Groswald¹; Suzanne K. Higginbotham³; Sara Li². ¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²General Internal Medicine, The Ohio State University, Columbus, OH; ³General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4061412)

STATEMENT OF PROBLEM/QUESTION: Over 40% of the U.S. adult population is obese, yet FDA-approved anti-obesity medications are only prescribed to a small fraction of eligible patients.

DESCRIPTION OF PROGRAM/INTERVENTION: The Ohio State University General Internal Medicine New Albany Outpatient Care Clinic is an academic primary care practice in Columbus, Ohio. This practice has an embedded clinical pharmacist who co-manages chronic diseases such as hypertension and diabetes. Despite increasing therapeutic options for obesity, the prescription of anti-obesity medications to eligible patients remains low. As anti-obesity medications require frequent follow-ups, clinics may be unable to accommodate the increase in demand due to a lack of provider availability.

We expanded the pharmacist-led model to initiation and dose-titration of anti-obesity medications. We developed the following workflow: 1) primary care physician (PCP) completes a weight management intake visit; 2) PCP places referral to pharmacy in the electronic health record (EHR); 3) pharmacist initiates a telehealth visit for education on the medication; 4) pharmacist orders the medication and completes prior authorization; 5) pharmacist conducts monthly telehealth visits to evaluate weight change and tolerance; 6) pharmacist follows for each dose-escalation until optimal therapeutic target is reached.

MEASURES OF SUCCESS: The number of patients prescribed one of five FDA-approved anti-obesity medications for patients with a BMI of 30.0 or greater was compared from the year before the intervention (11/1/2021 to 11/1/2022) to the year after the intervention (11/1/2022 to 11/1/2023). The data was acquired using the Slicer Dicer of the Epic EHR. The medications included were semaglutide, tirzepatide, liraglutide, phentermine and phentermine-topiramate, and naltrexone-bupropion.

FINDINGS TO DATE: Pharmacist-led management of anti-obesity medications increased the prescription of anti-obesity medications from the year before the intervention to the year after. Semaglutide prescriptions increased from 99 to 297; tirzepatide 0 to 52; phentermine and phentermine-topiramate 18 to 38. Naltrexone-bupropion and liraglutide were unchanged. The total number of anti-obesity medication prescriptions increased from 128 for the pre-intervention year to 401 for the post-intervention year, for a more than a three-fold increase. The percentage of patients prescribed anti-obesity medication increased from 3.6% pre-intervention to 8.9% post-intervention.

KEY LESSONS FOR DISSEMINATION: This project shows that pharmacist-led initiation and follow-up of anti-obesity medication can increase the prescription of these medications to eligible patients. Given their training, background, and increased clinic availability, clinical pharmacists are uniquely qualified to educate patients, complete prior authorizations, and perform timely dose escalation. We also found that this approach decreased the time to completion of prior authorization, reduced the number of patient portal messages to providers, and increased the types of anti-obesity medications started.

PHYSICIAN PERCEPTION OF AN ACADEMIC MEDICAL CENTER-RURAL HOSPITAL PARTNERSHIP CLINICIAN STAFFING MODEL SUSTAINABILITY

Yun Li. Department of General Internal Medicine, Mass General Brigham Inc, Boston, MA. (Control ID #4060669)

STATEMENT OF PROBLEM/QUESTION: In recent decades the US has encountered a growing rural physician workforce shortage. Many past and present efforts have attempted to address the widening urban-rural physician supply disparity. Recently there has been an emergence of academic medical center-rural hospital partnerships which tap into the pool of urban-based academic physicians to perform clinical work and teach at rural community hospitals. Our program is one such example. Our rural partner hospital, an Indian Health Service facility, is remotely located in South Dakota and serves 21,000 enrolled tribal members. The academic partnership staffs 25% of its outpatient and 100% of its adult inpatient clinician roles. Physicians travel to and work at the rural site for one to two weeks at a time. The study intends to evaluate physicians' perception of this academic-rural hospital partnership work model sustainability and also intends to identify potential influencing factors.

DESCRIPTION OF PROGRAM/INTERVENTION: A survey was administered to 49 physicians and physicians-in-training affiliated with our academic-rural hospital partnership, who were from 4 academic universities and medical centers.

MEASURES OF SUCCESS: Measurements include survey completion and information analysis. Survey results were feedbacked to the partnership leadership as part of clinician recruitment and retention efforts.

FINDINGS TO DATE: 19 (38.8%) responses were collected. All respondents have urban-based academic affiliations. All attended urban-based medical schools and 90% of respondents trained or were training in urban-based residency programs. The majority of respondents practiced less than or equal to 12 weeks annually in rural settings. All saw themselves continue practicing in a rural setting for some time in the next two years. However, only 5 physicians saw themselves increase time allocated to rural practice. More than half of the physicians still preferred to spend the majority of their clinical time in urban/suburban settings. Interestingly the COVID-19 pandemic did not lead reduced rural practice time. While most respondents perceived the academic-rural partnership staffing model was sustainable for themselves, they did not believe it was sustainable for average urban-based physicians. The model was perceived to be more sustainable for physicians close to retirement. Some factors identified affecting the sustainability of the work model include family needs, the burden of travel, and flexibility in clinical scheduling in the academic medical centers.

KEY LESSONS FOR DISSEMINATION: Almost all urban-based academic physicians in our academic medical center-rural hospital partnership perceive the current work model of spending part of their academic clinical time in rural settings as sustainable. This type of partnership can potentially increase rural physician supply. However, factors such as individual career development preference, family obligations, travel burden, and schedule flexibilities need to be considered in physician recruitment and retention processes.

PILOTING A REMOTE MANAGEMENT-CENTRIC POST-DISCHARGE PATHWAY FOR PATIENTS ADMITTED TO GENERAL INTERNAL MEDICINE WITH CONGESTIVE HEART FAILURE.

William K. Silverstein^1,2; Sarah Lawrason³; Iris Carabuena³; Rodrigo B. Cavalcanti^2,4; Stella Kozuszko³; Thomas MacMillan^2,4; Shail Rawal^2,4; Lara Wyss⁴; Anne Simard³; Tarek Abdelhalim^2,4. ¹Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; ²Medicine, University of Toronto, Toronto, ON, Canada; ³Cardiology, University Health Network, Toronto, ON, Canada; ⁴General Internal Medicine, University Health Network, Toronto, ON, Canada. (Control ID #4064388)

STATEMENT OF PROBLEM/QUESTION: While most heart failure (HF) patient hospitalizations are to GIM, few GIM-specific HF transition of care programs exist.

DESCRIPTION OF PROGRAM/INTERVENTION: We developed, piloted, and evaluated a 30-day post-GIM discharge pathway for patients admitted to our academic hospital with acute decompensated HF that incorporated a remote management program (Medly). GIM, Cardiology, and nurse clinicians co-designed the pathway. Eligible patients were identified by the GIM MRP. Integrated care coordinators enrolled patients and determined who would provide HF care post-discharge from hospital and pathway (as our clinic is unable to longitudinally follow patients). A GIM physician determined patient’s weight, blood pressure, and heart rate thresholds. Cardiology nurse clinicians provided orientation to Medly, as well as mobile phones, data plans, blood pressure cuffs, and scales, if needed. Upon hospital discharge, patients and their families input daily measures of heart rate, weight, blood pressure, and related symptoms into Medly’s mobile app. Medly’s rules-based algorithm provided feedback and actionable self-care instructions (e.g., take an extra dose of furosemide). Patients were also monitored by GIM physicians and Cardiology nurse clinicians, who were alerted in real-time during regular working hours when measures fell outside thresholds and responded as required. Dedicated in-person clinic visits were available if needed. A discharge note, including weight range and medications, was sent to the patient’s pre-determined HF clinician upon pathway completion.

MEASURES OF SUCCESS: We evaluated our pathway’s impact on outcomes (90-day HF-related death, re-admission, emergency department (ED) visit) and clinician workload (number of emails, phone calls).

FINDINGS TO DATE: We enrolled 10 patients from May 27/2023 to July 24/2023 for a median of 36 days (IQR:33-41). Median age was 85 years (IQR:79-87). Most were female (60%; N=6), did not speak English as their primary language (80%, N=8), had a preserved ejection fracture (80%, N=8), and had a family member input data into Medly (90%; n=9). Approximately 75% of participants input all measures into Medly daily. All were prescribed furosemide and half used a diuretic sliding scale (instructions provided by Medly). There were no HF-related deaths, re-hospitalizations, or ED visits within 90 days of hospital discharge (usual readmission rate: 20%). One urgent GIM clinic visit occurred. An average of 21 (SD:15) emails per patient (~4/week) were sent between providers. Each patient received an average of 7 (SD:3) phone calls from the care team.

KEY LESSONS FOR DISSEMINATION: This novel post-GIM discharge pathway for patients with HF that incorporates a remote monitoring program effectively supports transitions of care in this patient population. Key enablers included dedicated nursing support, integration into other hospital programs, and caregiver assistance to input data if needed. Further studies should assess if this innovation can be sustained and scaled.

PILOTING A VALUE-BASED CARE MODEL FOR DUAL ELIGIBLE SENIORS WITHIN A LARGE ACADEMIC PRIMARY CARE PRACTICE

Chloe Ciccariello¹; Daniel Oates²; Sonia Sieger³; Ennette Heaggans³; Carolyn Leblanc³; Sarah Shields³; Laurie Grant³; Edeleide Lutaaya³; Lauren Donnelly³; Samuel Figaro^3,1; Margaret Horvath⁴; Larry Lawhorne³. ¹General Internal Medicine, Boston Medical Center, Boston, MA; ²Geriatrics, Boston Medical Center, Boston, MA; ³Wellsense, Boston, MA; ⁴Population Health, Boston Medical Center, Boston, MA. (Control ID #4024180)

STATEMENT OF PROBLEM/QUESTION: Fee for service (FFS) primary care models may not always meet the needs of medically and socially complex patients encouraging a shift to value-based care (VBC); therefore, we piloted one approach to transition an academic, safety net practice to a VBC model.

DESCRIPTION OF PROGRAM/INTERVENTION: The pilot was conducted at a busy academic General Internal Medicine (GIM) practice serving over 40,000 patients. Penetration of risk contracts has increased to over 45% of the overall clinic population in 2023. Despite the growing incentives to move to VBC, FFS care delivery dominates, in part due to a lack of a roadmap to shift to this new care model.

We piloted a model where we grouped high risk dual eligible seniors enrolled in an insurance based comprehensive case management program onto the panel of a single PCP. Since September 2021, an integrated, interdisciplinary team from patients’ clinic and insurance plan meets biweekly for structured rounds and communicates asynchronously to co-manage this groups of high-risk patients in a VBC model of care.

MEASURES OF SUCCESS: We tracked several metrics including inpatient admissions, ED visits, total cost of care (TCOC), no-show rate, pharmacy costs and HCC scores for our pilot members in the 6 months pre-enrollment and compared this to their utilization 2 years following enrollment in this pilot.

FINDINGS TO DATE: Initial findings indicate that measures of acute care utilization decreased by 34%. However, TCOC increased by 10%, despite reduced inpatient utilization, likely due to increased use of ambulatory services and pharmacy costs. No show rate decreased by 42% and HCC score increased by 91% (likely due to improved capture). Limitations of our findings include a small sample size (n=31) and confounding variables (care delivered by single team). We did not directly measure quality scores or patient and staff satisfaction, though we suspect these would be positively impacted by this pilot as well.

KEY LESSONS FOR DISSEMINATION: Carving out dual eligible patients from the larger clinic population may promote a more patient-centered care approach for high-risk individuals and serve as a roadmap to implement VBC delivery innovations in a traditional primary care practice.

PROMOTING HIGH VALUE, LOW-COST CARE FOR VETERANS REQUIRING RECURRENT LARGE VOLUME PARACENTESIS

Christina Stull, Jeffrey Eaton, Holli Sadler. Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4064142)

STATEMENT OF PROBLEM/QUESTION: With a high burden of cost associated with medication-refractory ascites in patients with decompensated cirrhosis, we aimed to analyze the financial savings, clinical benefits, and improved competencies associated with an outpatient paracentesis clinic.

DESCRIPTION OF PROGRAM/INTERVENTION: Routine care of patients with decompensated cirrhosis comes with high mortality and burden of cost. Management of medication-refractory ascites often involves costly emergency department visits as coordinating outpatient large volume paracentesis (LVP) can be challenging. Our Southern outpatient-only VA clinic includes LVP services weekly to meet the needs of veterans requiring recurrent LVP for minimal cost and ease of care coordination. It also teaches Internal Medicine residents procedural skills, further fostering a patient-primary care physician relationship, and surveilling patients longitudinally with opportunities to intervene when additional medications or evaluations are warranted.

MEASURES OF SUCCESS: We analyzed objective cost comparisons using national data compared to our VA’s costs and applied it to the number of monthly visits. Additionally we reviewed the number of veterans accessing the LVP clinic, the percentage of veterans with advanced directives notes, referrals for diuretic measurement, and a survey of residents for a sense of professional fulfillment and procedural confidence.

FINDINGS TO DATE: Per Medicare data, the national average cost of a non-image-guided paracentesis is $502 in ambulatory surgical centers and $898 in hospital outpatient departments. Some sources show an estimate of almost $1000 per inpatient-performed paracentesis not accounting for emergency department visits (average cost of $1,150 in 2020 per the Agency for Healthcare Research and Quality), daily rates of admission, and burdens of wait time and lost productivity. Our Southern VA center is not only able to provide this service at a fraction of the cost without facility fees, but also offer opportunities for veterans to undergo timely workup and be referred for pharmacologic management to optimize diuretic use to lengthen time between LVP. Additionally, these veterans are connected with services to provide advanced directives given the frailty and high mortality of patients with decompensated cirrhosis. Further, signs and symptoms of hepatic encephalopathy and other indicators of further decompensation are assessed at visits. The clinic utilizes a teaching model to instruct residents who are able to gain procedural skills for improving professional fulfillment and competency.

KEY LESSONS FOR DISSEMINATION: A primary care physician-run outpatient paracentesis clinic is not only cost-effective, but beneficial by training residents for procedural competence and comfort, providing opportunity to longitudinally care for complex patients, creating avenues for discussion of advanced directives, and providing opportunities to intervene in medication adjustments or recognition of deterioration such as hepatic encephalopathy or spontaneous bacterial peritonitis.

REVOLUTIONIZING HEALTHCARE IN A RESOURCE-LIMITED CLINIC: LEVERAGING FREE AUTOMATION SOFTWARE FOR POPULATION HEALTH

Hector Mora¹; Erika Berrios²; Robin Canada¹. ¹Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; ²Temple University, Philadelphia, PA. (Control ID #4063586)

STATEMENT OF PROBLEM/QUESTION: Many resource-limited clinics, particularly those focusing on the care of uninsured patients, face technological constraints on the ability to perform proactive, intervisit care due to the limitations of the available electronic medical record (EMR) system. Panel management is a critical component of patient-centered care and without built-in population health tools, clinicians are limited in their ability to track, monitor, and coordinate the care of acute and chronic illnesses. This a particular challenge for undocumented patients, who often work multiple jobs to make ends meet and a visit to the doctor’s office can result in lost wages. Without intervisit care, patients need to return to clinic to review results and adjust medications. Ultimately, this results in under-utilization of preventative health services and over-utilization of emergency health services.

DESCRIPTION OF PROGRAM/INTERVENTION: The innovative use and implementation of the free automation software ‘Microsoft PowerAutomate’ for chart review and panel management has significant potential to revolutionize population health level care for undocumented patients. This software can comprehensively and efficiently automate the review of patient charts to identify gaps and trends in care, review previous treatments, and provide timely medical outreach and interventions.

MEASURES OF SUCCESS: 1) Improvement in Patient Health Outcomes: evaluate the success of chronic disease management using HbA1c levels and BP readings. 2) Increased Efficiency in Healthcare Delivery: Measure the reduction in time healthcare providers spend on manual chart reviews. 3) Enhanced Access to Care: Track the number of regular health check-ups as well as no-show. 4) ROI Analysis: Conduct a return-on-investment analysis to assess the financial benefits of using free automation software versus the costs of implementing the more advanced EMR software.

FINDINGS TO DATE: We have found an increase in uncontrolled diabetes since the onset of the COVID-19 pandemic as well as the number of patients who have missed follow up visits. We have decreased the time to efficiently review dozens of medical charts from hours to minutes. We are working on investigating the cost-savings this technology could produce when compared to more expensive EMRs with in-built population health tools such as Epic.

KEY LESSONS FOR DISSEMINATION: The strategic integration of free automation software such as Microsoft PowerAutomate can significantly improve the care of underserved patients by creating the ability for panel management in clinics where it is lacking. This can help identify patterns and barriers to care that otherwise go unnoticed. Clinics should ensure that the automation tools they adopt comply with healthcare privacy regulations and have robust data security measures. Modern healthcare requires a proactive approach to preventative care and the implementation of existing, easily accessible software can help bridge the gap in health disparities for underserved communities.

RIGHT-SIZING THE PRIMARY CARE TEMPLATE TO MEET MODERN DEMANDS

Robert Doolan²; Lauren A. Drake¹; Lisa M. Schilling³; Brittney R. Fraumeni⁴; Gena Weir⁵; Mark Earnest¹. ¹Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ³Medicine, University of Colorado System, Denver, CO; ⁴Department of General Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ⁵Internal Medicine, University of Colorado System, Denver, CO. (Control ID #4064629)

STATEMENT OF PROBLEM/QUESTION: Can providing dedicated time to complete asynchronous clinical tasks improve provider satisfaction without negatively impacting patient satisfaction, patient access, and clinical revenue?

DESCRIPTION OF PROGRAM/INTERVENTION: Asynchronous clinical work (e.g. patient messages, clinical results, prescriptions) is essential to modern primary care – implemented effectively, it helps assure optimal health outcomes while strengthening relationships between patients and clinical teams. The volume of asynchronous work has grown steadily for years without adequate adjustment in time allotted for the work. This mismatch between clinical expectations and time allotted for providers to perform the work is a fundamental threat to primary care, contributing to burnout, loss of job satisfaction, reductions in clinical effort, and shortened careers.

We conducted a 2-phase trial in academic general internal medicine (GIM) practices in the Mountain West to evaluate schedule templates that provided dedicated asynchronous work time within clinic sessions. In Phase 1, 19 (35%) providers across four GIM practices piloted 5 templates for 3-months. Using a Plan, Do, Study, Act framework, we evaluated feasibility and implementation. Two models performed sufficiently well to advance to Phase 2 where we expanded participation to 47 (70%) provider volunteers across five GIM practices over a 6-month period.

MEASURES OF SUCCESS: We compared pre- and post- pilot surveys and thematically analyzed post-pilot focus groups to assess pilot provider satisfaction (burnout, intentions to continue clinical effort, benefits of pilot). We compared participants to non-participant reference providers using a difference-in-differences approach to assess patient satisfaction, patient access, work RVUs, and visit volume.

FINDINGS TO DATE: Participant satisfaction with the pilot was high. Participant burnout scores decreased by .2 and intentions to reduce clinical FTE decreased by 35%. Participants shared positive feedback on the pilot, citing flexibility and autonomy during the clinical workday as the biggest benefits.

Percent providers meeting the benchmark for a “provider listened” patient satisfaction item was a relative 7% higher in participants.

Percent providers meeting the access benchmark decreased in both groups but decreased more in participants (-22% participants, -8% reference).

Among participants, visit volume and wRVUs decreased by 5% and 2% respectively, significantly less than the 12.5% hypothesized based on the percent of time blocked.

KEY LESSONS FOR DISSEMINATION: 1. Modifying clinical templates to better align the workday with modern expectations of primary care can be successfully implemented and evaluated.

2. Protecting time for asynchronous tasks, while allowing for flexibility and autonomy, positively impacted provider satisfaction.

3. Patient satisfaction improvement suggests the pilot may have improved providers’ abilities to be more present during patient encounters.

4. Dedicated asynchronous work time was less costly in terms of financial impact and patient access than predicted.

SCALING SUCCESS: OPTIMIZING A DIABETES OUTREACH BY TEXT (DOT) BOT PROGRAM TO LARGE PRIMARY CARE POPULATIONS

Marguerite Balasta, Gaibriel De Guzman, Alice Rossmann, Anna U. Morgan, Gillian Lautenbach, Corinne Rhodes. Department of General Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4055370)

STATEMENT OF PROBLEM/QUESTION: Evaluate the effectiveness of scaling a bidirectional text-based outreach program called the Diabetes Outreach by Text (DOT) bot, which targets patients who have lapsed in diabetic care, to a large primary care population.

DESCRIPTION OF PROGRAM/INTERVENTION: Patients with diabetes are considered uncontrolled by HEDIS measures if they do not have a documented A1c in the past 12 mo or if documented A1c is > 8. The Diabetes Outreach by Text (DOT) bot was developed in partnership with Penn Way to Health to engage this population. Bulk automated, bidirectional text-messages supported by a non-clinical population health (PH) staff member offers labs to diabetic patients without an A1c in the past year. We previously presented data from a DOTbot pilot at 3 urban academic primary care practices in 2022-23 which showed increased efficiency and efficacy compared to prior phone and patient portal-message outreach campaigns in 2021-22. In 2023, DOTbot was scaled to 6 academic and 17 community-based internal medicine and family medicine located in urban and suburban locations. Collectively, these practices serve 134,051 patients of whom 25,312 have diabetes and 51.6% of patients who are considered uncontrolled have not had a documented A1c in the past year. Our team studied the effectiveness of scaling and which populations most benefited from the intervension.

MEASURES OF SUCCESS: Primary outcome is completion of A1c labwork within 60 days of patient receiving text outreach. Secondary outcomes include scheduled office visits and predictive factors of lab completion including patient demographics, payor, and practice characteristics. Process metrics include engagement of patients interacting with bulk text messages and/or the PH team.

FINDINGS TO DATE: DOTbot pilot data showed patients engaged more by text compared to portal-messages and phone calls, completed more A1c labs within 60 days, and utilized less staff time (9 mins vs. 50 minutes per patient). Scaling to larger and more diverse population maintained patient engagement at 46% vs. 45%. Less patients completed labs (13% vs. 27.0% p-value = 0.000001) compared to pilot, but rate of completion was still better compared to previous outreach efforts by portal-messages and calls (13% vs. 11.8%, p-value = 0.0000025). We will highlight modeling that examines which patient attributes predict completion of primary endpoint of lab completion. Despite reductions in lab completion, 225 of the 293 patients or 74.74% who did complete labwork had a controlled A1c. We were able to reach a large number of patients with efficiencies that are inherent within this model.

KEY LESSONS FOR DISSEMINATION: Attendees will understand the necessity of assessment during implementation of a text-based outreach from pilot to scale. DOTbot is more efficient in terms of person time and similarly effective in primary end point of lab completion across a large population. It is important to assess patient characteristics predicting lab completion to help personalize implementation efforts across varied and diverse clinical populations.

SECRET-SHOPPERS EVALUATE CLINICAL CARE: IMPLEMENTATION OF A MULTI-SITE, COLLABORATIVE ASSESSMENT OF AN URBAN PUBLIC HEALTHCARE SYSTEM

Lisa Mayevsky¹; Jeffrey A. Wilhite²; Khemraj Hardowar³; Lisa Altshuler⁴; Christine P. Beltran²; Kathleen Hanley⁵; Kevin Chen⁶; Ross Kristal⁶; Hannah Jackson⁶; Andrew Wallach⁷; Colleen Gillespie⁸; Sondra R. Zabar². ¹Program for Medical Education Innovations and Research, NYU Langone Health, New York, NY; ²Medicine, New York University Grossman School of Medicine, New York, NY; ³PRMEIR, New York University, South Ozone Park, NY; ⁴Medicine, NYU Langone Health, New York, NY; ⁵Internal Medicine, NYU Langone Health, New York, NY; ⁶Office of Ambulatory Care, New York City Health and Hospitals Corp, New York, NY; ⁷Medicine, NYU/NYC Health + Hospitals, New York City, NY; ⁸PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY. (Control ID #4064726)

STATEMENT OF PROBLEM/QUESTION: Developing a methodology for engaging healthcare systems in quality improvement projects using Unannounced Standardized Patients

DESCRIPTION OF PROGRAM/INTERVENTION: Decades of research suggest that unannounced standardized patients (USPs) can effectively evaluate patient care. We – an urban academic medical research group – partnered with a large safety net hospital system with multiple primary care sites to implement a quality improvement project using USPs to assess post-pandemic in-person and telehealth care.

Project partners co-produced goals, cases, and feedback measures aligned with the health system’s priorities. Case development occurred through collaborative meetings, ultimately choosing hypertension with housing insecurity as the primary chief complaint.

The implementation plan involved planning, engaging, executing, and evaluating the project. The planning phase included actor recruitment, training, and site visits to five ambulatory care sites to understand clinic flow. Biweekly meetings with the Office of Ambulatory Care leadership were held to share data progress, troubleshoot issues, and reflect on feedback. Data encompassed USP checklists and feedback for in-person and telehealth visits. Two waves of 8 in-person and 8 telehealth visits were planned for each site, with refined audit and interview feedback reports distributed to site leadership and clinicians. Using the CFIR framework, we collected site-level data and gathered staff and leadership perspectives on factors influencing USP visit feedback actions (Damschroder 2022).

MEASURES OF SUCCESS: We plan to assess changes that clinic leadership implemented after receiving the initial data and then deploy USPs to assess their impact. Our ongoing systematic data collection will deepen the health system's understanding of clinical practice in telehealth vs in-person visits, including follow-up care, lab work, and care experience.

FINDINGS TO DATE: To date, 9 actors were trained and have conducted 22 in-person and 24 telehealth visits across four of the five sites. Feedback report distribution is underway across these four sites. Focus groups were completed at two of five sites, one of which has also completed informant interviews. The feedback and data have been presented at the local sites’ operations meeting to inform ongoing quality improvement work. While clinicians and staff note the benefits of telehealth as increasing accessibility, they identified both patient and system-level factors that present challenges to quality telemedicine care.

KEY LESSONS FOR DISSEMINATION: Implementing a cross-site telehealth quality improvement project in an urban, safety-net healthcare system is feasible when working closely with both health system and individual site leadership. Research goals must closely align with healthcare system needs.

Moreover, audit and feedback cycles that test both patient- and system-level interactions allow for changes to clinical workflow that can better serve patients and improve their experience. USP methodology could adapt as the goals and targets within a system change.

SEEING CLEARLY - REFLECTIONS ON THE DEVELOPMENT OF A MOBILE VISION CARE PROGRAM TO ADDRESS THE CRISIS OF VISION INEQUALITY IN THE UNITED STATES

Colin R. Whitmore¹; Minda Liu¹; Sonja Knudson¹; Rebecca AbuAyed¹; Rashika K. Shetty¹; Margaret Eckerstorfer¹; Jonathan Kirsch¹; Shahid Jaffer^1,2. ¹Mobile Health Initiative, University of Minnesota Twin Cities School of Medicine, Minneapolis, MN; ²Hospital Medicine, University of Minnesota Medical School Twin Cities, Minneapolis, MN. (Control ID #4027228)

STATEMENT OF PROBLEM/QUESTION: Inequality in access to traditional vision care services is a public health emergency that disproportionately impacts underserved communities - how can mobile vision screening help bridge this gap?

DESCRIPTION OF PROGRAM/INTERVENTION: There is an overwhelming need for vision problem prevention and treatment in the United States. 93 million adults in the US are at high risk for vision loss and 1 in 11 individuals who need glasses are unable to afford them. Poor access to vision screening due to socioeconomic factors are compounded by geographical inequalities in access to vision providers. Nearly 25% of US counties do not have a single ophthalmologist or optometrist. To address both dimensions of this clear public health disparity, our institution piloted an interprofessional mobile vision program in 2021. We planned pop-up vision clinics with local partners in accessible, familiar community locations.

Intervention stages were stratified by complexity and availability of resources. The most basic vision screening evaluation assesses visual acuity with referral to local vision clinics for patients with abnormal exams. This requires establishing relationships with local nonprofits and community agencies with the use of a voucher system. It includes public health interventions like safety glasses, sunglasses, and dietary interventions for vision preservation.

The next level of screening assesses and corrects for refractive error, and includes the provision of both prescription and reading glasses. This stage requires additional expertise (OD/MD) and volunteer coordination, equipment (i.e. an autorefractor and trial lens kit), and more complex care coordination.

The most intensive screening program builds upon the previous by implementing tools such as portable slit lamp, tonometer, and binocular indirect ophthalmoscope to assess for advanced eye diseases in addition to visual acuity. An OD and volunteers are needed during and after events as care coordination at this stage includes the distribution of frames, follow-up calls, and measuring patient satisfaction.

MEASURES OF SUCCESS: The number of patients seen at the vision clinics, the number of corrective lenses ordered, and patient satisfaction.

FINDINGS TO DATE: The following findings were collected from the program:

- Number of patients seen: 331

- Rate of refractive error: 141/331 (42.5%)

- Diabetes prevalence: 55/331 (16.7%)

- Diabetic pts needing yearly DR screening: 11/55 (20%)

- Referrals provided to OSH clinics: 45/331 (13.6%)

Improved understanding of the community has led to the development of more targeted services. Follow-up calls measured patient satisfaction to be 9.33/10, demonstrating the ability of the program to meet our population's needs.

KEY LESSONS FOR DISSEMINATION: - Mobile vision screening is a viable way to reduce vision health disparities.

- Reaching target populations is key to a successful community health initiative.

- Our experience serves as a testament to the feasibility of a mobile vision program and underscores the potential for others to replicate this model with similar success.

TACKLING OVER-EMPANELMENT: A CASE SERIES OF STRATEGIES IN ACTION

Christopher Hanks¹; Seuli B. Brill²; Harrison Jackson¹; Shengyi Mao³; Nathan Richards¹; Neeraj H. Tayal⁴; Daniel E. Jonas⁵; Jodi M. Grandominico-Bradford⁵. ¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, Ohio State University College of Medicine, Columbus, OH; ³General Internal Medicine, The Ohio State University College of Medicine, Columbus, OH; ⁴Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ⁵Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4064250)

STATEMENT OF PROBLEM/QUESTION: Managing panel size, including reducing faculty panels that are above target, is an integral part of primary care practice management that directly impacts patient access, safety, and physician wellness.

DESCRIPTION OF PROGRAM/INTERVENTION: Optimizing panel sizes for primary care physicians (PCP) is an important goal but remains understudied¹. Over-empanelment is a likely contributor to poor patient access, lower quality care, and physician burn out². Academic PCPs have high patient contact time early in their careers which often decreases as academic roles accrue, potentially resulting in over-empanelment. We describe a case series of four over-empaneled PCPs who employed different strategies for decreasing their panel size within a Midwest academic medical center General Internal Medicine division with about 90 faculty. Primary care panel size targets were 1800 weighted patients for a full-time clinical FTE for this cohort. PCP 1 opted for gradual attrition while setting firm boundaries not to accept any new patients. PCP 2 instituted a plan to redistribute patients to partner PCPs within the office when patients voiced concerns about access or when patients were seen by partner PCPs for acute visits. PCP 3 personally identified patients to transfer to other PCPs within their practice and assisted with identifying a new PCP. PCP 4 sent a patient portal message to all their patients explaining their situation, and requested patients consider switching to a new PCP. Patients were also provided a list of PCPs accepting new patients. Patients who replied via the patient portal were scheduled with a new PCP by registration staff.

1. Paige N., et al. Ann Intrn Med 2020 4;172(3):195-201

2. Christiansen E., et al. J Am Assoc Nurse Pract 2016;28(8):423-8

MEASURES OF SUCCESS: reductions in panel size

FINDINGS TO DATE: Over 12 months, relative to target panel size, PCP 1 patient count (PC) decreased from 1223 to 1083 and weighted panel size (WPC) decreased from 131.1% to 119.6%, PCP 2 PC decreased from 1109 to 949 and WPC decreased from 149.1% to 123.6%, and PCP 3 PC decreased from 475 to 367 and WPC decreased from 283.7% to 212.7%. PCP 4 patients received portal messages 2 months ago. To date, PC has decreased from 1158 to 1130 and WPC has decreased from 157.6% to 153.3%

KEY LESSONS FOR DISSEMINATION: For academic PCPs who increase non-clinical duties after establishing a full panel, decreasing panel size to match clinical time is challenging. Our findings suggest that more intentional panel size reduction strategies may result in more rapid reduction than passive attrition strategies. More structured strategies could be developed to reduce barriers for clinicians taking on increased academic responsibilities .

TAKING ADVANTAGE OF THE UNANTICIPATED BENEFITS OF TELEMEDICINE IN TRANSITIONS OF CARE

Margot Rogers, Juhee McDougal, Vasudev Mandyam. Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA. (Control ID #4015853)

STATEMENT OF PROBLEM/QUESTION: Can telemedicine transitions of care clinic visits reduce hospital readmission rates for our most vulnerable patients?

DESCRIPTION OF PROGRAM/INTERVENTION: Patients being discharged from the hospital are vulnerable to readmission to the hospital. Telemedicine can serve to help improve access to care for high risk patients. Our clinic is primarily telemedicine and incorporated a multidisciplinary team model to improve patient’s access to health care and address other barriers to care at the time of their hospital discharge follow up visit. A nurse served in a care management role, making the initial telephone assessment within 48 hours of discharge and ensuring all care coordination and follow up tasks were completed. A pharmacy liaison and patient navigator addressed medication access, transportation, and other social barriers. A population health specialist coordinated outreach and scheduling. The transitions of care clinic is staffed by general internists who do focused clinical outpatient sessions. We have expanded our access to all moderate to high risk General Internal Medicine discharges and are working to share this model of care with other departments at our institution.

MEASURES OF SUCCESS: Compare outcomes in patient show rates and readmission rates between patients seen in our transitions of care clinic to patient seen within our General Internal Medicine department but outside of this clinic, as well as to patients not seen for a hospital discharge follow up appointment. We will also compare how these outcomes differ for patients seen via telemedicine versus in person in our transitions of care clinic as well as within our overall GIM clinic.

FINDINGS TO DATE: Telemedicine transitions of care appointments have significantly higher show rates compared to in-person transitions of care appointments. Telemedicine transitions of care appointments have comparable show rates to all telemedicine appointments within GIM. Patients seen in the GIM transitions of care clinic have demonstrated lower readmission rates across all readmission risk scores when compared to patients being seen in GIM but outside of the transitions of care clinic and to patient without follow up appointments from January to June of 2022. We will measure revenue generated from CPT codes designated for transitions of care visits in order to make this a sustainable clinical model.

KEY LESSONS FOR DISSEMINATION: Key lessons from this model are the value of using a team-based approach to address barriers to health care access and the value of telemedicine in the realm of transitions of care given the large improvement in show rate. Implementing this clinic model reduces readmission rates. Given these findings, we have expanded our clinic to cover all moderate-to-high risk GIM patient discharges at our hospital system. Our next steps include continuing to evaluate the clinic’s impact on readmissions on a quarterly basis, and completing a more thorough case review to determine specific factors with the highest impact in reducing readmissions.

TAKING CHARGE OF DISCHARGE: A PATIENT-CENTERED APPROACH

Michelle Yan¹; Kimia Ziafat²; Yassine Lamzadrhi³; Emmanuel Cruz⁴; Tyler Anstett⁵; Michelle Knees⁶; Sam Porter⁷. ¹Medicine, Washington State University, Pullman, WA; ²Medicine, The University of British Columbia Faculty of Medicine, Vancouver, BC, Canada; ³Faculty of Medicine, Universite Cheikh Anta Diop de Dakar, Dakar, Dakar, Senegal; ⁴School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ⁵Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ⁶Department of Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ⁷Medicine, University of Colorado, Denver, CO. (Control ID #4054134)

STATEMENT OF PROBLEM/QUESTION: Using design thinking, create an intervention that improves patients’ understanding of their health and medications at the time of discharge.

DESCRIPTION OF PROGRAM/INTERVENTION: Previous studies have shown that high-quality discharge communication is vital for patient safety, with poor communication leading to decreased medication adherence, unplanned readmissions, and poorer health outcomes. Using HCAHPS data from a hospital medicine division at an academic institution, we identified opportunities for improvement in patients' understanding of their medications and their responsibility to manage their health post-discharge. As part of a student-led, faculty-supported health innovation program, we sought to improve patient education and communication at discharge using design thinking and user-centered design techniques such as user interviews, Points of View, Journey Mapping, “How Might We” statements, and iterative prototyping and testing.

MEASURES OF SUCCESS: We started by interviewing patients, providers, and discharge nurses to better understand discharge experiences. These interviews were consolidated into “points of view” and a journey map reflecting time-pressured, disjointed, and passive delivery of large amounts of information to patients. There was a mismatch between patient-reported confidence, which was high, and knowledge in managing their health, which was lower.

We next drafted “How Might We” statements on increasing engagement during the discharge process to improve knowledge retention and confidence. We created three solution prototypes. Prototype one, a simplified information page (SIP), was adapted from a previously published project that highlighted the most important discharge information and encouraged active learning with patient notetaking. Prototype two was a combination of a graphic storyboard and calendar for post-discharge appointments. Prototype three was a discharge kit with stationery and stickers, allowing patients to interact directly with the standardized discharge instructions.

FINDINGS TO DATE: Nurses and patients provided feedback on the prototypes to drive iterative improvements. Patients disliked the test-like and complicated SIP. They were enthusiastic about the graphic storyboard organization but felt it had too many components. The discharge kit was well-received, and nurses predicted benefits for patients who are less engaged or have lower health literacy. Based on this feedback, the next iteration of the prototype was a simplified version of the storyboard accompanied by the discharge kit, which was being actively utilized at the time of our program conclusion.

KEY LESSONS FOR DISSEMINATION: Our project identified that patients do not have a clear understanding of their responsibilities or medications at discharge especially if the process does not actively engage patients. Design thinking allows for low-cost prototypes that yield rich and rapid feedback on workflow and patient-centered solutions with the potential to increase patient engagement and empower active involvement during the discharge process.

THE "HYBRID" GENERALIST - A NOVEL SOLUTION TO DECLINING INTEREST IN PRIMARY CARE

Rae Witt, Chelsea R. Navarrette. Internal Medicine, University of Nebraska System, Lincoln, NE. (Control ID #4062509)

STATEMENT OF PROBLEM/QUESTION: Primary care is experiencing a growing - and soon to be critical - shortage of providers. A contributing factor is new residency graduates opting for hospitalist careers or pursuing fellowships.

DESCRIPTION OF PROGRAM/INTERVENTION: At an urban Midwestern academic institution, a “hybrid” general internist role has grown rapidly in popularity. In this model, two partnered physicians alternate monthly between primary care and hospitalist practice. Hybrids thus maintain skills and knowledge across the whole spectrum of internal medicine and can balance the practice of longitudinal patient care with the high-acuity pace and shift scheduling of hospital medicine. Work-life integration and burnout mitigation strategies are increasingly valued by the next generation of physicians. The hybrid model minimizes the challenges encountered in both practice areas. Compared to ambulatory practice, hybrids have a smaller patient panel (less inbox demands) and a more competitive salary. Whereas compared to hospitalists, hybrid schedules allow for more nights, weekends, and holidays away from work, while also valuing long-term relationships with patients. This diversity of practice may be protective against burnout.

MEASURES OF SUCCESS: The IRB has approved our proposal to study the impact of the hybrid model through interviews and focus groups of hybrid physicians. We plan to qualitatively describe the experience of hybrids regarding their enjoyment of work, rate of burnout, and efficiency of practice. In addition, we will compare hybrid physician to traditional PCP performance in metrics such as value-based targets, patient satisfaction ratings, and clinic productivity.

FINDINGS TO DATE: Since the introduction of the hybrid role in 2016, our institution has hired 13 traditional ambulatory physicians, while losing 14 (including retirement). Alternatively, we have hired 16 hybrid physicians, with 3 choosing to leave the hybrid role (1 transitioned to outpatient only, 2 became hospitalists).

KEY LESSONS FOR DISSEMINATION: The hybrid model creatively tackles challenges inherent in traditional primary care and hospitalist jobs. It is an attractive career for general internists who wish to practice full-spectrum care without sacrificing work-life integration. Due to the model's simplicity and flexibility, it is reproducible in a variety of settings - whether large, small, academic, or private. Offering a hybrid practice may allow for increased recruitment and retention of primary care physicians.

THE BOOST PROGRAM: A QUALITATIVE APPROACH TO UNDERSTANDING HOW CLINICIAN-INITIATED OUTREACH IMPACTS RURAL WOMEN AND TRANSGENDER VETERANS

Kara Zamora^1,4; Jenny K. Cohen^1,3; Caitlin L. McLean²; Mariam Jacob¹; Tara Stacker⁵; Evana L. Mack⁵; Jennifer Childers⁶; Mayan Bomsztyk^6,1. ¹General Internal Medicine, San Francisco VA Health Care System, San Francisco, CA; ²VA Central Western Massachusetts Healthcare System, Leeds, MA; ³University of California San Francisco School of Medicine, San Francisco, CA; ⁴University of California San Francisco, San Francisco, CA; ⁵Medicine, San Francisco VA Health Care System, San Francisco, CA; ⁶VISN 21 VA Sierra Pacific Network, Pleasant Hill, CA. (Control ID #4063602)

STATEMENT OF PROBLEM/QUESTION: Rural women and transgender Veterans face barriers to healthcare access and are not receiving timely, high-quality, gender-specific healthcare services.

DESCRIPTION OF PROGRAM/INTERVENTION: The Boost Program is a pilot telehealth outreach service whose goal is to connect rural women and transgender Veterans to Veterans Health Administration (VHA) services by providing real-time primary and urgent care delivered by a Nurse Practitioner (NP). Clinician-driven outreach is a radical departure from typical outreach and raises questions about impact and value. Thus, we are conducting a program evaluation to better understand how clinician-driven outreach impacts access to care.

MEASURES OF SUCCESS: Qualitative research methods are central to understanding the experiences of key stakeholder groups’ interactions with a novel outreach program. Two qualitative researchers conducted 30-minute semi-structured telephone interviews that were tailored for each stakeholder group: Veterans, health system leaders and clinic staff members.

We used a Rapid Qualitative Analysis approach developed for health services research settings, which allows for qualitative results to be analyzed concurrently with data collection to inform the development and testing of interventions and implementation strategies. To synthesize data, we used a matrix analysis approach to identify emergent themes.

Several key themes emerged across 24 stakeholder interviews.

FINDINGS TO DATE: Veterans described the outreach calls from the Boost Team NP as an overall positive experience that helped their concerns feel heard. Veterans reported a dearth in healthcare services in rural communities, citing specific barriers to accessing VHA care (e.g., lack of specialty care services and high staff turnover at their local VHA outpatient clinics) and difficulty accessing limited community care offerings through VHA referrals. Given this, the telehealth outreach calls administered by an NP were seen as a helpful resource to connect them to needed services.

Health system leaders and clinic staff reported that the Boost Program outreach calls provide additional support to under-resourced clinic staff, educate Veterans about services, and ensure that Veterans with gender-specific care needs are matched to the appropriate care team. Respondents also shared that the outreach signals to women and transgender Veterans that VHA is concerned with gender-specific needs, thus helping to build trust and promote culture change.

KEY LESSONS FOR DISSEMINATION: The qualitative arm of our program evaluation suggests clinician-driven outreach positively impacts access to care for rural women and transgender Veterans and alleviates burden on rural clinic staff. The Boost Program bridges health disparity gaps by linking low-resourced Veterans to care, reducing isolation, and offloading under-staffing in local clinics. Next steps include completing Veteran interviews and the quantitative arm of our program evaluation.

THE DOCTOR WILL SEE YOU(R CHART) NOW: USING AMBULATORY INTERPROFESSIONAL ECONSULTS TO EXPAND ACCESS TO TIMELY CARE

Jennifer L. Girard, Andrew M. Land, Kimberly A. Smith, Eric Wallace. College of Medicine, The University of Alabama at Birmingham College of Arts and Sciences, Birmingham, AL. (Control ID #4061379)

STATEMENT OF PROBLEM/QUESTION: In an overcrowded healthcare system, innovative solutions are needed to deliver timely access to care despite a growing shortage of providers.

DESCRIPTION OF PROGRAM/INTERVENTION: Our large southeastern academic medical system serves as a major referral center for our state and region, though many of our specialties struggle with new patient access. We developed an ambulatory interprofessional eConsult service aiming to provide timely asynchronous provider-to-provider consultation for questions not necessitating the patient being seen in person by the specialist. This program is available to all ambulatory providers across our institution and currently includes 35 services. With an eConsult, ordering providers receive recommendations documented in the chart within 1-2 business days. The consulting providers receive compensation for eConsults (wRVU similar to a low-complexity return visit) and can subsequently focus their clinic time on patients who benefit from being seen in-person.

Following the initiation of the program, we endeavored to expand the eConsult program beyond the walls of our institution. Given most counties in our state qualify as health professional shortage areas, we are piloting a program to allow providers in a local Federally Qualified Health Center access to our eConsult services.

MEASURES OF SUCCESS: To understand the utilization and success of the program, we track the number of eConsults requested and completed as well as final 90-day outcomes from each consult. We also collect data on the turnaround time for completed eConsults, time spent by specialists on eConsults, and the number and affiliation of providers requesting consults.

FINDINGS TO DATE: To date, more than 3,500 eConsults have been requested by over 380 providers across 41 different departments or divisions. Approximately 76% of all eConsult requests come from primary care and related fields. 45% of all eConsult requests are for benign hematology, rheumatology, and neurology. 64% of requests can be handled with the eConsult alone without an in-person visit. In 9% of cases, the patient was scheduled for an expedited clinic visit without an eConsult. Almost 60% of eConsult requests are answered within 24 hours. 61% of completed eConsults take 10 minutes or less for the consultant to complete.

For external eConsults to be successful, we found that easy, reliable, and efficient access to pertinent outside records was critical.

KEY LESSONS FOR DISSEMINATION: - The eConsult program is valuable in addressing the overcrowded healthcare system with long wait times for subspecialty services in an efficient and cost-effective manner.

- External eConsults can serve patients outside the health system, but easy and reliable access to records is critical.

THE EFFECT OF COMPLIMENTARY HOME BLOOD PRESSURE CUFFS ON BLOOD PRESSURE CONTROL

Kristin Huang, Tyngwei Chen, Julie Tishler. Internal Medicine, Tufts Medical Center, Boston, MA. (Control ID #4062034)

STATEMENT OF PROBLEM/QUESTION: Hypertension control remains suboptimal and there are multiple barriers to patients being seen frequently in person. Telehealth management of hypertension is possible, but not all patients have home BP cuffs or are able to purchase them. We distributed free home blood pressure cuffs for better blood pressure data and management.

DESCRIPTION OF PROGRAM/INTERVENTION: At our urban academic medical center’s primary care practice, we serve 10,950 patients with hypertension (HTN), 32% of whom are classified as uncontrolled (BP > 140/90). Home BP measurements are known to be more accurate than one-time clinic-based BP, but most insurance programs do not cover home BP cuffs and purchasing a cuff out-of-pocket presents a financial hardship to many of our patients. Additionally, in-person clinic access is often limited.

Through a grant from our medical system, we implemented a pilot program of free BP cuff distribution to patients with uncontrolled HTN whose medical insurance did not cover home BP cuffs and for whom purchasing a BP cuff would be a financial hardship (based on patient assertion or PCP judgment).

MEASURES OF SUCCESS: We tracked the patients who received complimentary home BP cuffs over 6-12 months and recorded the number of in-person visits, number of televisits, HTN-related medication changes made over the course of the study, and last BP in our electronic health record (EHR). Our aim was to increase the rate of HTN control in these patients from 0% (by definition) to 25%.

FINDINGS TO DATE: Since the program started, we have distributed 102 BP cuffs to patients. Only 67 of the 102 patients who received a BP cuff had uncontrolled HTN at the time of enrollment. We excluded the 35 patients who started the study with well-controlled HTN from the analysis. Of the 67 patients with uncontrolled HTN at the time of BP cuff distribution, 36 (54%) had changes made to their medication. 41 (61%) of the 67 patients had a most recent BP in our EHR that is considered controlled (<140/90). As the number of follow-up visits (telemedicine or in-person visits) increased, the likelihood that a patient’s blood pressure became controlled also increased, though this started plateauing after six follow-up visits.

KEY LESSONS FOR DISSEMINATION: Complimentary home BP cuffs can be a helpful tool in the outpatient management of HTN. Acting on uncontrolled BP by making medication changes is correlated with a great likelihood that the ending BP is controlled.

THE INBOX CONUNDRUM: STANDARDIZED PROTOCOLS FOR PRIMARY CARE TEAMS TO ADDRESS PATIENT MESSAGES

Matthew Mulligan¹; Stacy Johnson¹; Michael Flynn²; Sofia Loucao²; Erin McCormack²; Molly Conroy¹. ¹General Medicine, The University of Utah School of Medicine, Salt Lake City, UT; ²University of Utah Health, Salt Lake City, UT. (Control ID #4060423)

STATEMENT OF PROBLEM/QUESTION: Primary care providers (PCPs) are overwhelmed by inbox management, and new approaches to inbox management are critically needed.

DESCRIPTION OF PROGRAM/INTERVENTION: We implemented standardized protocols for medical assistants and nurses to respond to patient messages at 11 primary care clinics in November 2022. Staff were empowered to use the protocols to manage messages more efficiently. Protocols were embedded within an Epic SmartText, used standardized Smartphrases for patient and PCP communications, and covered topics such as general questions, form requests, test result questions, and medication questions. Protocols were jointly developed by primary care and nursing leadership, and staff were trained in their use.

MEASURES OF SUCCESS: We defined success as both the uptake of SmartText use and a decrease in measures of PCP inbox workload, including percentage of MyChart message threads routed to a PCP, number of PCP touches per message thread, and PCP time in inbox per clinic visit. We plan to survey clinic staff to evaluate their experience with the SmartText. We used interrupted time series analysis to evaluate outcomes.

FINDINGS TO DATE: PCPs (n=119) received an average of 0.6 (SD 0.4) MyChart message threads per clinic visit. PCPs were routed 51.5% of MyChart message threads starting in November 2021, which decreased by 0.2% (p<0.01) per month prior to the intervention date (November 2022), decreased 2.7% (p=0.01) during the month of the intervention, and then increased 0.6% (p<0.01) per month following the intervention. PCPs had 1.6 touches per MyChart message thread starting in November 2021, which decreased by 0.02 (p<0.01) per month prior to the intervention, did not change 0.00 (p=0.92) during the month of the intervention, and increased 0.02 (p=0.01) per month after the intervention. SmartText use increased to 52% of MyChart message thread in March of 2023; however, in linear regression models SmartText use was not associated with changes in clinician touches or percentage of message threads routed to the clinician. PCPs spent 1.4 minutes in the inbox per visit in November of 2021, and there were no statistical changes before, during or after the intervention.

KEY LESSONS FOR DISSEMINATION: It is essential for health systems to address patient message burden, and standardized protocols for primary care teams is an attractive option. However, the use of standardized protocols did not decrease available measures of clinician workload in primary care. Many factors may contribute, including adherence to protocols (by both staff and PCPs) and overall complexity of messages that defy standard management. More work is needed to identify barriers to success, evaluate other impacts of standardized protocols such as safety and consistency of message handling, and identify other metrics of PCP workload.

THE PRE-VAIL CLINIC: A NOVEL MULTIDISCIPLINARY CLINIC TO IDENTIFY AND TREAT THE RIGHT TARGETS FOR PATIENTS WITH CHRONIC PAIN AND DISABILITY

Shawn P. Corcoran¹; Steven J. Krause²; Lauren Tiemeier²; Christina D. McGhee²; Lora Black²; Kim Karels². ¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4065012)

STATEMENT OF PROBLEM/QUESTION: Traditional pain clinics focus on pain without structurally focusing on the impact of pain within the context of our patients’ lives. We created a interdisciplinary pain clinic to address that gap.

DESCRIPTION OF PROGRAM/INTERVENTION: Chronic pain is a major cause of suffering and disability in the United States, impacting roughly 100 million adults. Traditional pain management programs focus on reducing pain, often with a biomedical approach using medications and procedures. For the many patients with chronic pain, these traditional approaches have failed. This failure stems in part from the fact that chronic pain often has many causes, including past physical, mental, emotional, and spiritual traumas. In turn, treatment using solely a biomedical approach can be both misguided and potentially harmful. Acknowledging this, as well as the widespread evidence supporting interdisciplinary, biopsychosocial-based programs, we created PRE:VAIL – Pain Rehabilitation and Education: Values and Activities that Improve Life. Operating in an outpatient clinic accessible to an underserved population as part of a Midwest academic medical center, our program uses a biopsychosocial model of assessing and managing pain as suffering related to past traumas. We aim to reduce suffering and disability by offering active therapies that help repair the damage of these traumas. The therapies include Pain-focused Physical Therapy and Pain Psychology, along with Pain-focused Occupational Therapy, Nutrition, and Medical Management. These therapies target four aspects of life that decline due to pain: mobility, function, coping, and quality of life.

MEASURES OF SUCCESS: Global pain level – Defense and Veterans Pain Rating Scale, 0 – 10

Mobility – 5x sit-to-stand test

Mobility – 2-minute walk test

Function – Fear avoidance belief questionnaire

Coping - Pain catastrophizing scale

Quality of life – Patient-Reported Outcomes Measurement Information System (PROMIS)-29

FINDINGS TO DATE: The table below lists data demonstrating the effectiveness of PT in improving mobility and function in past iterations of our program. This data is from 55 patients who completed an average of 12 sessions of pain-focused PT over a 12-week period from September 2018 – August 2021.

Mobility – 5x sit-to-stand test: Pre-test 19.4 sec, Post-test 12.3 sec, Goal < 15 sec

Mobility – 2-minute walk test: Pre-test 0.9 m/sec, Post-test 1.2 m/sec, Goal >= 1.2 m/sec

Function – Fear avoidance belief questionnaire: Work-related fear avoidance decreased by 13 points, Physical activity-related fear avoidance decreased by 10.2 points

KEY LESSONS FOR DISSEMINATION: a. Chronic pain has multiple etiologies, often stemming from past trauma, and traditional methods focusing just on the physical etiologies of, and biomedical treatments for, chronic pain and disability are often ineffective.

b. Multimodal, interdisciplinary care, including pain psychology, pain-focused physical therapy, occupational therapy, nutrition, and medical support, can improve mobility, function, coping, and quality of life in the setting of chronic pain.

TRACKING SUBSTANCE USE DISORDER RELATED HEALTHCARE VISITS IN REAL TIME

Kriya Patel¹; Tyler Winkelman²; Riley Shearer²; Nayanjot K. Rai²; Bjorn Westgard². ¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Medicine, Hennepin Healthcare, Minneapolis, MN. (Control ID #4064015)

STATEMENT OF PROBLEM/QUESTION: Harms from substance use are complex and rapidly evolving. Real time data of acute healthcare data can help inform a nimble public response.

Substance Use Disorder (SUD) related acute healthcare remains common, and the specific substances involved are changing. A deeper understanding of real-time trends and communities impacted can help inform responses.

DESCRIPTION OF PROGRAM/INTERVENTION: This project tracks SUD-related emergency department (ED) and hospital (IP) use in real time, with data updated monthly. Monthly reports on ED/IP visits allow for tracking substance use and informing policy and practice in near-real time. Data are used by the County’s Public Health Department and Opioid Coordinator.

Data from six health systems was analyzed from electronic health records from 1/1/2012 to the present using a distributed data model that utilized the OMOP common data model. We identified SUD-related ED/IP encounters using SUD-related ICD-10 coding.

MEASURES OF SUCCESS: Development of a regularly updated dashboard that is user friendly for County stakeholders

FINDINGS TO DATE: Opioids:

Opioid-related visits have been consistently high since 2017 but decreased slightly in 2023. Opioid-related encounters for Black/African American population have increased more than any other group since 2021. Rates for Native American residents are many times higher than other racial/ethnic groups and have consistently been so since 2012. Since 2019, opioid-related visits have increased more for men than for women, leading to a pronounced gender gap. Opioid related visits is highest among ages 18-24 and 25-34; in 2023 usage in 18-24 age range overtook ages 25-34

Psychostimulants:

Psychostimulant-related visits hit an all-time high in 2021 and have declined since that time. Rates of psychostimulant use for Native American residents have been consistently high, but rates for black residents have increased dramatically in the past two years. The largest share of psychostimulant visits continues to be for those ages 25-44, with usage in 18-24 year-olds declining. Men have more visits than woman, and the gender gap has widened steadily over time. Proportionally psychostimulant use accounts for the same amount of SUD visits for each gender.

Alcohol:

Alcohol-related visits have declined since a peak in 2019 and are at their lowest levels since 2012. Alcohol visits continue to account for more SUD-related hospital visits than opioids and psychostimulants combined. Rates for Native American residents are many times higher than other racial/ethnic groups. Alcohol visits account for the majority of SUD visits for men. Alcohol visits are make up a similar proportion of SUD-related visits across racial groups.

KEY LESSONS FOR DISSEMINATION: EHR data can be used to effectively monitor trends in substance-related healthcare use. Trends are near real-time and can be used to inform policy at a local level.

UTILIZING A DATA ANALYTICS PLATFORM TO IDENTIFY CHRONIC KIDNEY DISEASE IN A GENERAL INTERNAL MEDICINE PATIENT POPULATION BY ESTIMATED GLOMERULAR FILTRATION RATE (EGFR)

Jasmin Tharakan²; Sonya Wegman²; Mary C. Wirtz¹; Jodi M. Grandominico-Bradford¹; Neeraj H. Tayal²; Daniel E. Jonas¹; Thomas Brancazio³. ¹Internal Medicine, The Ohio State University, Columbus, OH; ²Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ³Information Technology, The Ohio State University, Columbus, OH. (Control ID #4064321)

STATEMENT OF PROBLEM/QUESTION: Chronic Kidney Disease is a common problem within general internal medicine but may go unrecognized, having significant implications for patient care and medication safety.

DESCRIPTION OF PROGRAM/INTERVENTION: Chronic Kidney Disease (CKD) is defined by persistently decreased glomerular filtration rates (GFR) and is present in 14.2% of US adults^(1). Unrecognized, markers of progression (e.g. albuminuria), monitoring, and new therapeutics may be missed. Medication adjustments may not occur. Using Qlik sense©, a data visualization tool, we developed a platform to streamline identification of patients with CKD in a Midwestern academic general internal medicine division consisting of 8 practices and ~70,000 total patients. Focusing on one practice of ~11,000 patients from 6/2023 until 8/2023, we performed an initial screen of patients who had an outpatient chemistry panel in the electronic medical record (EMR) with an eGFR <60mg/dl. Three physicians (two faculty, one PGY2 resident) performed an analysis of patients screening positive. eGFRs were calculated using the CKD-EPI equation beginning February 1^st, 2022. Prior to this, they were calculated using the MDRD calculation. For each patient, they visualized trending eGFR values over a rolling 60-month period. If a patient had at least two eGFRs <60mg/dl for more than three months, they were designated as having CKD. Pts were further stratified by CKD stage (ie: 3A, 3B, 4, or 5). EMR problem lists were reviewed for accuracy. CKD with stage was added to problem lists or adjusted to correct stage based on our analysis. Prior to changing problem list entries, physicians in the clinic were educated on the project so they might anticipate seeing new CKD diagnoses on problem lists. We anticipated patients might also see new diagnoses of CKD on portal accounts. Templated notes were developed to explain the quality improvement project based on patient inquiries.

MEASURES OF SUCCESS: Number and percentage of patients newly identified as meeting criteria for CKD based on eGFR (overall and by stage).

FINDINGS TO DATE: 1,196 patients were initially screened as having a decreased eGFR. 532 (44.4%) met diagnostic criteria for CKD. Of those with CKD, 40.0% (213/532) did not have CKD on their active problem list. Of those, 77.9% (166/213) had stage 3a CKD, 19.2% (41/213) had stage 3b CKD, 1.4% (3/213) had stage 4 CKD, and 1.4% (3/213) had end stage renal disease (ESRD). Analysis to identify accurate staging of CKD on the patient’s problem list revealed: Of 319 meeting criteria for CKD with CKD documented on the problem list, 60 patients (18.8%) had the incorrect stage of CKD documented.

KEY LESSONS FOR DISSEMINATION: CKD is under recognized within our patient population. A data visualization tool and dedicated team to screen a population for CKD is an efficient way to identify patients who may meet criteria for this diagnosis. This may assist clinicians to identify and manage patients with CKD to provider proper monitoring (ie: protienuria), therapeutics (SGLT2/ACE), and medication adjustments for safety.

VIRTUAL WAITING ROOM: AN INNOVATIVE APPROACH TO IMPROVING SAME-DAY ACCESS TO PRIMARY CARE

Mayu S. Runge, Paul A. Pirraglia. Internal Medicine, Baystate Health, Springfield, MA. (Control ID #4034384)

STATEMENT OF PROBLEM/QUESTION: Community health centers are safety-net facilities that provide primary care for the medically underserved communities. High no-show rates have been identified as one of the significant barriers to care for this population as it reduces access to others in need for an appointment and can lead to potential adverse health outcomes.

DESCRIPTION OF PROGRAM/INTERVENTION: Our aim was to improve outpatient access and low visit utilization for our health center clinicians due to high no-show rates of patients. We created a virtual waiting room (VWR) for same-day telehealth urgent appointments to fill the no-show slots in clinician schedules. The pilot began in April 2023 and fully implemented by June 2023.

The VWR pool was utilized as follows:

Health center patients with acute concerns were triaged by the nurses on the phone for telehealth appropriateness, and informed that a clinician will contact them within 24 hours to address the acute issue.

The patient’s name would then be placed into the VWR pool in the EMR to wait for a virtual visit with a clinician.

When a scheduled patient fails to show up within their 15-minute grace period, the clinician would access the VWR pool and add a patient from the pool into their no-show slot to initiate a virtual visit.

MEASURES OF SUCCESS: Metrics used to assess the implementation were: Utilization rate, number of patients seen, patient wait time, and provider satisfaction.

FINDINGS TO DATE: There was immediate improvement of our weekly utilization rate from 76% to as high as 94% post-implementation. When comparing clinician-level utilization in FY23 (post-implementation) to the same months in FY 22 (pre-implementation), there was overall increased utilization and total number of patients treated. The VWR has successfully improved healthcare accessibility to our population by ensuring that clinicians' schedules were filled to capacity. We had improved patient wait time as most patients’ concerns were addressed within a 24 hour time frame. Most visits were for acute concerns:UTI, ENT infections, anxiety and asthma/COPD exacerbations. Our findings suggest a trend in diversion from the emergency facilities allowing for the primary care clinicians to address the acute issues for their patients. A clinician survey showed 100% positive feedback, with comments noting improved productivity and access for patients. Clinicians felt empowered that they could help out the huge demands put onto the triage nurses to find appointments for acute visits while still having control over filling the open slots.

KEY LESSONS FOR DISSEMINATION: By taking advantage of the telehealth and in-person hybrid care model prompted by the COVID-19 pandemic, the VWR has allowed us to use the unfilled or no-show slots in clinician schedules and fill them with urgent same-day telehealth visits. This innovation is reproducible in outpatient offices that utilize telehealth visits, and can be easily implemented to help improve timely access for patients, in other areas of medicine.

WHAT'S OUR SECRET SAUCE? SUCCESSFUL RECRUITMENT INTO ONE ACADEMIC GENERAL INTERNAL MEDICINE PRACTICE

Elizabeth A. Murphy, Deborah Blazey-Martin. General Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4054258)

STATEMENT OF PROBLEM/QUESTION: There is a national shortage of Primary Care Physicians as many providers are leaving the field and fewer trainees are entering the field. For almost a decade, our academic internal medicine practice struggled with recruiting faculty to help replace our aging workforce.

DESCRIPTION OF PROGRAM/INTERVENTION: We have used several interventions which we feel have led to successful recruitment. 1) We started a Primary Care Track in 2020 which is funded by our clinical system and our department of medicine. The track was designed based on best national practices and has used innovative clinical experiences to allow for frequent exposure of residents to long-term primary care physicians (Presented at APDIM Spring 2023). 2) Faculty recruits were offered competitive salaries and sign on bonuses, 6 clinical sessions per week, 1 precepting session with residents per week, protected time for scholarly activity (research, DEI, medical education), an assigned mentor, and a structured onboarding program. 3) Clinic Transformation where each provider works 1:1 with Medical Assistant. 4) Support from our Department of Medicine leadership.

MEASURES OF SUCCESS: We aim to recruit diverse and talented faculty with varied scholarly and clinical interests. We would like to recruit our own trainees, but also those from outside our system. We want to retain our current faculty and insure professional satisfaction for all.

FINDINGS TO DATE: We had not recruited any residents from our training programs from 2014-2021. Since July of 2021, we have recruited 15 new faculty members to our division, including 3 graduates of our primary care track, 5 graduates of our categorical internal medicine program (including 3 former Chief Residents). We have recruited brand new faculty and established faculty from other institutions. Another recent primary care graduate joined our Community Medical Group practice, which is also part of our clinical system. We have seen a renaissance of our division. We are currently limited by exam room space or would be able to recruit more faculty. We encourage all our residents to interview at various practices in our area, but still a majority choose to join our academic practice. We are surveying our current faculty to determine the reasons they joined our practice and why they stay.

KEY LESSONS FOR DISSEMINATION: We have been able to successfully recruit diverse and talented faculty into our General Internal Medicine academic practice despite so many other systems struggling to do so. We think our "Secret Sauce" is a combination of factors: 1) Creating a culture of support and collegiality within the division of General Internal Medicine and Department of Medicine. 2) Market fair salary and sign on bonuses. 3) Primary Care Track with innovative approaches to clinical experiences and curriculum, including increased resident time with established, respected faculty. 4) Protected time for areas of interest. 5) Mentorship and structured onboarding program. 6) Focus on faculty retention as well as recruitment.

Innovation in Healthcare Delivery (IHD) - Health Care Policy and Health Services Research

AN INNOVATIVE MEDICAID PAYMENT STRATEGY TO INCREASE AVAILABILITY OF LONG-ACTING REVERSIBLE CONTRACEPTION IN PRIMARY CARE: EARLY RESULTS FROM 1 ACCOUNTABLE CARE ORGANIZATION

Chloe Ciccariello¹; Viveka R. Prakash-Zawisza^2,3; Felicia Heider⁴; Robert Weinstein⁵; Deana Blanc⁵; Lydia E. Pace⁶. ¹General Internal Medicine, Boston Medical Center, Boston, MA; ²MassHealth, Boston, MA; ³University of Massachusetts Chan Medical School, Worcester, MA; ⁴Population Health Services, Boston Medical Center, Boston, MA; ⁵Signature Healthcare, Brockton, MA; ⁶Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4064868)

STATEMENT OF PROBLEM/QUESTION: Increased primary care provision of long-acting reversible contraception (LARC; i.e. IUDs and contraceptive implants) is critically needed in the United States, but to be successful, strategies must address 2 major challenges: a) the risk of reproductive coercion observed in initiatives designed to encourage LARC use among historically marginalized communities; b) implementation barriers to incorporating LARC in primary care.

DESCRIPTION OF PROGRAM/INTERVENTION: In April 2023, our state launched an innovative primary care payment model for primary care practices within its Medicaid Accountable Care Organizations (ACOs). Instead of paying primary care practices via fee-for-service, Medicaid now pays practices with tiered per-member-per-month (PMPM) capitated fees. To receive higher-tier payments, clinics must offer specific high-value clinical services, including on-site LARC. This policy promotes LARC availability rather than incentivizing provision, potentially lessening the risk of reproductive coercion. In addition, the policy permits practices to develop their own strategies to incorporate LARC. This may permit contextually relevant strategies, though it could also leave practices with insufficient implementation support.

It will be important to examine how the policy impacts delivery of patient-centered comprehensive care. To provide initial feedback to policymakers and ACO leaders, we examined the early experience of one Medicaid ACO responding to the policy change.

MEASURES OF SUCCESS: We compared the number of primary care clinicians trained in LARC, the number of clinics where LARC is available and the type of LARC services provided within 1 ACO before and after the policy change.

FINDINGS TO DATE: This ACO has 8 primary care practices, including 2 pediatric and 6 family medicine practices. Prior to 2023, none of these practices provided on-site LARC. Since the policy change was announced in April 2022, the ACO has trained 16 providers on contraceptive implant insertion/removal and ensured that all 8 practices offer on-site LARC. None of the practices yet provide IUDs on-site.

Implementation barriers observed by the authors included the need for upfront resources for training providers and ensuring sufficient volume to maintain clinicians’ skills.

KEY LESSONS FOR DISSEMINATION: These findings demonstrate the promise of Medicaid primary care sub-capitation as a strategy to improve availability of LARC services, a service that has been a policy priority in many states and is particularly important in the post-Roe era. Further examination is needed to understand the degree to which this policy advances comprehensive patient-centered contraceptive care and identify how to optimally support primary care practices across the diverse ACO landscape.

EFFECTS OF TELEHEALTH PROVISION ON PRIMARY CARE PROVIDER LABOR SUPPLY

Sooyeon Song^1,2; Aaron Legler²; Jessica Lum²; Steven Pizer^1,2; Christine Yee^1,2. ¹Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA; ²Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, West Roxbury, MA. (Control ID #4061316)

STATEMENT OF PROBLEM/QUESTION: During the COVID-19 pandemic, clinicians experienced a doubling in turnover due to increased care demands and practice turmoil, prompting insurers to introduce policies that enhanced care capacity, including telehealth flexibility.

DESCRIPTION OF PROGRAM/INTERVENTION: Telehealth flexibility expanded the types of providers eligible for reimbursement for telehealth visits and the range of services that patients can receive through telehealth. Telehealth offers flexibility in work location and eliminates travel time, potentially influencing labor supply of providers. We examine the effects of telehealth provision on primary care provider labor supply decisions.

MEASURES OF SUCCESS: Primary care provider labor supply decisions, focusing on clinical hours, provision of visits, and turnover.

FINDINGS TO DATE: We study 10,929 physicians, physician assistants, and nurse practitioners nationwide. They collectively worked 255,905 provider-months, conducting 26,752,170 primary care encounters between January 2019 and December 2021 at the Veterans Health Administration. Using an instrumental variables approach, we estimate three linear probability models for physicians and separately for physician assistants and nurse practitioners: 1) whether the provider quit in a certain month, 2) monthly clinic hours for a provider, and 3) monthly number of visits for a provider. Because video visit provision may be endogenous, we instrument for video visit provision using county-level internet broadband coverage. Increases in patient internet broadband coverage is associated with increases in a provider’s video visit provision.

After controlling for the facility nurse turnover rate, county unemployment rates, the number of physicians per capita, newly confirmed COVID-19 cases in the county, facility, quarter, and quarter trend fixed effects, we find that a 10% increase in the video visit rate decreases monthly clinic hours for primary care physicians by 1.76 (1.51%) hours and 0.80 (0.66%) hours for physician assistants and nurse practitioners. In terms of the total number of visits, the 10% increase in video visit rate decreases the number of visits by 2.96 (2.72%) for physicians and 1.61 (1.72%) for physician assistants and nurse practitioners. There were no statistically significant effects of video visit provision on turnover for any type of provider. These results are robust when using other instruments of internet broadband coverage.

KEY LESSONS FOR DISSEMINATION: We find that telehealth reduces clinical hours and visits for primary care providers during COVID-19 but didn't affect turnover. It's uncertain whether providers spent less time on patient care or shifted focus to administration, educationl, or research, potentially due to administrative burdens associated with telehealth.

Some are concerned that telehealth may serve more as a supplement to in-person visits rather than as a substitute, thereby increasing utilization and spending without providing additional benefits. However, our results suggest that telehealth did not increase the number of visits in primary care.

Innovation in Healthcare Delivery (IHD) - Health Equity, Diversity, and Inclusion

ADDRESSING INEQUITIES IN PATIENT EXPERIENCE AT AN ACADEMIC MEDICAL CENTER: A MIXED-METHODS EVALUATION

Rohan Rastogi¹; Rupal J. Shah²; Malcolm John⁴; Heather A. Nichols³; Amy Lu⁵; Tung Nguyen¹; Jane Jih¹. ¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA; ³Health Experience Excellence, UCSF Medical Center, San Francisco, CA; ⁴Infectious Diseases, University of California San Francisco, San Francisco, CA; ⁵Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. (Control ID #4046449)

STATEMENT OF PROBLEM/QUESTION: Despite increased attention to US health inequities, patients from marginalized groups continue to report worse healthcare experiences, a crucial aspect of care quality. Not only does the Centers for Medicare Services (CMS) require public reporting of patient experience scores for their value-based payment programs, but positive patient experience is also associated with increased care plan adherence, improved health outcomes, and lower costs. Limited evidence on effective interventions to improve patient experience for minoritized groups poses a challenge for health systems seeking to achieve care quality equity.

DESCRIPTION OF PROGRAM/INTERVENTION: At our academic medical center, an interdisciplinary team of health system patient experience and health equity leaders and anti-racism researchers formed in response to a presentation of preliminary disaggregated patient experience data from an employee racial affinity group. This team aimed to improve institutional care quality by exploring and addressing inequities in the experience of marginalized patients. We will link electronic health record data with adult, pediatric, inpatient, and ambulatory patient experience surveys, including Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey (PG) instruments, to evaluate patient experience disparities across demographic, healthcare use, and disease burden domains. We will also do a qualitative analysis of written patient comments from these surveys. Throughout, we will collaborate with patients and caregivers to understand findings and design and implement interventions.

MEASURES OF SUCCESS: Improvement in HCAHPS and PG scores for patients from racial and ethnic minority groups. Secondary measures: a) implementation of initiatives to address inequities, b) institutionalization of collaboration between health system leaders and anti-racism researchers.

FINDINGS TO DATE: In 2022, 771,535 adult ambulatory patient visits and 32,512 adult inpatient discharges received surveys, with a response rate of 11% for both. After adult ambulatory visits, Asian, Black, Latinx, Native American/Alaskan Native, Southwest Asian/North African, and multi-racial patients rated their experience as below the institutional average on all 16 patient experience metrics, while non-Hispanic White patients rated their experience as above the average on all metrics. Similarly, after adult inpatient discharges, patients from nearly all minoritized groups rated their experience as below the average on almost all metrics, while non-Hispanic White patients rated their experience above the average on most metrics.

KEY LESSONS FOR DISSEMINATION: Though CMS publicly shares and reimburses based on aggregate CAHPS metrics, health systems should proactively seek to identify inequities in patient experience across multiple patient sociodemographic and health-related domains. Collaboration between researchers, health system leaders, patients, and caregivers represents an opportunity for data-driven, patient-centered intervention implementation and dissemination.

CLOSING THE DISPARITY GAP: LEVERAGING INTERDISCIPLINARY COLLABORATION AND PATIENT VOICE TO IMPROVE BLOOD PRESSURE CONTROL AMONG BLACK PATIENTS

Heather Martin^3,2; Heather Leisy²; Ben Rasmussen^2,1; Mark Moubarek⁴; Reshma Gupta^1,2. ¹Department of Internal Medicine, University of California Health or University of California Davis Health, Morgan Hill, CA; ²Population Health, University of California Davis, Sacramento, CA; ³Pharmacy, UC Davis Health, Sacramento, CA; ⁴Emergency Medicine, University of California Davis, Sacramento, CA. (Control ID #4064041)

STATEMENT OF PROBLEM/QUESTION: Disparities with the control of hypertension (HTN) are seen nationally within the Black population and at our health system 6.1% disparity gap existed prompting a need to develop a comprehensive population health approach to reduce this disparity.

DESCRIPTION OF PROGRAM/INTERVENTION: We are a large, West Coast academic health-system with 12 ambulatory care medical clinics providing primary care to approximately 160,000 patients, of which close to 20,000 are diagnosed with HTN. Our institution’s core values are anchored in principles of diversity, equity, & inclusion. In late 2021 we identified a 6.1% disparity gap (62.5% vs. 68.7%) in HTN control (<140/90 mm Hg) for Black persons compared to persons of all other demographic groups. An interdisciplinary, multispecialty workgroup developed a population health initiative to reduce this disparity and associated cardiorenal outcomes risks from uncontrolled HTN. The process included obtaining patient voice, leveraging EHR technology to prompt clinical decision making, educating providers in diversity inclusive communication practices, and adopting care team models using clinical pharmacist HTN management services. Additionally, ongoing metric tracking with continuous process improvement increased achievements over time.

MEASURES OF SUCCESS: Qualitatively we assessed feedback from providers and staff monthly during our interdisciplinary, multispecialty workgroup as well as from patient input. Quantitatively we tracked monthly hypertension control rates defined as an average of the last two ambulatory BP values <140/90 mm Hg and compared between the Black population and all other race demographic groups. Utilization data and provider feedback on EHR best practice alerts were obtained. Additionally, during our pilot phase of the outreach intervention we gained patient input and tracked effectiveness measures for numbers of outreach attempts made, intervention appointments scheduled with a clinical pharmacist, declinations to participate, and patients who we were unable to contact. This showed an average 30% scheduling rate for pharmacist HTN management appointments and a further 50% completion rate for intervention appointments.

FINDINGS TO DATE: After implementing the intervention, the HTN control disparity decreased from 5.5% in September 2022 to 1% as of October 2023. This disparity reduction was achieved while overall HTN control across all demographics improved by 5.0%, and the population denominator increased by 1600 additional patients. Evaluation of clinical pharmacist's impact on HTN control efforts in this population found a shorter time to achieve BP <140/90 mm Hg compared to standard of care (41 vs 100 days, p<0.001). Project efforts are ongoing and will include new intervention methods launching in 2024.

KEY LESSONS FOR DISSEMINATION: The use of an interdisciplinary, multi-modal population health initiative to reduce health disparities and improve hypertension control. Implementation strategies for leveraging EHR technology solutions and ancillary health providers to improve health equity.

COMMUNITY HEALTH WORKER STRATEGY FOR HYPERTENSION IMPROVEMENT: LESSONS FROM IMPLEMENTING WITH AN EXISTING MULTI-DISCIPLINARY TEAM IN A LARGE ACADEMIC CENTER.

Thao-Vi Dao¹; Elizabeth R. Pfoh²; Nazleen Bharmal¹; Robert W. Jones³; Alex Rennick³; Sarah Reinhold⁴. ¹Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; ²Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ³Value Based Operations, Cleveland Clinic, Cleveland, OH; ⁴Community Health Equity, Cleveland Clinic, Cleveland, OH. (Control ID #4060017)

STATEMENT OF PROBLEM/QUESTION: Community Health Workers (CHWs) can improve health equity by serving as a trustworthy bridge between patients and health systems. However, there are no clear guidelines on how to integrate CHWs within existing multi-disciplinary teams. Prior efforts utilized research support, which can ease the resource and integration burden. Sharing real-world experience can inform health systems of best practices as they integrate CHWs into their existing care models.

DESCRIPTION OF PROGRAM/INTERVENTION: We integrated CHWs within a multidisciplinary team of RN care coordinators (RN-CC) and licensed social workers (LISW) who work remotely in a large health system in the Mid-West region. We launched a 3-month pilot focused on patients with hypertension in August of 2023. CHW care consisted of monthly interactions in a clinic or the patient’s home. We included patients with specific value-based payor, an uncontrolled or no BP reading in the last 12 months, ≥2 ED visits, and residing in an urban zip code with significant socioeconomic disadvantage. The RN-CC team called eligible patients to enroll in care coordination and introduced the CHW as a team member. Once enrolled in care coordination, the LISW was able to receive referrals for social needs from either the RN-CC or the CHW.

MEASURES OF SUCCESS: We focused on implementation outcomes: the number of patients contacted, the number enrolled, whether social need screenings were completed, and if needs were met. We also measured the completion of personalized health goals and change in BP control 3- and 6-months post-intervention.

FINDINGS TO DATE: Initially, only 38 patients were eligible. Of those, we could not reach 8, and 13 were excluded due to residing in a facility. Seven were enrolled with RN-CC and LISW team but declined a referral to a CHW. Ten referrals were sent to the CHW team. Of those, only 2 patients were enrolled; the remainder were unable to reach or uninterested.

During team discussions, which included direct CHW feedback, we decided that phone calls for a population affected by financial constraints are ineffective. Based on experience with other CHW pilots, we believe CHWs are more successful when introduced in person to build trust with patients who are potentially ambivalent towards the healthcare system. We are modifying our pilot to embed the CHW team in the clinic and synchronize the initial CHW visit to co-occur with a primary care office visit, allowing the opportunity for warm handoff from provider to CHW.

KEY LESSONS FOR DISSEMINATION: Using asynchronous telephone calls for outreach is an ineffective approach for connecting to patients affected by health disparities. It is important to consider how CHW services are initiated to maximize the uptake of services. Other health systems considering CHW deployment should minimize the number of contact points before the patient reaches the CHW and try to ensure the connections occur in person.

FOSTERING RELATIONSHIPS WITH COMMUNITY PARTNERS TO GUIDE INPATIENT HEALTH EQUITY FOCUSED IMPROVEMENT WORK

Archna Eniasivam¹; Martha Ockenfels-Martinez²; Elizabeth Dzeng³; James D. Harrison²; Ian James⁴; Michael Lezak⁴; Isoke Femi⁴; Holly Joshi⁴. ¹Internal Medicine, Pediatrics, UCSF, San Francisco, CA; ²Division of Hospital Medicine, University of California San Francisco, San Francisco, CA; ³Medicine, University of California San Francisco, San Francisco, CA; ⁴GLIDE, San Francisco, CA. (Control ID #4060277)

STATEMENT OF PROBLEM/QUESTION: Hospitals often engage in work to improve patient care and ensure health equity but rarely seek direct engagement from patients and communities.

DESCRIPTION OF PROGRAM/INTERVENTION: Our division of hospital medicine based in an urban academic health system sought to engage with the communities we serve. We identified GLIDE, a well established local Community Based Organization (CBO), focused on care of historically marginalized communities. Based off their recommendation, members of our division partnered with GLIDE to develop opportunities for our division to participate in a 3-day Institutionally sponsored training program coordinated by GLIDE to reduce stigma and harm experienced by patients in the hospital. Over the next 18 months, we deepened the engagement, inviting GLIDE to speak at Divisional meetings and partnering in obtaining funding to further this work.

This resulted in a successful $80,000 grant to pilot a series of community listening sessions faciliated by GLIDE, with a goal of better understanding their clients’ experiences with our hospital and to identify areas for improvement from their perspectives. Participants for the listening sessions were recruited directly by the GLIDE and compensated for their time. Twenty-six people participated in the first two hour-long listening sessions.

MEASURES OF SUCCESS: Upcoming sessions will bring together a subset of the community members and inpatient health equity initiative leaders to discuss the community members’ recommendations and brainstorm ways they could inform future and current equity initiatives. Implementation will be facilitated by a $50,000 divisional commitment to support a community-focused QI project. We plan on using surveys and focus groups to evaluate the partnership, specifically the model of community listening sessions as a way for community members to share their experiences with the healthcare system and offer guidance on improving care.

FINDINGS TO DATE: Listening sessions were recorded and thematically analyzed generating a list of themes: (1) Patients and community are experiencing racism and stigma at the hospital; (2) Make sure healthcare workers attend anti-racism and anti-discrimination training; (3) Emergency departments are understaffed causing many downstream effects; (4) Patients who use substances are treated worse; (5) There isn’t an easy way for community members to share their hospital experiences with the healthcare system; (6) We should continue to go into the community to get guidance on improving the hospital experience; (7) There is an urgent need to expand the hospital’s services around social support resources; (8) A sterile hospital environment limits healing.

KEY LESSONS FOR DISSEMINATION: Partnering with CBOs provides a crucial opportunity to incorporate patient and community voices, especially from historically marginalized populations, to inform inpatient health equity focused improvement work. Divisional investment, taking time to build a relationship, and deference to CBOs expertise to guide involvement are important first steps.

LGBTQ+ GERIPACT: A NEW WAY TO ADDRESS AN OLDER HEALTH INEQUITY

Jennifer Carnahan¹; Joy L. Lee²; Heather A. Sperry⁵; Alexia M. Torke³; Michelle M. Hilgeman⁴. ¹Medicine, Indiana University School of Medicine, Indianapolis, IN; ²General Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; ³Medicine, Indiana University, Indianapolis, IN; ⁴Research & Development Service, Tuscaloosa VA Medical Center, Tuscaloosa, AL; ⁵Richard L Roudebush VA Medical Center, Indianapolis, IN. (Control ID #4029211)

STATEMENT OF PROBLEM/QUESTION: LGBTQ+ older Veterans have unique needs but may be reluctant to disclose their identity to healthcare providers due to a history of discrimination in the military and in healthcare.

DESCRIPTION OF PROGRAM/INTERVENTION: GeriPACT (Geriatrics Patient Aligned Care Team) outpatient clinics are primary care clinics in the VA system for older Veterans who need dedicated geriatric care. LGBTQ+ Veterans Care Coordinators are located at every VA facility to help LGBTQ+ Veterans access the healthcare they need. However, there are no VA clinics designed to meet the needs of aging LGBTQ+ Veterans. These older adults are at higher risk of adverse outcomes such as delayed care, decreased functional ability, increased cardiovascular disease, and nursing home admission. Older LGBTQ+ Veterans, experts in geriatric care, and experts in LGBTQ+ care completed six interviews to identify best practices and recommendations on the clinic design as part of a needs assessment and formative evaluation. In October 2023, the geriatrics service at the Indianapolis-based Richard L Roudebush VAMC established the first LGBTQ+ GeriPACT. The clinic is embedded within the GeriPACT service. All clinicians interacting with the patients undergo cultural competency training. The medical director of the clinic is a geriatrician with additional training in LGBTQ+ clinical care.

MEASURES OF SUCCESS: Both qualitative and quantitative measures of success will be collected. To assess acceptability and adequacy of the services provided, semi-structured interviews will be conducted with Veterans who have been clinic patients for a year or more. The interviews will also address whether and how Veterans felt the services provided were SGM identity-affirming. We will also evaluate the Veterans’ need and ability to access services intended to address social determinants of health such a community food programs, home health support, and housing counseling as well as their use of such services. Finally, because LGBTQ+ Veterans are often unable to rely of family of origin for aging support, we have set a goal for 100% of patients to receive information about advance directives, including the healthcare power of attorney (HCPOA).

FINDINGS TO DATE: A referral order was created and added to the electronic health record system and went live on October 01, 2023. To date, seven patients have been referred to the clinic. Of those referred to the clinic, all have received information about advance directives and one has documentation of an HCPOA. Expanded outreach activities, which will include educational talks, outreach to LGBTQ+ elder groups, and promotion at VA health fairs, will begin in February 2024.

KEY LESSONS FOR DISSEMINATION: LGBTQ+ older adults need support for healthy aging. This includes dialogue about advance directives and who they trust to make decisions for them should they no longer be able to make decisions for themselves. Access to specialists with dual training in LGBTQ+ health and geriatrics is a unique feature of the newly implemented LGBTQ+ Geri-PACT that may improve outcomes over time.

THE IMPACT OF SOCIAL DETERMINANTS OF HEALTH ASSESSMENT ON LINKING PATIENTS LIVING WITH HIV TO COMMUNITY RESOURCES

Pritika Sharma¹; Wei Tang²; Vihanga Perera¹; Rebecca Glassman². ¹Internal Medicine, Westchester Medical Center Health Network, Valhalla, NY; ²Medicine, Westchester Medical Center, Valhalla, NY. (Control ID #4061105)

STATEMENT OF PROBLEM/QUESTION: Social determinants of health (SDOH) are a key factor in health disparities. Addressing these needs minimizes inequities in healthcare outcomes. Patients living with HIV (PLWH) are a historically vulnerable population at higher risk of having multiple SDOH needs that affect their ability to adhere to treatment, remain retained in care, and prevent the spread of infection.

DESCRIPTION OF PROGRAM/INTERVENTION: This intervention was conducted at a primary care clinic providing comprehensive services to PLWH. All patients are insured through Medicare, Medicaid, or the AIDS Drug Assistance Program (ADAP). Around 48% of patients are racial and ethnic minorities. To better understand the needs of these patients and connect them to potential internal and community resources, medical case managers used a standardized screening tool for SDOH developed by the New York State Department of Health AIDS Institute (NYSDOH AI). The screening tool addresses the 5 categories of SDOH using 11 questions. For patients with positive screens in any category, the case managers will determine appropriate resources needed, and in some cases, connect them to appropriate intensive case management programs embedded within the clinic.

MEASURES OF SUCCESS: We aim to enroll nearly 100% of patients with three or more unmet SDOH needs to intensive case management programs. All patients will be reassessed at 6 months to determine improvement in unmet SDOH needs.

FINDINGS TO DATE: SDOH assessments were completed for 82 adults and 13 adolescents and young adults (AYA, aged 11-29) between September 1, 2023, and December 31, 2023. In our adult population, financial instability was the leading unmet SDOH need (73%), followed by health literacy (44%), social isolation (41%), food insecurity (33% to 43%), transportation issues (26%), housing (20%), employment assistance (17%), disabilities (15%), and social stigma (10%). Among the AYA population, transportation was the leading unmet SDOH need (54%), followed by health literacy and social isolation (38% each), food insecurity (15% to 23%), employment assistance, disabilities, and social stigma (8% each). Around 60% adults and 40% AYA had three or more SDOH needs. As a result of intervention, case managers have enrolled over 40% adults and over 90% AYA to appropriate intensive case management programs. The impact of these interventions will be assessed at 6 months by administering SDOH assessment tool.

KEY LESSONS FOR DISSEMINATION: SDOH needs are often difficult to identify and address in a clinical setting despite their contribution to limited engagement in care and control of chronic illnesses. The unmet need for equity in SDOH can be surprisingly high and lead to poor health outcomes. The NYSDOH AI SDOH Assessment Tool proved to be efficient for screening for needs, and intensive case management is an effective method for identifying community resources. Early identification and intervention can improve health inequities and yield better patient outcomes. Our method can be extrapolated to outpatient clinics catering to underserved populations.

THINKING OUTSIDE OF INCARCERATION: EVALUATING TRANSITIONAL SERVICES BY MEETING PEOPLE WHEN INCARCERATED

Yadhu Dhital¹; Kristi Batzel²; Divya Venkat³; Thomas Robertson⁴; CAROL L. BIBBENS². ¹Internal Medicine Residency Program, Allegheny General Hospital, Pittsburgh, PA; ²Center for Inclusion Health, Allegheny Health Network, Pittsburgh, PA; ³Internal Medicine, Allegheny General Hospital, Pittsburgh, PA; ⁴Internal Medicine, Allegheny General Hospital, Pittsburgh, PA. (Control ID #4063726)

STATEMENT OF PROBLEM/QUESTION: Former inmates face heightened morbidity and mortality risks, encountering challenges in care management, highlighting the need for innovative methods to engage individuals as part of an effective post-incarceration care model.

DESCRIPTION OF PROGRAM/INTERVENTION: Within two weeks of release, former inmates face about a 13-fold increase in all-cause mortality compared to the general population, primarily due to drug overdose. Only 15-25% of former inmates seek healthcare beyond the ED in the initial 12 months of release due to disengagement during incarceration, a fragmented release process, discrimination, stigma, and limited coordination by community-based providers.

This abstract introduces the RIvER Clinic, an outpatient post-incarceration care model promoting collaboration among healthcare providers, community health workers (CHWs), social workers (SWs), and jails. To our knowledge, our clinic is the only one in the US that engages patients in jail, utilizing CHWs and SWs to establish a meaningful connection. CHWs/SWs meet people in jail, building trust and providing support and advocacy. Upon release, the County Jail notifies the clinic, allowing CHWs/SWs to contact individuals within 24 hours of release. CHWs/SWs can immediately engage a clinician for an initial telemedicine assessment. Multiple touchpoints occur before the first in-person visit, during which the clinician manages healthcare needs, including substance use disorder, while CHWs/SWs address social determinants of health. This comprehensive approach bridges healthcare gaps, ensures enhanced continuity of care, and improves health outcomes.

MEASURES OF SUCCESS: Engagement of CHWs/SWs with inmates

Post-release telemedicine or in-person follow-up with the RIvER Clinic

FINDINGS TO DATE: From July 2021 to February 2023, the RIvER Clinic received 565 patient referrals from the county jail, and all (100%) engaged with the CHWs/SWs while incarcerated. Of these referrals, 101 followed up with an in-person visit, while 464 faced challenges in post-incarceration contact. Out of 464 individuals, 270 were unreachable, 43 initially engaged but stopped responding, 43 reported no substance use needs, 24 were uninterested, 21 received interim prescriptions but stopped responding, 17 attended rehabs upon release, 14 were reincarcerated or transferred, 14 sought methadone only, 10 had existing MAT providers, 5 were released to diversionary programs, and 3 relocated/escaped/ passed away.

KEY LESSONS FOR DISSEMINATION: Integrating CHWs and SWs into the post-incarceration care model, especially engaging with inmates before release, fosters trust and support— a key takeaway for other healthcare settings. The presented findings showcase the importance of a proactive approach to address the complex needs of individuals transitioning from incarceration to community care, allowing for increased engagement in the immediate post-incarceration period. This replicable and adaptable model offers valuable insights for implementation in diverse healthcare settings aiming to improve post-incarceration care delivery.

Innovation in Healthcare Delivery (IHD) - Hospital Medicine

IDENTIFICATION AND PREVENTION OF INAPPROPRIATE INTER-HOSPITAL TRANSFERS

Caitlin M. Kelly¹; Stephanie Mueller¹; Luci K. Leykum²; James D. Harrison³. ¹Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; ²Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ³Division of Hospital Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4064618)

STATEMENT OF PROBLEM/QUESTION: Inter-hospital transfer (IHT) practices vary greatly without clear guidelines as to what defines appropriateness of transfer or clear estimates of inappropriate IHT across the healthcare system.

DESCRIPTION OF PROGRAM/INTERVENTION: During the first Aim of a 5-year study, we conducted seven 1-hour long focus groups between March and June 2023 involving 40 total participants from 13 tertiary care hospitals and affiliate referral hospitals geographically dispersed across the United States. Each focus group included 6-8 participants with at least one member from each of the following stakeholder groups: Patient and Family Advisory Council member; accepting clinician from a tertiary care center; transferring clinician from a referral hospital; and hospital/healthcare system leadership (e.g., Chief Operating Officer). IHT patient case examples and semi-structured discussion guides were used to gather perspectives on the potential benefits and risks of each transfer. Discussions also considered environmental factors (e.g., institutional relationships), potential alternatives to IHT (e.g., tele-consults), and consideration of risks of non-transfer. Sessions were recorded, transcribed, and coded into major- and sub-themes by four reviewers, using a constant comparison, grounded theory approach. We utilized coded themes to finalize an adjudication tool that will be used to conduct targeted chart reviews of 1800 patient transfers to 18 geographically diverse tertiary care hospitals across the US to determine the prevalence of potentially inappropriate IHT. In advance of adjudication, we are conducting reviewer training using 4 IHT patient cases and measuring for concordance in determination of appropriateness of transfer.

MEASURES OF SUCCESS: Concordance in adjudicator determination of appropriateness.

FINDINGS TO DATE: We have conducted the first wave of reviewer training among 21 adjudicators across 9 hospitals (Wave two begins January 2024). Concordance in determination of appropriateness across the 4 training cases was 81.6%.

KEY LESSONS FOR DISSEMINATION: Throughout the focus groups, several key themes were identified as being important to stakeholders when considering IHT including but not limited to: Patient and family engagement, Inter-hospital communication, Patient demographics, Moral distress of clinicians, and Alternatives to transfer (ambulatory alternatives and transferring hospital support). We have successfully used this stakeholder input to identify factors that contribute to a consensus definition of inappropriate transfer and have incorporated this into a targeted chart review tool that will determine the prevalence of inappropriate IHT across a national sample of hospitals. Ongoing stakeholder input will be imperative to translate our findings into actionable recommendations for future prevention of inappropriate IHT.

IMPLEMENTATION AND EVALUATION OF CONTINUOUS GLUCOSE MONITORING IN A RURAL MID-ATLANTIC COMMUNITY HOSPITAL

Victoria Belcher¹; Jessica Thayer²; Michelle Wiltison³; Margaret A. Kaiser³; Nadia Barghouthi⁴. ¹Internal Medicine, West Virginia University Health Sciences Center, Morgantown, WV; ²General Internal Medicine, West Virginia University School of Medicine, Morgantown, WV; ³Garrett Regional Medical Center, Oakland, MD; ⁴Department of Medicine Division of Endocrinology, West Virginia University Health Sciences Center, Morgantown, WV. (Control ID #4064519)

STATEMENT OF PROBLEM/QUESTION: Continuous glucose monitoring (CGM) has been found safe and effective in the outpatient setting; however, similar use in the inpatient setting is uncommon due in part to unknown feasibility.

DESCRIPTION OF PROGRAM/INTERVENTION: During the SARS-COV-2 pandemic, rural hospitals faced the challenge of treating high acuity patients in limited resource environments. Current inpatient diabetes management relies on point-of-care testing, which requires frequent capillary blood testing throughout the day. With the increased nursing time spent donning protective personal equipment (PPE), scheduled finger sticks became a significant burden to efficient patient care. After FDA emergency use authorization, a rural Mid-Atlantic community hospital sought to reduce the time burden for admitted patients with diabetes through the implementation of CGMs. A CGM value was acceptable if within 20% of the capillary blood test when a capillary glucose reading was >100 mg/dL or within 20 points if <100 mg/dL (20%/20-point rule). Selection criteria during this piloted protocol was solely a diagnosis of diabetes.

MEASURES OF SUCCESS: Following three months, a retrospective analysis was performed to evaluate protocol feasibility and CGM accuracy. Each documented capillary glucose reading was compared to a CGM value within 5 minutes of capillary testing. The percentage of values outside the designated 20%/20-point rule and a proposed 25%/20-point rule, the average of capillary and CGM values, and the mean absolute relative difference (MARD) of CGM values were calculated for each patient.

FINDINGS TO DATE: Eleven patients had CGMs placed over three months, with one exclusion due to significant protocol non-adherence. The average CGM value for all patients was 218 mg/dL, while average capillary glucose value was 201 mg/dL. Overall, CGM values met acceptable validation criteria 76% of the time with the standard 20%/20-point rule. With the retrospective application of a 25%/20-point rule, this increased to 83%. The average calculated MARD value was 14%. Five patients had MARD values < 12%, with two patients < 8%.

KEY LESSONS FOR DISSEMINATION: This retrospective protocol evaluation shows the successful initiation and safety of CGMs in hospitalized patients with diabetes. CGM accuracy may improve with directed selection criteria, as this study found a correlation between poor CGM performance and lower BMI, fewer days of use, and high inflammatory states. Additionally, this study illustrates that for rural and critical access hospitals, CGMs could represent a powerful solution in addressing nursing time demands, staffing shortages, and limited access to specialty care.

OPTIMIZING LATERAL TRANSFERS TO ALLEVIATE HOSPITAL CAPACITY CHALLENGES

Timothy Judson¹; Rashmi Manjunath¹; Maggie Jones¹; Toni Braden²; J. Matthew Aldrich²; Nirja Shah³; Nicholas Fong⁴; Ryan McCarthy⁵; Rasmyah Hammoudeh⁶; Molly Shane⁵; Catherine Lau¹; Tip TIlton²; Jill Reynolds²; Raman Khanna¹; Michelle Mourad¹; Bradley Monash^1,7. ¹Medicine, UCSF, San Francisco, CA; ²Patient Capacity Management Center, University of California San Francisco, San Francisco, CA; ³University of Florida College of Medicine, Gainesville, FL; ⁴School of Medicine, University of California San Francisco, San Francisco, CA; ⁵UCSF Medical Center, San Francisco, CA; ⁶Clinical Innovation Center, University of California San Francisco, San Francisco, CA; ⁷Pediatrics, University of California San Francisco, San Francisco, CA. (Control ID #4062165)

STATEMENT OF PROBLEM/QUESTION: Large health systems often include multiple acute care hospitals, each with different capabilities. The main or “flagship” hospital in these systems are often overwhelmed by high patient volumes, leading to potential patient safety concerns, and negatively impacting patient experience, while lower acuity satellite hospitals may have excess capacity.

DESCRIPTION OF PROGRAM/INTERVENTION: We formed a multidisciplinary team with the goal of improving the lateral transfer process within our tertiary/quaternary, academic health system and making better use of available acute care beds at satellite hospitals. Our team conducted baseline data collection and interviewed patients and providers, which led us to identify three main contributors to ineffective transfers: 1. difficulty identifying eligible patients, 2. unclear provider roles, and 3. patients not agreeing to transfer. To identify patients, we designed two new informatics tools. First, we built a report to identify patients admitted to the main hospital who might be appropriate for lateral transfer. Second, we are in the process of building a clinical decision support tool to guide physicians to admit patients to the most appropriate acute care site. We clarified provider roles to ensure that a single provider is responsible and accountable for each aspect of the transfer process, including by programing a daily, automated SMS-based nudge that prompts the provider to report their progress. Finally, to improve patient assent, we applied findings from patient interviews to create a patient flyer to answer Frequently Asked Questions about transfer.

MEASURES OF SUCCESS: We aim to decrease the number of available, unfilled beds at satellite hospitals while improving patient and provider satisfaction. We are therefore tracking transfers, proportion of staffed unfilled beds, survey data and process metrics related to the informatics tools we developed.

FINDINGS TO DATE: From July-September 2023, we conducted pre-intervention provider surveys. Providers rated their overall experience with the lateral transfer process at 4.5/10 and identified several barriers to transfers. In December 2023, we validated our lateral transfer report and found that approximately one in three patients on the report were eligible for transfer, and nearly all eligible patients appeared on the report, consistent with the goal to create a high-sensitivity tool. The report decreased the number of patients who needed to be screened for transfer by over 60%, greatly improving the efficiency of identifying appropriate transfer candidates.

KEY LESSONS FOR DISSEMINATION: Quaternary hospitals are increasingly faced with high volumes, limiting their ability to serve all patients with complex care needs. One solution is to transfer lower acuity patients to satellite hospitals. However, doing so is complex. Our multi-disciplinary work emphasizes providing “the right care, at the right place, at the right time” and equipping providers with the informatics and workflow tools they need to successfully identify and transfer appropriate patients.

PRAGMATIC PILOT OF A NOVEL BEDSIDE COMMUNICATION CARD TO IMPROVE CARE FOR HOSPITALIZED PATIENTS WITH NON-ENGLISH LANGUAGE PREFERENCE

Nnamdi Igwe¹; Shira Winter³; Mary Ellen Dupont¹; Silvina de la Iglesia³; Andrew Dunn¹; Beth G. Raucher²; Anne S. Linker¹; Tao Xu¹. ¹Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Internal Medicine, Mount Sinai School of Medicine, New York, NY; ³Medicine, Mount Sinai Health System, New York, NY. (Control ID #4064428)

STATEMENT OF PROBLEM/QUESTION: Use of interpretation is mandated and improves quality of care for patients with non-English language preference (NELP), but barriers exist to consistent interpreter use, especially for brief bedside interactions.

DESCRIPTION OF PROGRAM/INTERVENTION: Accurate interpretation decreases communication errors and improves patient comprehension. Studies show interpreters are not consistently used, especially for brief bedside interactions. This pragmatic pilot aimed to identify patterns in interpreter use in the inpatient setting, and to develop/implement an accessible tool to improve bedside communication with patients/families with NELP.

A survey of nurses (RNs) and patient care associates (PCAs) on 2 acute care units at an academic medical center in the mid-Atlantic region assessed modes of communication used with patients with NELP, perceived frequency of interpretation service use, and staff experience when communicating with patients with NELP. Survey responses, collaboration with the Language Services Department, frontline nursing/care assistant staff, patient and family member feedback were used to revise card content and design. The card included icons and captions, and was translated into 6 languages, as well as English for non-verbal English-speaking patients.

MEASURES OF SUCCESS: Proportion of staff response to the survey, qualitative staff/patient perception of the tool, and units requesting distribution were used to measure success. Digital versions were reqeusted by other specialties and 3 other health system hospitals.

FINDINGS TO DATE: 75/113 staff (66.4%) responded to the survey; 55 nurses and 20 PCAs. A majority (n=66, 88%) reported baseline difficulty communicating with patients with NELP. 56 (75%) reported using telephone interpreter services; 42 (56%) reported using hand motions; and 49 (65%) reported using simplified English. Regarding average frequency of telephone interpreter use per shift: 46% reported 0-1, 46% reported 2-3, and 8% reported 4+ times. Many noted that the time required to call an interpreter and scarcity of video interpretation devices (one per unit) were barriers to consistent use of interpretation services.

13 educational huddles were performed across 10 inpatient units. 14 interviews of patients/caregivers were conducted by an in-person interpreter. Translated statements regarding the patient right to formal interpretation and an icon to request an interpreter were added. Interviews were sometimes limited due to patient fatigue or disorientation.

KEY LESSONS FOR DISSEMINATION: Despite initial enthusiasm for the communication card, it was difficult to maintain engagement in the setting of staff turnover, to maintain workflows to ensure distribution of cards, and patients had more difficulty interacting with the card than expected.

At our center, many frontline staff experience barriers to bedside communication with patients with NELP. Future work to promote equitable access to interpretation for patients with NELP should prioritize streamlining existing services and explore new tools to make communication more seamless.

REDUCING UNNECESSARY DAILY LABORATORY TESTING

Aesha F. Aboueisha¹; Cadfael Soulard²; Ankur Segon²; Juan Garza². ¹Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ²Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4064927)

STATEMENT OF PROBLEM/QUESTION: Up to 50% of the American healthcare spending is estimated to be wasteful. The largest type of wasteful spending is on overuse of tests and treatments. Among the diagnostic tests that are overused, excessive phlebotomy stands out due to its multifaceted implications, including hospital-acquired anemia, patient discomfort, provider burden, and avoidable downstream testing. The imperative to deliver high-value care necessitates the implementation of strategies to curtail unnecessary laboratory testing.

DESCRIPTION OF PROGRAM/INTERVENTION: This study focuses on a three-phase intervention targeting the overuse of phlebotomy at University Hospital (UH) in San Antonio, TX. Our project was launched in December 2022 and is divided into three phases: 1. Educational Sessions 2. Provider Feedback, and 3. Electronic Health Record (EHR) based tactics. In phase 1, educational sessions consisting of a didactic slideshow followed by interactive Q&A segments addressing potential barriers and hesitations to change were conducted. These sessions were conducted twice with the hospital medicine physicians and advanced practice providers, once with internal medicine residents, and once with nursing supervisors, who subsequently cascaded the information to their staff. In phase 2, monthly provider feedback packets showing individual provider laboratory utilization rates compared to average utilization rates for the hospital medicine group started going out in August 2023. In phase 3, a hard stop will be introduced in the EHR limiting the ability of providers to order daily laboratory tests for more than 48 hours at a time. Data encompassing the total number of laboratory tests conducted by UH's hospital medicine department were collected from November 2021 to April 2023.

MEASURES OF SUCCESS: Statistical Process Control (SPC) Charts were employed to visualize the ratio of labs ordered per patient for Complete Blood Count (CBC), Basic Metabolic Panel/Comprehensive Metabolic Panel (BMP/CMP), Renal Function Panel (RFP), and the aggregate of these tests.

FINDINGS TO DATE: SPC chart demonstrates a trend towards reduction in laboratory test utilization after implementation of educational sessions. Aggregate test utilization declined by 37.4%. The utilization of CBC, BMP/CMP and RFP declined 41.2%, 35.9% and 27.1%, respectively. The total cost savings as a result of decreased laboratory test utilization were estimated at $6,310 per month.

KEY LESSONS FOR DISSEMINATION: Education is a key component of Quality Improvement initiatives, empowering healthcare providers to pursue exceptional patient care. While our educational efforts yielded positive outcomes, it is acknowledged that sustaining these results through education alone is resource-intensive, involving instructor preparation, time investment, and ongoing training. Therefore, we have started phase two of our intervention with provider feedback packets that were started in August 2023. We are actively engaged in introducing a hospital-wide hard stop within the Epic EHR, limiting continuous daily lab orders to a 48-hour timeframe.

USING HOSPITALIST CONSULTS TO PROVIDE SAFER CARE FOR ED BOARDERS

Jessica Logan, Cherinne Arundel. Medical Service, Washington DC VA Medical Center, Washington, DC. (Control ID #4049372)

STATEMENT OF PROBLEM/QUESTION: Patients boarding in the emergency department (ED) awaiting admission are at increased risk for adverse events and mortality, but creation of a separate unit for boarders requires significant resources.

DESCRIPTION OF PROGRAM/INTERVENTION: In 2006, an Institute of Medicine report identified ED overcrowding and patient boarding as major concerns. Subsequent research has confirmed that boarding in the ED leads to adverse events including medication errors and higher mortality. Hospitalist groups have demonstrated success with assuming care of patients in the ED and opening a separate unit for boarders. However, this requires significant resources including hiring of physicians and nurses and many institutions do not have the necessary resources. In answer to this at our urban academic center, the hospitalist group has created a consult service to aid in the care of ED boarders.

The hospitalist consultation service in the ED was launched in September 2022. It is available during regular business hours and covered by the hospitalist who covers general medicine consults throughout the hospital. Acute, complicated patients and those where the level of care may be in doubt are prioritized. Hospitalists are encouraged to work collaboratively with the ED provider to identify appropriate patients. The overall goal is to provide safer care for patients awaiting an inpatient bed and to help the ED with throughput by ensuring that patients are assigned to the right level of care as telemetry beds are limited and in high demand.

MEASURES OF SUCCESS: The number of admission related patient safety reports and admit delay time in the ED have been used to assess success. Qualitative feedback has also been sought from the hospitalist group.

FINDINGS TO DATE: Our hospitalists have found this consultation service valuable. Hospitalists have improved consultant engagement with ED patients which has helped to expedite work-up including the scheduling of procedures. Our consultation has often resulted in improved triage and safer medication administration with more thorough reconciliations. Admission related patient safety reports from 9/2022 to 10/2023 were analyzed. There was no clear trend to a decrease in patient safety reports since the start of the consult service. The admit delay time in the ED was assessed to determine impact on flow. This is the median time from disposition decision to leaving the ED for an inpatient bed. In theory, the hospitalist consultant could improve this measure of ED flow by ensuring that level of care is appropriate and by communicating with the flow center. Unfortunately, we have been unable to move this metric.

KEY LESSONS FOR DISSEMINATION: Patient safety and patient flow are fundamentally multidisciplinary. A hospitalist consult service is valuable, but engagement from other services is needed to effect measures and bring about more meaningful change.

Innovation in Healthcare Delivery (IHD) - Medical Education and Training

GAMIFICATION AS A CURRICULAR TOOL TO IMPROVE RESIDENTS' ENGAGEMENT IN PANEL MANAGEMENT: EDUCATION ON SYSTEMS-BASED PRACTICES

M Marwan Dabbagh^3,1; Elizabeth Jean-Marie^3,2; Megan McNamara³. ¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Medicine, University Hospitals, Cleveland, OH; ³Internal Medicine, Louis Stokes Cleveland VAMC, Cleveland, OH. (Control ID #4047668)

STATEMENT OF PROBLEM/QUESTION: The pandemic has led to a decline in patient retention rates on resident patient panels, with an average of 26.5% of patients per panel having no follow-up appointments scheduled.

DESCRIPTION OF PROGRAM/INTERVENTION: At the Cleveland VA Medical Center, residents were taught how to use the Primary Care Panel Management tool to generate a list of patients who have no future appointments. Residents were then asked to work with their nurses and administrative staff to develop a plan to get these patients back in the clinic (schedule appointments). To improve resident engagement, we ‘gamified’ our curriculum with a competition. We held a 6-week long competition among the 12 resident panels in primary care. The residents all started at different rates of patients with "no future care". The resident with the greatest absolute decrease in their no future care rate after the competition would be awarded a $50 gift card. Residents who scored in second or third place were awarded “honorable mentions.”

MEASURES OF SUCCESS: The “success” of the intervention was measured by changes in each resident's rate of “no future care” within their own panel of patients. We compared each resident panel's number of patients without future appointments at the beginning to that at the end of the competition. The greater the net decrease in the number of patients with no future care, the better.

FINDINGS TO DATE: Overall, we had overwhelmingly positive results with 11 out of 12 resident panels showing a decrease in their “no future care” rate. On average, the rate of patients without future care decreased from 26.5% to 20.3%, which was significantly different with p < 0.01 on a paired T-test. The resident who won the competition decreased their rate from 22.8% to 6.1% in just two weeks. Learners reported during interviews that they “learned a lot more about [their] patients throughout the process, discussing [their] cases with the attending preceptor, the nurse, and the administrative clerks for the panel”.

KEY LESSONS FOR DISSEMINATION: Mastering crucial yet seemingly less engaging responsibilities within an already demanding resident physician's schedule can be challenging. Introducing friendly competition among peers enhances engagement in these learning activities by transforming them into more appealing tasks. In our experience, gamification has allowed residents to acquire relatively uncommon skills within systems-based practices, specifically in reconnecting patients with care and understanding their circumstances and barriers to care.

SUPPORTING CARDIOVASCULAR CARE AT PRIMARY CARE CLINICS IN THREE RURAL STATES USING A NOVEL TELE-EDUCATION COLLABORATION

Hannah Schmitt¹; Amie Pollack²; Kirsten K. Meisinger^1,3; Young-Jin Sohn¹; Heidi Ngov¹; David Duong⁴. ¹Center for Primary Care, Harvard Medical School, Boston, MA; ²The Center for Primary Care, Harvard Medical School, Boston, MA; ³Cambridge Health Alliance, Cambridge, MA; ⁴Global Health and Social Medicine, Harvard Medical School, Boston, MA. (Control ID #4064616)

STATEMENT OF PROBLEM/QUESTION: Cardiovascular diseases (CVD) are the leading cause of death in Arkansas, West Virginia, and Oklahoma, however, access to specialized cardiology care is limited for these patients.

DESCRIPTION OF PROGRAM/INTERVENTION: The“ECHO+” model involves Harvard Medical School and three rural health primary care systems in Arkansas, Oklahoma and West Virginia. ECHO+ integrates a tele-CVD course with robust QI and coaching. The 6-month tele-CVD course, taught by HMS cardiologist for rural primary care clinicians (PCP) to build clinician capacity and increase confidence in the diagnosis and management of CVD in the primary care setting. This is done through didactics and case-based discussions. Integrated into the ECHO+ program is QI methodology, incorporating an interdisciplinary team approach to implement CVD knowledge into clinical workflows to improve patient care. Teams at each site identified CVD quality indicators (i.e. blood pressure control and statin therapy optimization) to address using a QI approach.

MEASURES OF SUCCESS: The impact of ECHO+ on rural PCPs and related patient outcomes is evaluated through: (1) change in PCPs’ knowledge and confidence regarding CVD diagnosis, (2) change in PCPs’ knowledge and confidence regarding CVD treatment, (3) change in rates of cardiology referrals, and (4) change in performance on selected patient outcome metrics.

FINDINGS TO DATE: Post-intervention evaluation results showed that the course significantly increased participants' perceived CVD knowledge and confidence immediately following course completion and at 6-month follow-up. Post-module knowledge checks show an average score of 72% for the overall course with 79% of participants answering the review question correctly. Satisfaction was also high, with the majority of participants reporting that they would apply the information to their clinical practice. QI teams from each site demonstrated successful integration of CVD best practices through a series of PDSA cycles, and improvement in CVD-related metrics (e.g. a change from 72% to 86% of patients optimized on statin therapy).

KEY LESSONS FOR DISSEMINATION: Academic medical center collaborations with rural primary care sites through the ECHO+ model is a promising approach to increasing rural PCP capacity to care for CVD and improve population health outcomes.

Innovation in Healthcare Delivery (IHD) - Medical Ethics and Humanities

WHO ARE WE HELPING?—ETHICAL CONSIDERATIONS IN THE DOCUMENTATION OF PATIENT REFUSAL

Sourik Beltrán. Department of Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4064876)

STATEMENT OF PROBLEM/QUESTION: While patient refusal is a common phenomenon, its documentation risks characterizing certain patients as uncooperative or defiant which can negatively impact subsequent care experiences, particularly for vulnerable patients.

DESCRIPTION OF PROGRAM/INTERVENTION: Patient refusal is common and can take many forms including declining diagnostics, nonadherence to therapeutic plans, and general disengagement with healthcare. While documenting these behaviors is important, doing so may risk inadvertently stigmatizing patients by characterizing them as uncooperative or “difficult.” Such language included in patients’ electronic records can influence how patients are viewed and treated in subsequent clinical encounters and has previously been demonstrated to negatively impact patient care. This is further complicated by the potential influence of implicit bias in how such encounters are described by providers. To help address this issue, we build on concepts in medical ethics and sociology including Nosology, Virtue Ethics, and Labeling Theory to conduct a thorough account of key ethical considerations in the documentation of patient refusal. We generate a practical framework for general internists to think about how they document patient refusal including a list of practical recommendations to help clinicians document patient refusal in a way that accurately reflects the clinical encounter while preserving patients’ autonomy and reducing unnecessary stigma.

MEASURES OF SUCCESS: This project is an early iteration of a larger project aimed at improving the care provided to nonadherent or “treatment-resistant” patients. We are currently designing a qualitative study exploring provider attitudes about patients who appear to refuse care. At the same time, we are working to develop practical interventions to help providers minimize the stigma associated with patients’ refusal of care. These projects are still in development but draw from ethical foundation reflected in this abstract.

FINDINGS TO DATE: This intervention has not yet been formally studied

KEY LESSONS FOR DISSEMINATION: (1) Documenting patient refusal carries a risk of stigmatizing vulnerable patients which may further alienate them from accessing healthcare. (2) Active awareness of the ethical pitfalls in documenting patient refusal may help to mitigate some of these harms.

Innovation in Healthcare Delivery (IHD) - Mental/Behavioral Health and Substance Use Disorders

EVALUATING A COLLABORATIVE CARE MODEL FOR PATIENTS WITH METHAMPHETAMINE USE DISORDER AND ASSOCIATED CARDIOPULMONARY CONDITIONS: A CASE SERIES

Michael A. Incze¹; Annika Hansen³; Laura Stolebarger²; Jennalyn Mayeux¹; Katharine Clapham¹. ¹Internal Medicine, University of Utah, Salt Lake City, UT; ²Hospitals & Clinics, University of Utah Health, Salt Lake City, UT; ³School of Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4059501)

STATEMENT OF PROBLEM/QUESTION: Can a collaborative care (CoC) model with contingency management (CM) improve cardiopulmonary health and substance use for patients with methamphetamine-associated pulmonary hypertension (MA-PAH)?

DESCRIPTION OF PROGRAM/INTERVENTION: Methamphetamine use disorder (MUD) has been associated with an increased risk of acute and chronic cardiopulmonary disease. There are no FDA-approved treatments for MUD, but behavioral interventions such as contingency management are effective. In July 2023, we started a CoC pilot between a primary care-based substance use disorder clinic and a pulmonary hypertension clinic where we provide CM, peer support services, harm reduction counseling, care management, and primary care coordinated with specialty care for MA-PAH. Our CM program incentivized appointment attendance, engagement in community recovery activities, and abstinence from methamphetamine. Informal communication about shared patients happened frequently between specialty and CoC treatment providers on an ad hoc basis. Our pilot program enrolled 6 patients.

MEASURES OF SUCCESS: We tracked appointment attendance (specialty and CoC), retention in treatment, self-reported substance use, urine drug test results, engagement with community recovery supports, World Health Organization Quality of Life (WHOQOL) score, Commitment to Sobriety (CSS) scale score, and subjective reports related to MA-PAH symptoms and methamphetamine use from both patients and clinicians.

FINDINGS TO DATE: Over 5 months, participants had attended an average of 6 CoC appointments (range 2-8) with average CM earnings of $36 (range $0-$80). All 6 participants were retained in treatment at 20 weeks. Patient 1 is a 51W with longstanding MUD and MA-PAH. She attended 46% of CoC visits (earning $50 in incentives) and 100% of pulmonology appts. Since fatigue was reported as her primary driver for methamphetamine use, we addressed sleep and started bupropion off-label for MUD. Her PHQ9 (2 to 1), GAD7 (8 to 3), and WHOQOL score (93 to 100) all improved. She engaged in 2 new community recovery activities and reported markedly reduced methamphetamine use, though not abstinence. Her pulmonologist reported her cardiopulmonary biomarkers improved so much that she became too healthy to qualify for a clinical trial they were considering. Similar outcomes are reported for the other 5 participants in our program.

KEY LESSONS FOR DISSEMINATION: As the prevalence of MUD rises, research and practice innovation related to methamphetamine-associated cardiopulmonary conditions are necessary. In order to address MUD and the multifarious symptoms that accompany conditions like MA-PAH (e.g., shortness of breath, fatigue), an interdisciplinary CoC model including cardiologists, pulmonologists, addiction medicine, and care management may improve patient-centered outcomes like quality of life and abstinence/reduced substance use. Next steps include better integration of our model into existing cardiology care, enrolling a larger sample, and assessing physiologic outcomes such as 6-minute walk test, NYHA class, and NT-proBNP.

FEASIBILITY OF PROVIDING SYRINGE EXCHANGE SERVICES IN AN URBAN PRIMARY CARE CLINIC

Eric Kutscher, Rubashruti Kanna, Farah Riazi, Carli Salvati, Meghna Mallapan, Betty Kolod, Eric Woods, Linda Wang, Jeffrey J. Weiss. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4063505)

STATEMENT OF PROBLEM/QUESTION: As the opioid overdose epidemic in the United States continues to cause significant morbidity and mortality, primary care providers are commonly at the front lines for patients with injection drug use seeking medical care. In addition to starting medications for opioid use disorder, primary care providers have an opportunity and responsibility to incorporate harm reduction techniques that prevent blood borne infections such as HIV and Hepatitis C. To best meet patient needs, we report on integrating syringe exchange services into an academic primary care practice.

DESCRIPTION OF PROGRAM/INTERVENTION: We integrated syringe exchange services for patients engaged in care at our urban primary care clinic in the Mid-Atlantic region in November 2021, receiving designation as the first Second-Tier Syringe Exchange Program (STSEP) located in a primary care clinic in the state. To implement the STSEP, the clinic developed policies and procedures for 1) proper handling, safeguarding, and disposal of syringes; 2) adherence to appropriate infection control practices; and 3) enlisting community support for the program. The clinic staff completed training on harm reduction and stigma, state syringe access, regulation, and law enforcement, and safe handling of syringes. The clinic received state-funded syringes, sharps containers, alcohol pads, non-latex gloves, cookers, and sterile water, naloxone kits, and fentanyl test strips to distribute to patients enrolled in primary care within the clinic. Medical providers are able to provide these resources as well as referrals to other harm reduction resources and services.

MEASURES OF SUCCESS: We monitored the number of services provided from November 2021 to November 2023, along with patient/client demographics.

FINDINGS TO DATE: In the first 24 months of the program, 8 providers had 197 patient interactions involving STSEP resources, with 1449 syringes, 172 naloxone kits, and 423 fentanyl test strips distributed. Interactions were mostly with individuals over age 50 (58%), male sex (66%), and White (29%%), Black/African American (27%) and/or Latinx (39%).

KEY LESSONS FOR DISSEMINATION: Through its unique position as a STSEP, our clinic was able to provide patients with the resources to prevent HIV and HCV infection as well as drug overdose. The availability of resources additionally allowed for deeper conversation during medical visits with patients around harm and provided opportunity for motivational interviewing around drug use practices. Recognizing the patchwork of laws and regulations that exist nationwide around the possession of drug paraphernalia and syringe exchange programs, becoming a designated STSEP may not be feasible for many clinics. Moreover, this program does not replace first-tier SEP, but is an important strategy to provide patients with more holistic healthcare services. We demonstrate the feasibility of ambulatory care-based harm reduction, which can serve as a model for other clinics seeking to provide syringe exchange services to patients who use drugs.

HOSPITALIST AS CONSULTANT FOR BEHAVIORAL HEALTH INPATIENTS: A HYBRID VIRTUAL AND IN-PERSON CONSULTATION MODEL

Kimberly Bloom-Feshbach¹; Rebecca E. Berger¹; Art Evans¹; Leo Lopez²; Sharon J. Parish^1,2. ¹Medicine, Weill Cornell Medicine, New York, NY; ²Psychiatry, Weill Cornell Medicine, New York, NY. (Control ID #4063563)

STATEMENT OF PROBLEM/QUESTION: Behavioral health inpatients have complex acute and chronic medical needs; it is uncertain how best to deliver both medical and psychiatric care in an integrated model.

DESCRIPTION OF PROGRAM/INTERVENTION: To expand the capacity of medical consultation services in a behavioral health center for 200 inpatients, we recruited 9 hospitalists (0.1 FTE each) from the affiliated academic medical center to join one on-site full-time internist (1.0 FTE) in providing 24/7 medical coverage. Hospitalists work 75% remotely and 25% in person, collaborating with a team of family medicine nurse practitioners (NPs) on site. Hospitalists’ duties include: medically evaluating patients prior to electroconvulsive therapy and ketamine treatments, co-signing NP history and physicals, reviewing electrocardiograms, and triaging and assessing patients with acute illnesses. Additional tasks include advising NPs on the medical appropriateness of new admissions and consulting on chronic disease management, test results, and medication adverse effects. In parallel with bedside assessments, hospitalists use remote computer access to the medical record and phone and video communication with on-site teams to guide care virtually.

MEASURES OF SUCCESS: Hospitalists and psychiatrists were surveyed about program implementation and experiences working in the new model including perceived clinical, systems, and professional impact and opportunities for program optimization.

FINDINGS TO DATE: Eleven psychiatrists and eight hospitalists completed the surveys. Psychiatrists valued hospitalists’ medical expertise, responsiveness, proactive communication, and collaborative problem-solving. Hospitalists valued expanding their scope of practice outside the acute hospital setting, developing expertise in a new clinical domain, and navigating medical complexity. Hospitalists appreciated the flexibility offered by the predominantly virtual role, which enhanced their ability to integrate their professional roles and personal responsibilities. Physicians in both specialties enjoyed interdisciplinary teamwork in applying hospitalist expertise in a new setting and found meaning in improving care for a structurally vulnerable patient population.

KEY LESSONS FOR DISSEMINATION: A hybrid virtual and on-site model allows hospitalists to effectively collaborate with psychiatrists in the care of behavioral health inpatients, providing meaning through teamwork, expansion of clinical scope, care of vulnerable patients, and enhanced work-life integration.

LINKING INDIVIDUALS TO OUTPATIENT CARE FOR OPIOID USE DISORDER AFTER EMERGENCY DEPARTMENT DISCHARGE

Rachel Wolf¹; Tyler Barrett²; Courtney B. Gibson²; David Marcovitz³. ¹Internal Medicine, Vanderbilt University Medical Center, Nashville, TN; ²Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; ³Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN. (Control ID #4061410)

STATEMENT OF PROBLEM/QUESTION: Life-saving medications to treat opioid use disorder are underutilized in the outpatient setting after emergency department discharge.

DESCRIPTION OF PROGRAM/INTERVENTION: Patients with opioid use disorder (OUD) frequently present to the emergency department (ED) or the psychiatric ED at our tertiary care academic medical center in the Southeast. There currently exists a critical gap in rapid, low-barrier access to medications for OUD (MOUD). Challenges include inadequate insurance coverage and shortage of accessible clinics and providers. To help patients access care, we implemented the Link-MOUD clinic, a grant-funded post-ED follow-up clinic to serve patients needing MOUD and facilitate transition to long-term treatment programs. Optimizing treatment for OUD as well as medical and psychiatric care may contribute to a foundation for future recovery. After referral by the ED provider or social worker, patients meet with a team consisting of an internal medicine physician, psychiatric nurse practitioner and nurse case manager. Patients can attend up to three visits, consisting of comprehensive review of medical, psychiatric and substance use history, treatment of comorbid medical and psychiatric conditions, providing MOUD, and referral to subsequent addiction treatment.

MEASURES OF SUCCESS: To evaluate our intervention, we calculated the proportion of patients who present to clinic after being referred and the number of visits each patient completed of the three visits allotted. Urine drug screens were collected at each visit to assess non-prescribed substance use and adherence to buprenorphine therapy. We assessed the number of prescriptions provided to treat comorbid medical and psychiatric conditions. In the future, we hope to track the number of ED visits to the same institution during enrollment in this clinic and determine rates of successful linkage to OUD treatment resources.

FINDINGS TO DATE: From June 2023 to December 2023, 37 patients were referred to the Link-MOUD clinic. Of these, 24 patients (64.9%) were seen for at least one visit. Nine (37.5%) of these patients completed all 3 allowed visits. Six (25%) patients completed two visits and 9 (37.5%) completed one visit. Twenty-one (87.5%) Link-MOUD patients had a urine drug screen at their initial visit. Of these, 19 (90.5%) had buprenorphine present in their urine and 6 (28.6%) had only expected buprenorphine, acetaminophen or salicylates. Of the total 42 urine drug screens obtained at all patient visits, 40 (95.2%) were positive for buprenorphine. Thirteen (54.2%) Link-MOUD patients received one or more prescriptions for a medical or psychiatric condition and 6 (25%) received a prescription for both.

KEY LESSONS FOR DISSEMINATION: Linking patients with OUD to a low-barrier post-ED clinic for MOUD is feasible and facilitates patient engagement in treatment for those who attend. Integrated delivery of addiction treatment with primary medical and psychiatric care is feasible. Future quality improvement studies will evaluate rates of successful linkage to longer-term OUD treatment.

NOVEL HARM REDUCTION PROGRAM IN A PRIMARY CARE-ADDICTION CLINIC

Margaret Shang¹; Brent W. Thiel¹; Ariana Freund¹; Jane Liebschutz²; Raagini Jawa¹. ¹General Internal Medicine, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4064265)

STATEMENT OF PROBLEM/QUESTION: Due to an increasingly toxic illicit drug supply, the US is facing unprecedented rates of drug-related morbidity and mortality, calling for a paradigm shift in care delivery for people who use drugs (PWUD).

DESCRIPTION OF PROGRAM/INTERVENTION: Harm reduction services such as provision of drug checking and safer use equipment can mitigate some risks related to substance use. Given rising rates of drug-related morbidity and mortality, opportunities to expand access to these services beyond community-based syringe service programs are imperative. While primary care clinics have the potential to be opportune venues for delivering these services, most focus on traditional abstinence-based approaches to care. In response, we designed a quality improvement initiative to provide harm reduction kits (kits thereafter) at an integrated primary care-addiction clinic within an urban academic medical center in the Mid-Atlantic region.

Our initiative launched in February 2023 after achieving appropriate stakeholder buy-in, delivering several staff and provider trainings, creating a clinical workflow with staff input, and identifying a clinic champion. We used a patient-facing menu to universally offer kits during in-person patient encounters. Paired with patient-facing educational material, pre-packaged kits included injection, smoking, snorting, boofing (per rectum), fentanyl or xylazine test strips, and wound care. Workflow processes were improved based on clinic staff and patient feedback in an iterative process.

MEASURES OF SUCCESS: We assessed kit uptake and associated costs of the initiative. We tracked kit number and type distributed using REDCap and calculated costs per kit based on unit price for each kit item.

FINDINGS TO DATE: Ten months post-implementation, we distributed at least one kit in 35% of the 802 in-person encounters. 1006 kits were distributed in total: 86 injection, 180 smoking, 120 snorting, 44 boofing, 190 fentanyl test strip, 62 xylazine test strip, and 324 wound care. Kit costs ranged from $0.47 to $6.08 each. Based on number of kits given, we spent an average of $335 per month.

KEY LESSONS FOR DISSEMINATION: Along with identifying a clinic champion, actively including staff in workflow design allowed for a culture shift to embrace harm reduction and non-abstinence-based approaches to care. By universally offering kits, we uncovered significant unmet needs among our patients. Moreover, we found costs of providing these services to be affordable at the clinic level. Increasing access and utilization of harm reduction tools in primary care settings is an important step in shifting the paradigm of care delivery for PWUD.

PARTNERED EVALUATION OF A LETHAL MEANS SAFETY CAMPAIGN FOR SUICIDE PREVENTION IN VETERANS

Alan R. Teo^1,2; Sean P. Rice⁵; Elizabeth Meyer⁶; Susan M. Strickland⁷; Steven Dobscha^3,4. ¹HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR; ²Department of Psychiatry, Oregon Health & Science University, Portland, OR; ³HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR; ⁴Department of Psychiatry, Oregon Health & Science University, Portland, OR; ⁵Biostatistics & Design Program, School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR; ⁶The District Communications Group, LLC (DCG), Washington, DC., DC; ⁷Office of Mental Health and Suicide Prevention, US Department of Veterans Affairs, Washington, DC. (Control ID #4026271)

STATEMENT OF PROBLEM/QUESTION: Conducting an evaluation of a population health campaign can be challenging for researchers due to the need to balance multiple stakeholder perspectives and understand technical aspects of digital media and advertising.

DESCRIPTION OF PROGRAM/INTERVENTION: Between September 2021 and June 2023, the Department of Veterans Affairs (VA) conducted a national paid media campaign called “Keep It Secure” that was designed to promote secure storage of firearms as part of its suicide prevention strategy. We led an evaluation of a subset of a $2.2 million campaign that employed video ads across multiple digital platforms.

MEASURES OF SUCCESS: Key quantitative metrics used to evaluate the campaign included process measures (impressions [total number of times content was delivered] and video views) and measures of engagement with campaign ads (clicks, click-through rate, and website visits).

FINDINGS TO DATE: We worked with a data set that comprised approximately 300 million ad impressions, 141 million completed views of the video ads, and 10 million clicks to the Keep It Secure website. Differences in process and engagement measures were evident in analyses of: a) several campaign ads; b) audience targeting, and c) geographical analyses (state-by-state comparisons). Through examination of the process of our evaluation, we developed 14 recommendations across 6 domains (engage stakeholders, describe the program, focus evaluation design, gather credible evidence, justify conclusions, share lessons).

KEY LESSONS FOR DISSEMINATION: The recommendations are broadly applicable to evaluation of other population health campaigns, and key lessons include: a) a focus on planning of the evaluation early in the project; b) collaboration among the sponsor, marketing team and evaluation team; and c) regular communication amongst teams using a shared, non-technical language.

RESULTS OF IMPLEMENTING COLLABORATIVE CARE - MENTAL HEALTH SCREENING AND TREATMENT IN AN ACADEMIC FACULTY PRACTICE

Caroline J. Schmidt³; Renee Fekieta²; Pamela Petersen-Crair³; peter ellis¹. ¹General Internal Medicine, Yale School of Medicine, New Haven, CT; ²Population Health, Yale School of Medicine, New Haven, CT; ³Psychiatry, Yale School of Medicine, New Haven, CT. (Control ID #4056310)

STATEMENT OF PROBLEM/QUESTION: Successful screening and treatment of anxiety and depression in primary care settings has been less effective than randomized controlled trials.

DESCRIPTION OF PROGRAM/INTERVENTION: Access to timely mental health services is a challenge for many Americans. Barriers include difficulty identifying persons suffering from depression or anxiety, lack of mental health specialists, and high cost/lack of insurance coverage. To address this crisis, experts have developed innovative programs such as Collaborative Care (University of Washington, Advancing Integrated Mental Health Solutions - AIMS) which identifies and treats patients with mild-to-moderate depressive and anxious symptoms in health care settings. This model has reduced depressive symptoms compared to usual care in more than 80 randomized controlled trials. However, implementation of the Collaborative Care model in real-world settings has demonstrated mixed results. One barrier is lack of implementation support.

In this QA/QI project, we analyzed the effectiveness of screening and treatment of depression and anxiety in our General Internal Medicine faculty practice during March 2019 to September 2023. With support from the AIMS center and our population health team we implemented the Collaborative Care model. Our practice consists of 6 MDs and 2 APRNs and cares for 5500+ patients.

We systematically screened patients for depressive and anxiety symptom severity using a team-based approach providing psychotherapy, psychiatric consultation, psychotropic medications, and social work. We implemented the key components of Collaborative Care: a) screen patients using validated outcome measures PHQ9 and GAD7, b) enroll screen positive, eligible patients into a Patient Registry, and c) treat patients collaboratively.

MEASURES OF SUCCESS: 1) Rate of screening for depression and anxiety using the Patient Health Questionnaire (PHQ9) and Generalized Anxiety Disorder (GAD-7) among eligible visits defined as a) all new patient visits b) physical exams and c) annual wellness visits

2) Treatment response, defined as percent of patients who attained 50 percent reduction in the PHQ-9 or GAD-7 scores or final PHQ9 or GAD7 score of ≤ 5.

FINDINGS TO DATE: During March 10, 2019 through September 28, 2023, we screened for depressive symptoms using the PHQ9 during 76.6% of eligible visits (9,093 of 11,873 visits).

We enrolled and treated 256 patients in the Patient Registry. Among these patients, treatment response rate was 64%.

KEY LESSONS FOR DISSEMINATION: Our practice increased screening for depressive and anxiety symptoms to 77% among eligible patients, and attained positive treatment response among 64% of 256 treated patients. We received significant initial training by AIM experts to inform organizational leaders and coach key personnel. Our practice also benefitted from critical organizational support from our department of Population Health, which saw the value in developing best practices for integrated behavioral health and projected increased revenues for pay-for-performance.

STATEWIDE PRIMARY CARE IMPLEMENTATION OF AN EVIDENCE-BASED PROTOCOL ADDRESSING WOMEN’S MENTAL HEALTH CONDITIONS INCREASES SCREENING, DETECTION, AND TREATMENT: AN INTERRUPTED TIME SERIES ANALYSIS

Seuli B. Brill²; Melissa Leonard¹; Lisa Christian⁴; Bethany Panchal³; Emily Lamb¹; Abigail Ezzeldin¹; Busra Ceviren¹; Wendy Groznik¹; Douglas Spence⁵. ¹Ohio Colleges of Medicine Government Resource Center, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, The Ohio State University College of Medicine, Columbus, OH; ³Family and Community Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ⁴Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH; ⁵Ohio Colleges of Medicine Government Resource Center, The Ohio State University, Columbus, OH. (Control ID #4062508)

STATEMENT OF PROBLEM/QUESTION: Low detection and treatment rates of mental health (MH) conditions in primary care (PC) disproportionately affect the health of women, who are twice as likely to experience conditions such as Generalized Anxiety Disorder (GAD) and Major Depressive Disorder (MDD) than men.

DESCRIPTION OF PROGRAM/INTERVENTION: Gender gaps in GAD and MDD prevalence have widened since the onset of the COVID-19 pandemic, with highest incidence of these conditions among reproductive aged women. Thus, limited mental health care capacity in primary care settings, which deliver most US mental health services, has outsized consequences for women, especially those who are minoritized or experiencing poverty. A Midwestern statewide learning collaborative (LC) developed the Focus on Me initiative (FOM) to broadly implement a Women’s Preventive Services Initiative aligned primary care mental health protocol for women aged 18-44 years across 20 PC practices, purposively selected for their care focus on Medicaid insured and minoritized women. FOM engaged multi-disciplinary clinical experts in protocol development, and then supported primary care practice roll-out with a clinician change package, monthly training, site quality improvement coaching, and electronic health record (EHR) data evaluation.

MEASURES OF SUCCESS: We conducted a single-group interrupted time series analysis of monthly EHR data extracts monthly for 14 months before (pre) and 12 months after (post) protocol rollout (March 1, 2022) to evaluate primary outcomes of interest: 1) change in practice-level GAD-7 and PHQ-9 screening, and 2) percentage of patients who received protocol-aligned treatment (PAC) after a GAD-7 or PHQ-9 screening score ≥ 10.

FINDINGS TO DATE: Practices collectively delivered an average of 2651 visits/month to 65,381 unique FOM eligible patients (pre: 32,245; post: 33,136) during the evaluation period. 32,298 (49.4%) were Medicaid beneficiaries and 35,567 (54.4%) identified as Black. The percentage of visits with GAD-7 screening increased from 5.7% (pre) to 29.6% (post), and PHQ-9 screening increased from 74.5% (pre) to 81.9% (post). After accounting for secular trends, statistically significant increases in initial GAD-7 anxiety screening (level change 25.41, p=0.003) and substantial but not statistically significant increase in initial PHQ-9 depression screening (level change 13.2, p=0.064). Over the 12-months after roll-out period, sites demonstrated statistically significant increase in the percentage of patients receiving protocol aligned mental health treatment after positive screening (Level change 26.06, CI 13.4 - 38.7, p=0.0006).

KEY LESSONS FOR DISSEMINATION: Our findings suggest that learning collaborative supported, evidence-based protocol implementation can yield large scale improvements in detection and treatment of women’s mental health conditions across a network of primary carepractices serving predominantly underserved and minoritized patients.

SUCCESSFUL INTEGRATION OF ALCOHOL USE DISORDER TREATMENT INTO A PRIMARY CARE CLINIC

Jennifer Lom¹; Shelly-Ann Fluker²; Lesley Miller¹. ¹General Medicine, Emory University, Atlanta, GA; ²Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4062199)

STATEMENT OF PROBLEM/QUESTION: Alcohol use disorder (AUD) prevalence is rising with increased morbidity and mortality and few patients are prescribed medications for AUD despite efficacy in decreasing alcohol consumption and maintaining abstinence.

DESCRIPTION OF PROGRAM/INTERVENTION: In 2020, 28.3 million Americans were diagnosed with AUD. Alcohol related deaths increased by 25% between 2019-2020. There are effective medications for AUD, however less than 8% of patients are prescribed these medications. Prior to the development of our AUD clinic, our health system’s only option for AUD treatment was psychotherapy.

To meet this need for medications for alcohol use disorder (MAUD), we developed a novel clinic in 2021. The clinic is embedded in our primary care-based Liver Clinic. Health system clinicians received education about the clinic and referral process. The clinic receives electronic referrals for patients who are motivated to cut down on their drinking and have an AUDIT-C score of 4 or higher. During the initial visit, a member of our team (the physician champion or NP) takes a thorough alcohol use history, utilizing the DSM-V criteria for diagnosing AUD, engages patients in motivational interviewing, and assess liver health via fibroscan testing. Patients are then prescribed MAUD if interested. Finally, they are referred to our integrated behavioral health team and peer recovery specialists. The team schedules follow-up visits every 4-6 weeks in person or via telehealth.

MEASURES OF SUCCESS:

1. Decreased hospitalizations related to alcohol use

2. Reduced alcohol use and cravings amongst the patients taking medication

3. Robust medication adherence, measured by number of second fills of the

FINDINGS TO DATE:

1. From 2021-2022, 54 individual patients attended at least 1 clinic visit. AUD severity was evenly split between mild, moderate, and severe.

2. In terms of MAUD- 38/54 patients elected to start treatment. 56% were prescribed naltrexone, 11% acamprosate and 4% gabapentin. 80% of patients on naltrexone had a second fill while 100% of patients on acamprosate and gabapentin had a second fill of their medication. 70% of the naltrexone group reported reduced cravings. 100% of the acamprosate and gabapentin group reported reduced cravings.

3. In the 6 months prior to attending their first AUD visit, 48% of the patients had an alcohol related hospital admission. In the 6 months after attending the AUD clinic, that number decreased to 13%.

KEY LESSONS FOR DISSEMINATION:

1. Integrating an AUD clinic into primary care is feasible and results in improved outcomes.

2. General internists can provide AUD treatment and counseling in the primary care setting.

3. A faculty champion to spearhead the effort and education for referring providers are critical components.

THE PATIENT EXPERIENCE RECEIVING BUPRENORPHINE FROM A MOBILE MEDICAL UNIT

Anna Patterson¹; Mackenzie Smith¹; Sarah Messmer²; Abigail T. Elmes³; Alex Infante³; Albert Murphy⁴; Jennie Jarrett³. ¹Medicine, University of Illinois Chicago, Chicago, IL; ²Internal Medicine-Pediatrics, University of Illinois at Chicago, Chicago, IL; ³Pharmacy, University of Illinois Chicago, Chicago, IL; ⁴School of Public Health, University of Illinois Chicago, Chicago, IL. (Control ID #4057159)

STATEMENT OF PROBLEM/QUESTION: This study was conducted to assess the patient experience in receiving buprenorphine from a novel mobile medical unit in two neighborhoods with the highest opioid overdose rates in a large city in the United States.

DESCRIPTION OF PROGRAM/INTERVENTION: In 2022, there were over 100,000 deaths in the United States due to drug overdose, the vast majority of which were opioid related. Medications for opioid use disorder (MOUD), such as buprenorphine, have demonstrated effectiveness in the treatment of opioid use disorder (OUD), with reduction in mortality and overdose events. Less than 20% of patients with OUD receive treatment with MOUD, citing a number of barriers. In July 2021, the DEA updated their regulations via 86 FR 33861 to allow mobile units to dispense MOUD. Under this new regulation, the Community Mobile Unit Program began dispensing buprenorphine, in addition to existing primary care services, to patients in neighborhoods with the highest rates of opioid overdose. This study assessed the patient experience in receiving buprenorphine from this novel Mobile Unit.

MEASURES OF SUCCESS: To assess patient perceptions and satisfaction with receiving buprenorphine from the mobile unit, an anonymous 7-item survey was developed utilizing 5-point satisfaction scales (1 being “not satisfied at all” and 5 being “extremely satisfied”), a free response item related to reasons for their satisfaction level, and multiple-choice items related to previous methods of buprenorphine access and barriers to receiving buprenorphine from a pharmacy. Surveys were conducted on-site at the mobile unit immediately after buprenorphine provision.

FINDINGS TO DATE: A total of 54 surveys were completed. 48 of the 54 people surveyed rated their satisfaction in receiving buprenorphine from the Mobile Unit as a 5 out of 5 (extremely satisfied). 32 respondents had received buprenorphine from a pharmacy in the past year. Of these 32, 29 individuals rated their satisfaction at the Mobile Unit as a 5, compared to only 14 who rated their pharmacy experience as a 5. Common open responses highlighted convenience in location and staff friendliness as key factors in their satisfaction. The most common barriers to filling a prescription at a pharmacy were delay time in filling prescriptions (16 respondents) and lack of transportation (15 respondents). Of note, 44% of respondents stated they had previously turned to a non-health professional to supply them with buprenorphine. Only 13% of respondents said they would have started buprenorphine that day if the clinic had not been there.

KEY LESSONS FOR DISSEMINATION: Most patients who were dispensed buprenorphine from the Mobile Unit are very satisfied with their experience. The majority of patients also reported they would not have started therapy that day without the convenience and accessibility of the clinic. This preliminary data points to mobile clinics as an acceptable and effective means of expanding access to opioid use disorder treatment, particularly for patients who otherwise might not engage in treatment.

“I WISH THE CLINIC TEAM TREATED ME WITHOUT JUDGEMENT”: AN EVALUATION OF PATIENT SATISFACTION WITH CARE IN A PRIMARY CARE ADDICTION MEDICINE CLINIC

Debora Ghosh¹; Jessica Ristau²; Irina (Era) Kryzhanovskaya². ¹Division of General Internal Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4063455)

STATEMENT OF PROBLEM/QUESTION: To evaluate patient satisfaction with the provision of trauma-informed, strengths-based, patient-centered substance use disorder (SUD) care in a welcoming, low-barrier, embedded primary care addiction medicine (PCAM) clinic, we developed a patient satisfaction survey to gauge how our services are perceived and how we can use patient voices to inform future practice.

DESCRIPTION OF PROGRAM/INTERVENTION: We developed and launched a 16-item patient satisfaction survey based on validated surveys in the literature. This survey was administered through patient calls and Qualtrics survey link invitations via patient portal messages. We contacted patients with SUD seen at least twice in PCAM clinic in the last 9 months and received 20 responses. Patient satisfaction with the care they received, patient experience and time to first appointment, and time between visits were assessed through Likert Scale-based questions and open-ended questions,

MEASURES OF SUCCESS: We developed a survey, evaluating patient satisfaction in three categories: (a) Care and Communication with Provider, (b) Times Spent in Clinic and Between Visits, and (c) Experience (including any barriers or stigma encountered). Upon data collection, we performed quantitative and qualitative content analysis, with coding of the open-ended responses into themes.

FINDINGS TO DATE: 20 patients (12 males, 8 female) with SUD responded to the survey and reported positive treatment outcomes and high patient satisfaction with the embedded addiction medicine clinic. 75% of patients strongly agreed that they felt autonomy in decision-making related to their care and comfortable with discussing concerns with the provider. 80% of patients were satisfied with the time spent during visits and with services they received in our clinic. Over 65% of patients were satisfied with the time from referral to the initial visit and with the time between follow-up visits. 96% of patients felt that the provider understood their needs, and 86% were satisfied with the progress they made during their recovery. The main themes coded from patients’ open-ended responses regarding barriers they encountered are: (1) addressing stigmatizing behaviors by clinic staff, (2) resolving issues with the pharmacy dispensing medications, and (3) buprenorphine not meeting patient expectations for pain management.

KEY LESSONS FOR DISSEMINATION: Based on expressed barriers and themes from open ended questions, the main timely and actionable priority was addressing stigmatizing behaviors by clinic staff. We plan to address this barrier by organizing trainings for clinic staff with spaces to discuss experiences with stigma and time to share best practices to create destigmatizing clinical care areas. We hope addiction medicine care practices can incorporate trainings to review a didactic on the definition of stigma, its interplay in the healthcare system, and strategies to destigmatize addiction care. We hope this training will reduce bias and stigma towards addiction medicine care and improve patient experience in PCAM and outcomes in SUD treatment.

Innovation in Healthcare Delivery (IHD) - Quality Improvement and Patient Safety

A COLLABORATIVE APPROACH TO IMPROVING DIABETES CO-MANAGEMENT THROUGH POPULATION HEALTH

Jennifer Chen^3,2; Heather Leisy²; Gabrielle Salter²; Heather Martin^1,2; Ally Elder²; Katie Grant²; Reshma Gupta^3,2. ¹Pharmacy, UC Davis Health, Sacramento, CA; ²Population Health, UC Davis Health, Sacramento, CA; ³Internal Medicine, UC Davis Health, Sacramento, CA. (Control ID #4063861)

STATEMENT OF PROBLEM/QUESTION: Diabetes is one of the leading causes of morbidity and mortality in the US and only 71% of patients with diabetes mellitus followed by a primary care provider (PCP) at our California-Hawaii region academic institution are considered to have “controlled blood sugars” (defined as A1c <8%) as of July 2023.

DESCRIPTION OF PROGRAM/INTERVENTION: We provided targeted outreach to patients followed by a PCP in our health system diagnosed with diabetes and with the most recent HbA1c ≥ 8% in the prior 12 months. An interactive electronic medical record workbench report was developed to identify this population. To start, a centralized licensed vocational nurse (LVN) messaged the PCP with a standardized description of the project and a request to sign pended referrals to the primary care pharmacist and patient education classes if appropriate. If signed, the LVN would send the patient a letter describing the referrals and available resources. After the letter, a scripted phone outreach by the LVN took place to schedule with the pharmacist. Signed referrals allowed the pharmacist to initiate and/or adjust medications under the referring provider’s name per a collaborative practice agreement with the provider notified of any changes. For referrals unsigned after two weeks, the LVN would call the patient and offer to schedule a consultative pharmacy visit instead, which is a single visit with written recommendations provided to the PCP. Pharmacists could also collaborate with providers about offering additional resources if needed. For signed referrals for education classes, the Health Education Department would call the patient to discuss and schedule classes related to diabetes appropriate for the patient.

MEASURES OF SUCCESS: We plan to review quantitative process and outcome metrics monthly to evaluate the effectiveness of the outreach. These metrics include: number of patients outreached, referrals placed, scheduled visits, and levels of A1C control (<8%) for our various project interventions.

FINDINGS TO DATE: We piloted this outreach at 2 clinic sites in September 2023 with planned rollout to all 12 clinic sites by February 2024. Within these 2 pilot sites, there were 142 patients with A1c ≥ 8% that met criteria for outreach. Of these 142 patients, 94 have received outreach thus far. Of these outreached patients, 76 (80.9%) have been scheduled to meet with a pharmacist, 1 (1%) scheduled with their primary care provider, 6 (6.4%) pharmacy referrals were declined by the primary care provider, and 11 (11.7%) patients declined scheduling with pharmacy.

KEY LESSONS FOR DISSEMINATION: Diabetes care can be enhanced by centralized pharmacy and nursing outreach to assist PCPs in management and increase utilization of available health resources.

ADVANCING LIVER HEALTH IN DIABETES CARE: A QUALITY IMPROVEMENT INITIATIVE FOR ENHANCED SCREENING OF LIVER FIBROSIS IN TYPE 2 DIABETES AND PREDIABETES

Syeda Y. Rizvi¹; Omar Jumaah¹; Valeria Turcan¹; Andreas Ruppel¹; Sindhu Chadalawada^2,1; Natalia Plotskaya³. ¹Internal Medicine, Capital Health Regional Medical Center, Trenton, NJ; ²INTERNAL MEDICINE, Capital Health, Trenton, NJ; ³Internal Medicine, Capital Health, Trenton, NJ. (Control ID #4064833)

STATEMENT OF PROBLEM/QUESTION: There is a gap in the routine screening for liver fibrosis among patients with type 2 diabetes mellitus (T2DM) and prediabetes, resulting in delayed risk stratification for nonalcoholic fatty liver disease (NAFLD).

DESCRIPTION OF PROGRAM/INTERVENTION: The Family Health Center (FHC) identified the prevalence of T2DM among Hispanics, the majority of their patients. A blood-based screening for liver fibrosis using the Fibrosis-4 (FIB-4) score was implemented, leveraging the comprehensive metabolic panel (CMP) and complete blood count (CBC). The FIB-4 calculator was incorporated into the electronic medical records (EMR), and resident physicians were educated on its use. Patients with T2DM and prediabetes were provided with laboratory orders for CMP and CBC during routine appointments, followed by discussions on results and lifestyle modifications.

MEASURES OF SUCCESS: Employing the Plan-Do-Study-Act (PDSA) model, the project aimed to screen 85% of patients with T2DM and prediabetes for liver fibrosis. Over six months, from January to May 2023, 86% of patients were screened. Patients were categorized into low, intermediate, and high-risk based on FIB-4 scores. Further evaluation with ultrasound elastography and gastroenterologist referrals were conducted for intermediate and high-risk patients.

FINDINGS TO DATE: Of the 89 patients screened, 63 were low risk, 24 were intermediate risk, and 2 were high risk. Intermediate and high-risk patients underwent additional evaluation and were referred to a gastroenterologist.

KEY LESSONS FOR DISSEMINATION: The successful adoption of the FIB-4 score screening tool demonstrated its effectiveness in identifying high-risk patients with NAFLD and liver fibrosis. The tool is cost-effective, easily accessible in the EMR, and facilitates early lifestyle counseling and follow-up for at-risk patients. The initiative aims to raise awareness among resident physicians in primary care settings, promoting the widespread implementation of noninvasive screening tools for liver health in diabetes care.

A MULTI-COMPONENT PROJECT TO INCREASE NALOXONE PRESCRIPTIONS AMONG VETERANS EXPERIENCING HOMELESSNESS USING A BROADENED DEFINITION OF RISK

Vi Nguyen^1,2; Catalyst Twomey¹; Sophie J. Rosenmoss^1,2; Katharine M. Borthwick^1,2; Peter Capone-Newton^1,2; Patrick Chapman¹; Brianna Cowan^1,2; Janice Grandi^1,2; Huy Ha¹; Kimberly Inouye¹; Kristin Kopelson^1,3; Allison Krupa¹; Daisy Kyu¹; Lauren Matsuno^1,2; Nathan McLaughlin^1,2; Cleo Penamon¹; Laura Santangelo^1,2; Lillian Gelberg^1,4. ¹Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA; ²Internal Medicine, University of California Los Angeles, Los Angeles, CA; ³School of Nursing, University of California Los Angeles, Los Angeles, CA; ⁴Family Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4056237)

STATEMENT OF PROBLEM/QUESTION: In response to the marked increase in opioid overdose deaths among people experiencing homelessness, we implemented a multi-component quality improvement project to increase naloxone prescribing at a Veterans Administration (VA) Homeless Patient Aligned Care Team (HPACT).

DESCRIPTION OF PROGRAM/INTERVENTION: Despite experiencing a disproportionate burden of opioid overdose deaths compared to the general population, people experiencing homelessness are less likely to have access to naloxone. An interprofessional trainee-led team at an urban HPACT, an interdisciplinary medical home for approximately 1700 Veterans experiencing homelessness or housing instability, targeted the following barriers to naloxone prescribing: a) staff knowledge gaps identified through chart review and interviews, b) the health record’s automated naloxone reminders’ inclusion of only Veterans with a formal substance use diagnosis or opioid prescription, and c) lack of on-site naloxone distribution. We sought to expand provider and pharmacist criteria for naloxone prescribing and education to include Veterans who use low to moderate amounts of drugs, including potentially contaminated non-opioid drugs, or who live in high-risk environments, where the Veteran may be present to respond to overdoses. Our intervention began in February 2023 and consisted of a) targeted education at a staff clinic meeting, b) creation of a progress note template to prompt staff to screen Veterans more broadly as above, and c) advocacy for and eventual procurement of on-site naloxone. We additionally distributed waiting room posters encouraging Veterans to ask their provider or pharmacist about naloxone.

MEASURES OF SUCCESS: We used aggregated dashboard data to determine percentage of HPACT Veterans with active naloxone prescriptions before and after our intervention.

FINDINGS TO DATE: Naloxone prescriptions increased from 20% in February 2023 to 34% in September 2023 (70% relative increase, p<0.001). Post-intervention, our clinic has maintained on-site naloxone dispensing.

KEY LESSONS FOR DISSEMINATION: In addition to substance use disorder diagnoses, we argue that low to moderate levels of drug use and living in high-risk environments are both important risk factors for experiencing or witnessing opioid overdose. Education for clinic staff and distribution of naloxone in clinics can increase naloxone prescriptions and therefore promote safer drug use for individuals and their communities.

A QUALITY IMPROVEMENT INITIATIVE AND NOVEL MEASUREMENT STRATEGY TO IMPROVE PHYSICIAN-NURSE COMMUNICATION

Esther Y. Hsiang, Sarah J. Flynn, Molly A. Kantor. Department of Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4059281)

STATEMENT OF PROBLEM/QUESTION: Despite the introduction of direct messaging technology, hospital medicine physicians and nurses at our institution reported dissatisfaction with interdisciplinary communication.

DESCRIPTION OF PROGRAM/INTERVENTION: To improve physician-nurse communication at our institution with geographically dispersed hospital units, we developed a multifaceted quality improvement initiative and utilized a novel tech-enabled measurement strategy to evaluate its success. We first conducted focus groups and semi-structured interviews with hospitalists and nurses; thematic analysis uncovered numerous issues driving dissatisfaction with physician-nurse communication. We designed interventions addressing these communication “pain points” with robust interdisciplinary stakeholder engagement. We developed a multifaceted initiative with an emphasis on creating opportunities for bidirectional information exchange and standardizing communication practices with direct messaging technology, and introduced these interventions in a staged approach. For continuous evaluation, we developed short assessment surveys for hospitalists and nurses, and utilized a novel software platform linked to clinical data from the electronic medical record to automatically create individualized, HIPAA-compliant surveys asking hospitalists about communication behaviors for specific patient encounters. These recurrent, twice weekly, short surveys provided a novel and feasible strategy to measure changes in communication satisfaction and behavior over time.

MEASURES OF SUCCESS: Our primary outcome was satisfaction with physician-nurse communication, rated by both physicians and nurses. Secondary outcomes were specific communication behavior process metrics (e.g., rates of physicians communicating patient care plans, rates of physicians inviting nurses to join for bedside rounds).

FINDINGS TO DATE: Early assessment indicates that implementation of our interventions has led to increased scores of satisfaction with communication for both physicians and nurses (physician: 4.02 pre, 4.55 post; nurse: 3.44 pre, 3.9 post; scale ranging from 1=very unsatisfied to 5=very satisfied), as well as improvements in physician self-reported behaviors of inviting nurses to join bedside rounds (20.1% pre, 27.7% post).

KEY LESSONS FOR DISSEMINATION: Hospitals with medicine patients managed across geographically dispersed units may face similar challenges with dissatisfaction in physician-nurse communication. With robust stakeholder engagement and tech-enabled measurement strategies, institutions can diagnose key communication pain points and design targeted interventions to address this. Utilizing individualized, automated recurrent evaluations and surveying both physicians and nurses allows for frequent assessment of communication practices, continued refinement of interventions based on real-time feedback, and fostering of sustained improvements in physician-nurse communication.

A QUALITY IMPROVEMENT PROJECT TO IMPROVE DIABETES CARE IN MINORITY RACE AND ETHNICITY PATIENTS WITHIN AN ACADEMIC PRIMARY CARE PRACTICE

Cynthia Tsai¹; Agnes Chou²; Marina McIver². ¹Department of Medicine, Stanford University School of Medicine, Stanford, CA; ²Stanford Health Care, Stanford, CA. (Control ID #4063804)

STATEMENT OF PROBLEM/QUESTION: In May 2023, review of this academic medical center’s faculty primary care practice showed 19% (246/1321) of Asian diabetics and 20% (217/1065) of white diabetics had uncontrolled A1Cs. Among diabetic patients at this faculty practice, Asians and white patients represent the largest racial groups. In contrast, several minority groups had higher percentages of uncontrolled diabetics: 29% (59/205) of Blacks, 32% (42/130) of Native Hawaiian/Pacific Islanders, and 34% of Hispanic/Latinos (196/580) had poor A1C control.

DESCRIPTION OF PROGRAM/INTERVENTION: An interdisciplinary team of diabetes care providers utilized a LEAN A3 approach to improve equitable diabetes management. The team reviewed charts and interviewed patients to understand root causes for this observed disparity. Many minority patients reported feelings of emotional overwhelm living with diabetes that negatively impact their engagement in asynchronous and synchronous diabetes care. Patients noted competing practical challenges (e.g., work schedules, language barriers) and increased medical needs that increased this overwhlem. The team therefore pursued interventions that maximized patients’ diabetes care through the use of: (1) an infographic that communicated to patients their current level of diabetes control and invited re-engagement in diabetes care, (2) evening diabetes care events that allowed patients to interact with multiple disciplines of providers (PCP, pharmacist, dietitian) in a single visit, and (3) condensed 1-hour diabetes education classes offered at convenient times for working patients. The team also facilitated Spanish-concordant multidisciplinary events for Spanish-speaking patients.

MEASURES OF SUCCESS: 1) Comparison of the percentage of minority race/ethnicity versus Asian/white diabetes patients with inadequate diabetes control.

2) Tracking the number of patients before and after interventions that completed follow up visits with a diabetes provider in the prior 3 months.

3) Patient surveys indicating confidence in managing diabetes, and their likelihood of following up with their diabetes providers.

FINDINGS TO DATE: In 4 months, the difference in patients with uncontrolled diabetes between minority and non-minority groups decreased from 12% to 10%. Patients who received the diabetes infographic were more likely to complete follow up with a diabetes provider (50% of recipients had followed up before distribution, whereas 69% had followed up 2 weeks after distribution). Patients who participated in the multidisciplinary or condensed diabetes education events expressed increased confidence in managing their diabetes (6/10, to 9/10), and increased willingness to follow up with a diabetes provider (8.8/10, to 9/10).

KEY LESSONS FOR DISSEMINATION: Minority race and ethnicity diabetes patients disproportionally experience health inequities that increase feelings of overwhelm that contribute to disparities in their care. Interventions to improve equitable diabetes care among minority patients must address these unique psychosocial barriers that impede patient engagement.

BUILDING COMMUNITY HEALTH CENTER TEAMS: EVALUATING THE IMPACT OF TEAM-TRAINING

Young-Jin Sohn¹; Hannah Schmitt¹; Amie Pollack¹; Erin E. Sullivan²; Russell Phillips¹. ¹Center for Primary Care, Harvard Medical School, Boston, MA; ²Center for Primary Care, Harvard Medical School, Boston, MA. (Control ID #4062145)

STATEMENT OF PROBLEM/QUESTION: To evaluate the impact of the Advancing Teams Program (ATP) on practice transformation and quality improvement efforts among community health center (CHC) teams serving medically underserved communities (MUC) in Massachusetts.

DESCRIPTION OF PROGRAM/INTERVENTION: In Massachusetts, CHCs provide high quality care for nearly a million people in the most impoverished areas but struggle to recruit and retain clinicians and staff. Effective team building programs may increase CHC capacity to provide high-quality patient care, while reducing clinician workload. ATP is designed to strengthen community-based primary care through a focus on leadership, team-building, community and patient input, and QI. From 2016 to 2022, a total of 47 CHC teams participated in ATP, including 327 administrators, clinicians and providers, patient partners, and trainees. The 10-month ATP program includes planning, pre-work, and learning phases. The learning phase includes three full-day Learning Sessions and subsequent Action Periods focused on leadership, communication, team dynamics, and QI designed to improve quality of care and patient outcomes.

MEASURES OF SUCCESS: This study evaluates ATP’s ability to engage CHC teams from MUCs, and the impact of ATP participation on perceptions of clinic functioning, practice transformation, and QI project processes and outcomes. Participants’ perceptions of clinic functioning and practice transformation concepts were measured pre- and post-ATP by the Qualis Health Patient-Centered Medical Home Assessment (PCMH-A). Qualitative analysis of teams’ QI project Storyboards included disease/condition targeted, use of specific practice transformation strategies, and progress towards project aims.

FINDINGS TO DATE: CHCs participating in ATP served under-resourced communities, with > 65% serving high levels of Medicaid and uninsured patients. Change in PCMH-A scores from pre - post ATP showed significant improvement (p<.05) in team members’ perceptions of clinic leadership engagement, team-based care, evidence-based practices, patient-centered interactions, access, and care coordination. The largest improvement was seen in patient-centered interactions (+1.04, p=.001) with ATP participation strongly associated with increased encouragement of patients to expand their role in decision-making, health-related behavior change, and self-management. Positive change in perceived leadership engagement predicted greater improvement in clinic functioning (β=0.68, p<.001). Qualitative analysis indicated that teams utilized practice transformation approaches and QI strategies to successfully improve care in areas such as behavioral health, diabetes, substance abuse, and social determinants of health.

KEY LESSONS FOR DISSEMINATION: ATP is a promising approach to primary care team development in under-resourced CHCs. Future research should evaluate the impact of team quality and leadership commitment levels on ATP outcomes, and include robust approaches to evaluating QI project processes and outcomes.

CHARACTERIZING INTERNAL MEDICINE TRAINEES’ KNOWLEDGE AND PRESCRIBING HABITS FOR GLUCAGON-LIKE PEPTIDE 1 AGONISTS AT AN ACADEMIC TRAINING CENTER – A QUALITY IMPROVEMENT INTERVENTION

Lara J. Sokoloff¹; Alexandra C. Leto¹; Kimberly C. Balsama²; Christopher J. Whritenour²; Amber Bird². ¹Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; ²Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4064733)

STATEMENT OF PROBLEM/QUESTION: With the increased prevalence of glucagon-like peptide 1 (GLP-1) agonists in treatment of diabetes and obesity, we sought to better understand prescribing practices among Internal Medicine (IM) residents and design a novel quality improvement (QI) intervention to facilitate accurate medication titration within the electronic medical record (EMR).

DESCRIPTION OF PROGRAM/INTERVENTION: There is little data regarding best practices for dose titration and no existing curricula for IM trainees on effective prescribing strategies. We surveyed IM residents on their knowledge surrounding GLP-1 agonists. Initial survey data found that although residents are skilled at deciding when to initiate these agents, they lacked confidence in utilizing the EMR to ensure accurate prescribing. Additionally, residents reported a lack of standardized approach to educating patients regarding medication injection technique. Based on these findings, we collaborated with staff pharmacists to develop a novel, EMR-based order set to streamline GLP-1 agonist ordering. This order set allows consult to a dedicated pharmacist to assist with medication teaching and titration. Dedicated education on this intervention and GLP-1 agonists prescribing was added to the ambulatory curriculum.

MEASURES OF SUCCESS: After system-wide introduction of our order set, a post-survey will assess improvement in residents’ confidence with prescribing GLP-1 agonists and navigating EMR ordering. Utilization of the order set and collaboration with pharmacists will also be measured.

FINDINGS TO DATE: In a survey of 62 IM residents, 39% (23/59) of trainees reported no systematic way of communicating medication titration recommendations to patients. Regarding the logistics of ordering GLP-1 agonists in the EMR, nearly 40% (22/55) of trainees reported that they did not feel confident with the logistics of ordering this medication for diabetes and 37% (19/51) for obesity. Ultimately, 46% (25/54) of trainees report inadequate training on initiation of GLP-1 agonists during their ambulatory education. A large majority of residents (83%, 45/54) reported that they would benefit from more teaching on the topic of prescribing and titrating GLP-1 agonists in the outpatient setting.

KEY LESSONS FOR DISSEMINATION: With the rapid increase in GLP-1 agonists use for diabetes and obesity treatment, more education is needed to increase IM resident confidence in their prescribing practices.

A system-wide EMR-based order set was developed to standardize prescribing of GLP-1 agonists and facilitate interdisciplinary collaboration with staff pharmacists.

COMPLETE FOR TREATS - IMPROVING MEDICATION RECONCILIATION COMPLETION IN THE INPATIENT SETTING

Loren E. Barhold, Krystle Hernandez, Samuel Johnson, Kristy Huang. Medicine, Mount Sinai Health System, New York, NY. (Control ID #4065010)

STATEMENT OF PROBLEM/QUESTION: Medication Reconciliation is not always completed within 24 hours of admission during an inpatient hospital admission.

DESCRIPTION OF PROGRAM/INTERVENTION: Medication reconciliation is the process of identifying the most accurate list of a patient’s medications and utilizing the list to provide correct medications across the healthcare continuum. Accurate and prompt medication reconciliation is known to improve patient safety and reduce medication errors.

In 2006 the Institute of Medicine reports drug-related errors are the most common type of medical error and can result from discrepancies in patient medications during periods of transition of care. Studies show about 60% of medication errors occur during patient admission, discharge or transfer of care.

Interventions were designed to help reduce medication discrepancies and errors during the reconciliation process in an urban academic center. These interventions included a didactic presentation during academic protected time, an incentivized competition between general medicine teams for most completed medication reconciliation (“complete for treats!”). Future interventions will include a step-by-step guide displayed in provider work areas, refresher didactics for internal medicine residents, real-time EMR secure chat reminders and sharing safety data in regards to medication discrepancies and patient outcomes.

MEASURES OF SUCCESS: Percentage of completed medication reconciliation was measured for each general medicine team on a monthly basis. The percentage was compared to the previous month to evaluate for improvement with the goal of improving the percent of completed medication reconciliation. The aim is to improve medication reconciliation by 10% among general medicine teams over 7 months. The anticipated outcomes of this initiative include heightened patient safety, improved clinical outcomes and a greater overall efficiency in medication reconciliation processes. within inpatient hospital medicine.

FINDINGS TO DATE: After our first intervention, medication reconciliation completion within 24 hours was 23% within the first month. The next three months demonstrated improvements over baseline of 38%, 41%, and 33% respectively after introducing our medication reconciliation competition between the four general medicine teams. Moving forward we will identify gaps, challenges, and areas for improvement.

KEY LESSONS FOR DISSEMINATION: Implementing improvements in medication reconciliation in inpatient medicine can have several positive outcomes for both healthcare providers and patients. Our project helps identify and prevent discrepancies in a patient's medication list, reducing the risk of errors such as omissions, duplications, or incorrect dosages. We hope to change the culture at our institution and maintain medication reconciliation as a top priority in patient care.

ENHANCING INTERPRETER UTILIZATION AMONG TELEPHONE SCHEDULERS ASSISTING PATIENTS WITH LIMITED ENGLISH PROFICIENCY

Alice Lin¹; Eliana Bonifacino³; Joyce Rowan²; Tanya Nikiforova³. ¹School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²UPMC, Pittsburgh, PA; ³Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4059227)

STATEMENT OF PROBLEM/QUESTION: Limited data exists on the success and adequacy of interpreter use during telephone calls in the healthcare setting.

DESCRIPTION OF PROGRAM/INTERVENTION: In 2019, over 25 million people in the United States spoke English less than “very well” and were considered to have limited English proficiency (LEP). This large and growing population faces language barriers that impede effective communication and delivery of quality care. Patient safety incidents among LEP individuals often stem from communication breakdown due to lack of qualified medical interpreter usage. Recognizing call centers as pivotal points of contact for LEP patients, we proposed an intervention to evaluate and enhance interpreter utilization among telephone schedulers within a tertiary healthcare system.

Test calls were placed by staff interpreters and medical students to determine a baseline rate of successful interpreter utilization, with 30 calls placed to appointment schedulers and 15 calls placed to imaging schedulers. Callers posed as patients requesting the 5 most common non-English languages spoken in the county. Next, scheduling leadership was informed of the test call results, and recommendations were provided to guide protocol modification and scheduler training. A second round of test calls was placed 3 months later to assess for improvement. Additionally, schedulers participated in pre- and post-intervention surveys to gauge their confidence levels in accessing and utilizing interpreters.

MEASURES OF SUCCESS: Outcome measures included an increase in the successful execution of 3-way patient-scheduler-interpreter test calls and scheduler confidence levels with interpreter use.

FINDINGS TO DATE: Pre-intervention test calls yielded a 62% overall interpreter connection success rate, with 83% and 20% success rates among appointment schedulers and imaging schedulers, respectively. Areas of improvement in the scheduling protocol and training materials were identified and recommended to managers. Overall interpreter connection success rate post-intervention increased to 69%, with 83% and 40% success rates among appointment schedulers and imaging schedulers, respectively. The pre-intervention survey demonstrated that most schedulers (84%) agreed or strongly agreed that it is important to use a qualified interpreter, but 35% also agreed or strongly agreed that an English-speaking family member or friend are appropriate substitutes for a qualified interpreter. Most schedulers (69%) felt very confident or completely confident in their ability to access an interpreter. Post-intervention survey results are pending.

KEY LESSONS FOR DISSEMINATION: A quality improvement initiative using test calls and feedback to scheduling leadership improved the successful utilization of interpreters among imaging schedulers by 20%. Overall use of interpreters among scheduling services in this healthcare system remains suboptimal, and further test calls with feedback and protocol modification may continue to improve interpreter utilization among telephone schedulers assisting LEP patients.

ENHANCING PATIENT EXPERIENCE THROUGH REAL-TIME FEEDBACK AND A PATIENT-CENTERED CARE MODEL

Maria Farberov²; Theodore Strange¹; Daniel Yurkins³; Suzanne El Sayegh^1,4; Marianne Smith¹; Kathleen Ahern⁵; Georges Khattar³; Thomas Gut⁶; Mario Castellanos⁶. ¹Internal Medicine, Staten Island University Hospital, Staten Island, NY; ²Research, Staten Island University Hospital, Staten Island, NY; ³Patient Safety, Staten Island University Hospital, Staten Island, NY; ⁴Nephrology, Staten Island University Hospital, Staten Island, NY; ⁵Nursing, Wagner College, Staten Island, NY; ⁶Medicine, Staten Island University Hospital, Staten Island, NY. (Control ID #4064566)

STATEMENT OF PROBLEM/QUESTION: Effective physician-patient communication is essential for delivering high-quality care. Yet, no established mechanism currently exists for providing physicians with real-time feedback on these interactions.

DESCRIPTION OF PROGRAM/INTERVENTION: Patient-centered medical care prioritizes the patient experience. For hospitalized patients, this is assessed using post-discharge surveys like the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) scores by the Centers for Medicare and Medicaid Services (CMS). Scores are used as metrics by CMS and are linked to hospital reimbursement. However, a major limitation of this approach is physicians do not have the opportunities for service recovery. In response, our Medicine Department at a Northeast University-affiliated hospital launched the Real-Time Patient Experience Enhancement Program (R-PEEP). This program is specifically designed to collect real-time patient feedback with the goal of providing service recovery and enhancing overall patient satisfaction.

MEASURES OF SUCCESS: At the North Campus, a 14-item questionnaire for in-patients staying > 24 hours was developed, assessing patient-physician communication. The questionnaire used a scale ranging from “Always” to “Never.” Providers received immediate feedback for responses less than “Always,” and summaries were distributed through Microsoft Teams and emails. This site served to validate the questionnaire. At the South Campus, a 6-month study compared two groups of hospitalists: an Intervention Group that received real-time feedback from the RPEEP survey and a Control Group that continued standard care without real-time feedback. The HCAHPS scores of both groups were compared.

FINDINGS TO DATE: The North Campus included 1200 patients, showing improvements in R-PEEP survey scores over time, manifesting in an increase in the “Always” percentage from 55% to 89% in 6 months. However, at the South Campus, 1,887 patients received the RPEEP survey; there was no significant enhancement in HCAHPS scores concerning patient-physician communication among hospitalists.

KEY LESSONS FOR DISSEMINATION: We developed and validated a survey tool to assess the effectiveness of physician communication and patient satisfaction. At the North site, real-time feedback demonstrated potential, evidenced by a significant increase in survey scores. However, our brief, non-randomized pilot study utilizing real-time feedback did not yield changes in HCAHPS scores over a 6-month period. An extended evaluation period may prove more insightful. Despite this, the program has successfully increased physician engagement and improved patient experience at the North site.

EVALUATION OF A SYMPTOM-BASED ALCOHOL WITHDRAWAL ORDER SET FOR HOSPITALIZED MEDICINE PATIENTS

Natalie Baumann¹; Miranda Wright-Kauffmann³; Eli Deal³; Emily Fondahn². ¹Medicine, Washington University in St Louis School of Medicine, St Louis, MO; ²Medicine, University of Missouri System, Columbia, MO; ³BJC, St. Louis, MO. (Control ID #4027114)

STATEMENT OF PROBLEM/QUESTION: Alcohol use disorder is commonly encountered in hospitalized patients with 15-30% of patients having an alcohol-related condition. However, strong data supporting optimal therapy for alcohol withdrawal in patients with acute illness is lacking. There have been few adequately powered trials which evaluate the treatment of alcohol withdrawal in acutely ill patients, and much evidence for current treatments is not generalizable to hospitalized patients.

DESCRIPTION OF PROGRAM/INTERVENTION: Our institution, a large urban university-based medical center in the Mid-West Region, developed and implemented a symptom-based alcohol withdrawal order set for floor-level patients in January 2021. The order set is comprised of a nursing-driven assessment and a score-based linked order set to guide benzodiazepine administration. The composite score is generated using inputs from ten domains with five possible groupings (composite score 0-2, 3-5, 6-12, 12-18 or greater than 18).The order set instructs nurses to hold medications and contact the provider for signs of oversedation.

MEASURES OF SUCCESS: Demographic data and several key variables were measured for patients with an active order set, including composite scores, days with active orders, days with benzodiazepines ordered, cumulative benzodiazepine use, incidence of oversedation or ICU transfer, and length of stay.

FINDINGS TO DATE: Data for 335 patients were collected between March and September 2021, and patients were stratified by admitting department. Fifty percent of patients (n=167) were admitted to a medicine service (including General Medicine teaching services, Cardiology and Hospital Medicine). Medicine patients had active orders for an average of 3.9 days with an average length of stay of 6.2 days. The average composite score was 4.9 with cumulative benzodiazepine use of 13.2 mg lorazepam equivalents. Twenty percent of patients admitted to a medicine service (n=35) had a dose of benzodiazepine held due to oversedation as determined by nursing. When compared to patients without doses held for oversedation, patients with doses held for sedation had higher composite scores (7.2 vs 4.9), had active orders for longer (4.6 days vs 3.9 days) and higher cumulative benzodiazepine use (22.6 mg vs 13.2 mg). Two patients required ICU transfer related to treatment of alcohol withdrawal; however, no patients were transferred to ICU due to oversedation.

KEY LESSONS FOR DISSEMINATION: Use of a symptom-based alcohol withdrawal order set can be effective to prevent serious complications of alcohol withdrawal. Most patients on a medicine service had a low composite score. Teams should be aware of other medical syndromes that would elevate the composite score, such as tremor or tachycardia, not related to alcohol withdrawal. More high-quality research is needed to determine optimal therapy for alcohol withdrawal in hospitalized patients.

HYPERTENSIVE CRISIS IN COMMUNITY BLOOD PRESSURE SCREENINGS

Priya Sarin Gupta³; Nehal S. Munshi¹; Sarah N. Taylor¹; Kristene Tadese¹; Hong Chen Cheung¹; Elsie Taveras²; Allison S. Bryant³. ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Community Heath & Health Equity, Mass General Brigham Innovation Assembly Row, Somerville, MA; ³OCMO, Mass General Brigham Inc, Boston, MA. (Control ID #4065008)

STATEMENT OF PROBLEM/QUESTION: A hypertensive crisis is an abrupt and severe surge in blood pressure, characterized by a systolic blood pressure reading of 180/120 millimeters of mercury (mm Hg) or higher. This condition constitutes a medical emergency and can potentially result in serious health complications such as heart attacks, strokes, and other life-threatening issues.

Our mobile healthcare vans serve multiple areas where access to medical care may be hindered by social determinants of health (SDOH). During our screenings, we have observed that patients with severely elevated blood pressures often delay seeking care. This ultimately results in a failure to provide timely follow-up care to those who have a high risk of complications from hypertension.

DESCRIPTION OF PROGRAM/INTERVENTION: This Quality Improvement/Quality Assessment project will use an observational approach and the social-ecological framework to understand the process patients go through when access to clinical care corresponding to their blood pressure findings is not reliable. We will review charts of all patients that having elevated readings (SBP > 180 and/or DBP > 120) during an encounter on any of our vans within the project timeframe (3/1/2023 - 3/31/2024). We will review follow-up documentation for patients with elevated readings that had appropriate follow-up and use the progress they made in connecting to clinical care to review factors that can affect the clinical outcome of blood pressure readings and the process outcome of connecting to a medical home. These data will be used to inform PDSA (plan-do-study-act) cycles to improve the follow-up for patients with extremely elevated blood pressure readings.

MEASURES OF SUCCESS: Our aim is to increase by 10% the percentage of patients meeting our inclusion criteria (systolic BP measurement over 180 and/or diastolic BP measurement over 120) that have a follow-up visit at a medical home or with a primary care provider within 90 days of the corresponding screening visit. We will use a p-chart to evaluate the process change over time and in response to PDSA cycles.

Process variables, e.g., the number of days needed for follow-up, outcome variables, e.g., the number of patients with improvements in their blood pressure measurements, and balance variables, including patient volumes, will also be tracked and reported.

FINDINGS TO DATE: When conducting an initial chart review on patients visiting one of our vans between 3/1/2023 and 10/31/2023 having a systolic blood pressure measurement over 180 or a diastolic blood pressure measurement over 120, we found that when grouped on a monthly basis, an average of 39% of these patients received a follow up visit at a medical home or with a primary care provider within 90 days of the elevated reading.

KEY LESSONS FOR DISSEMINATION: We expect to achieve and share a better understanding of barriers preventing patients with multiple SDOH limitations in receiving appropriate follow-up care for elevated screening blood pressure measurements.

IMPACT OF REMOTE QUALITY IMPROVEMENT PROJECT ON OUTCOMES FOR PATIENTS WITH TYPE 2 DIABETES AND OBESITY

Natalie Sanfratello²; Erika Brechtelsbauer¹; Linda G. Baer²; Katelyn O'Brien³. ¹Continuing Professional Development, Clinical Education Alliance, Decatur, GA; ²Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ³Boston Medical Center, Boston, MA. (Control ID #4059529)

STATEMENT OF PROBLEM/QUESTION: Two Federally Qualified Health Centers affiliated with an academic medical center in the northeast lacked onsite quality improvement expertise to implement system-based changes to improve the care of patients with type 2 diabetes.

DESCRIPTION OF PROGRAM/INTERVENTION: At 2 FQHCs in the northeast, an estimated 25% of patients with type 2 diabetes and overweight or obesity had an A1C >9.0%. In order effectively improve the care of these patients, the FQHCs participated in a quality improvement (QI) initiative that incorporated remote mentoring from the QI hub within the academic medical center. From April 2022 – July 2023, team members at the FQHCs participated in virtual meetings and education with QI experts to equips them with the skills needed to implement a QI project based on the Institute of Healthcare Improvement Model. Teams at each FQHC evaluated their baseline data, developed an aim statement, performed a current state analysis, and utilized the Plan-Do-Study- Act cycles to implement and assess their interventions. Each clinic implemented multiple interventions within the domains of knowledge, systems improvement, and patient access. Examples of interventions include: implementing point-of-care A1Cs into office visits, development of patient education materials, referrals to pharmacists, standardizing care plans within electronic medical records, provider education through grand rounds.

MEASURES OF SUCCESS: The following measures were used to evaluate success: percent of patients with an A1C <9.0%, prevalence of overweight or obesity, percent of patients with endocrinology referral, percent of patients with up-to-date A1C, percent of patients prescribed a glucagon-like peptide-1 receptor agonist, team members perceptions, understanding, and skills related to quality improvement

FINDINGS TO DATE: At FQHC1, the percentage of patients with an A1C <9.0% increased by 7%. At FQHC2, the percentage decreased by 8%; however, this is primarily as a result of a QI intervention to re-engage patients who were lost to follow-up to return to clinic and had no recent A1C on file. At FQHC2, the overall number of patients with an A1C >9% remained relatively unchanged. Team members from the FQHCs reported high levels of agreement that they had significant contributions to the QI project, their QI skills were increased, and they were confident in their ability to lead a QI project in the future as a result of participating in the remotely mentored QI project.

KEY LESSONS FOR DISSEMINATION: Utilizing a remote model for QI project implementation is an effective strategy for broadening the reach of QI experts. Interprofessional collaboration within an environment that is supportive of change is necessary for sustainable improvement. Interventions targeting knowledge, systems improvement, and patient access are critical to achieve realistic and long-standing change.

IMPLEMENTATION OF LOW GLYCEMIC INDEX DIET TO IMPROVE TYPE 2 DIABETES CONTROL IN HISPANIC POPULATION AT ACADEMIC COMMUNITY CENTER.

Natalia Plotskaya¹; Farnaz Sadr¹; Syeda Rizvi¹; Valeria Turcan¹; Delaram Moazami²; Kateryna Chepenko¹. ¹Internal Medicine , Capital Health System Inc, Trenton, NJ; ²Internal Medicine, Capital Health, Trenton, NJ. (Control ID #4043494)

STATEMENT OF PROBLEM/QUESTION: We identified that 29 out of 62 patients had HbA1C >8 % which indicated 47% of our patient panel had uncontrolled type 2 diabetes.

DESCRIPTION OF PROGRAM/INTERVENTION: Type 2 diabetes mellitus (T2DM) is a well-known health crisis in the United States which disproportionately affects the Hispanic population. It is important to identify the factors and barriers that prevent physicians from achieving high success rates in controlling diabetes. Several socio-economic factors contribute to increased prevalence of T2DM among Hispanic patients, one of them is limited access to education and health care. Our internal medicine residency program provides care to a large Hispanic population with a high prevalence of T2DM at community health center. Low-glycemic index diet (LGID) appears to be an effective method of glycemic control in patients with T2DM when compared to other types of diet. Recent studies demonstrated that low carbohydrate eating pattern can reduce HbA1C and the need for antihyperglycemic medications for patients with T2DM.

We created and implemented a new order set for LGID counseling in our electronic health records (EHRs) to facilitate patient education and counseling process during ambulatory care visit. Educational LGID flyers in Spanish language were given to patients during counseling session.

MEASURES OF SUCCESS: Plan-Do-Study-Act model was employed during 6 month period. Root cause analysis was conducted to identify key factors affecting our patients with type 2 diabetes. Our goal was to improve glycemic control by at least 10% from baseline HbA1C among patients with uncontrolled diabetes by providing education on LGID along with lifestyle counseling. Action plan was developed and included the following steps: reviewing patients panel and identifying patients with uncontrolled diabetes in EHRs, scheduling diabetes nutrition counseling visit every month, educating patients during office visit and providing them printed handout about LGID.We conducted monthly meeting with primary care residents physicians to educate them how to use of a new diabetes nutrition counseling order set in EHRs.

FINDINGS TO DATE: Out of 69 patients with T2DM 29 patients had HbA1C of >8% at the beginning of our project. In 6 months 12 out of 29 patients with diabetes (41%) showed an improvement of HbA1c by at least 10% compared to their baseline HbA1C. Most of our patients were receptive and engaged with acquiring new dietary recommendations on LGID. New diabetes nutrition counseling order set facilitated effective counseling and accurate documentation about patients dietary habits.

KEY LESSONS FOR DISSEMINATION: Diabetes nutrition counseling on LGID is effective method to improve glycemic control among Hispanic patients with T2DM. Patient education is important part of diabetes care and primary care physicians from community health centers play an important role providing early dietary intervention to Hispanic population living in urban area.

IMPLEMENTATION OF NURSE BLOOD PRESSURE VISITS TO DECREASE DELAYS IN TREATMENT INTENSIFICATION OF UNCONTROLLED HYPERTENSION IN AN URBAN RESIDENCY PRIMARY CARE CLINIC: A QUALITY IMPROVEMENT STUDY

James A. Douglas²; Dylan M. Baker³; Dheepa Sekar¹. ¹Medicine, Emory University School of Medicine, Atlanta, GA; ²Department of Medicine, Emory University School of Medicine, Atlanta, GA; ³Internal Medicine , Emory University, Atlanta, GA. (Control ID #4063830)

STATEMENT OF PROBLEM/QUESTION: Limited physician availability limits timely management of uncontrolled hypertension in a busy resident primary clinic serving an underserved population.

DESCRIPTION OF PROGRAM/INTERVENTION: Hypertension is one of the most common chronic conditions managed in primary care and is strongly associated with vascular mortality. Delay in treatment intensification is associated with higher mortality. Limited resident clinic visit availability within 2-3 months limited timely treatment intensification in our clinic. Prior to the intervention, 48.2% of all patients in the resident primary care clinics had controlled hypertension based on CMS quality data goal of 140/90. The local health system identified a goal of 50.2%. We reviewed our clinic structure and identified an excess of nurse visits and physician telehealth visits. Protocol: For any patient with uncontrolled hypertension, providers scheduled the patient for both a nurse blood pressure visit (NBPV) within 2 weeks and a provider telehealth visit (PTV) within the 3 weeks thereafter to address the need for subsequent medication change.

MEASURES OF SUCCESS: We implemented the intervention in January 2023 and assessed for feasibility and change in blood pressure through retrospective chart review of scheduled NBPV. Patients over the age of 85 and those without uncontrolled hypertension were excluded. We recorded blood pressure at the initial provider visit, any initial medication change, blood pressure at NBPV, and medication change at follow up PTV. We have collected data for the first 2 months of the intervention. We plan to complete data collection for the 12 months following the intervention and report blood pressure at 3 months following the nurse visit.

FINDINGS TO DATE: Preliminarily, 118 charts were reviewed and 39 were excluded. At the initial provider visit, 67.1% of patients underwent medication initiation. 67.1% of patients attended the scheduled NBPV. Mean time to follow up was 17.3 days. Systolic blood pressure changed from an average of 168.6 at the initial visit to an average of 143.0 at NBPV with 46.7% controlled. Follow up visits occurred as PTV or in person provider visits 27.8% or 35.4% of the time, respectively. 36.7% did not follow up as scheduled. At the follow up provider visit, 36.2% underwent medication change. In November of 2023, 51.9% of all clinic patients had controlled hypertension.

KEY LESSONS FOR DISSEMINATION: Providing more frequent care points through nurse visits and telehealth allows for more timely management of blood pressure. This approach is feasible within a resident clinic that serves a primarily underserved population. Assessment of this intervention is limited by the retrospective review from NBPV, as we are unable to assess patients not managed through this protocol. Follow up rate at the in-person nurse visit likely reflects transportation barriers in our underserved patient population. The health system identified feasibility of this protocol and has since expanded it to other clinic sites. We plan to present remaining data at the time of the conference.

IMPLEMENTATION OF POPULATION HEALTH OUTREACH TO INCREASE BREAST CANCER SCREENING PARTICIPATION

Maxim Yaskolko^1,2; Corinne Rhodes³; Christopher K. Snider²; Stephanie Subbio³; Catherine Reitz²; Caitlin McDonald²; Shivan Mehta^2,4. ¹Molecular, Cellular, and Developmental Biology, Yale University, New Haven, CT; ²Center for Health Care Transformation and Innovation, Penn Medicine, Philadelphia, PA; ³Primary Care, Penn Medicine, Philadelphia, PA; ⁴Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4054532)

STATEMENT OF PROBLEM/QUESTION: Can population health outreach strategies increase breast cancer screening when implemented into routine operations?

DESCRIPTION OF PROGRAM/INTERVENTION: Breast cancer is one of the most common and deadly cancers among women in the US. Despite the efficacy of mammogram screening, approximately 25% of women between the ages of 50-74 are not up to date on their screening—a number that has remained consistent over the past 15 years. A recent pragmatic trial demonstrated that scalable population health interventions such as centralized outreach, bulk ordering, and text message reminders can increase screening, leading to the implementation of some of these strategies across a Mid-Atlantic academic health system.

To determine if these strategies remained effective when implemented, a centralized team conducted outreach to primary care patients due for a mammogram. Patients were excluded for having a bilateral mastectomy, frailty or advanced illness according to the HEDIS definition, and actively breastfeeding. Those with an active patient portal account were sent a message through the patient portal; otherwise, they were sent a letter. A subset of practices was sent text messages where population health staff were available, allowing for a comparison of effectiveness.

MEASURES OF SUCCESS: Successful implementation would demonstrate high fidelity and a correlation of outreach strategies with higher rates of mammogram screening.

FINDINGS TO DATE: We conducted a retrospective quality improvement study to evaluate the effectiveness of the implemented strategies in increasing mammogram screening. New breast cancer diagnoses were analyzed as a secondary outcome.

24,860 patients were included in the outreach. Overall screening rates were 10.39% and 18.52% three and six months after initial outreach, respectively, compared to 14.05% and 24.65% in the clinical trial. This decrease is possibly due to the resampling of non-responders. 53 or 0.21% of patients received a breast cancer diagnosis. Six months after the initial outreach, patients who received text message reminders (n = 19,385) had higher odds of screening (adjusted OR=1.21, p < 0.001) and receiving a breast cancer diagnosis (adjusted OR=3.69, p < 0.05).

In an exploratory analysis, a significant benefit from text messages was derived for patients who received and read their patient portal message, indicating that text messages may disproportionately benefit individuals engaged with the medical system. Patients who had an active mammogram order had higher odds of screening 6 months after outreach compared to patients who did not (adjusted OR=1.75, p < 0.001), suggesting standard or bulk orders may be an effective strategy for increasing screening. Having an active order but not text messaging increased the chance of screening among Black patients and patients on Medicare or Medicaid.

KEY LESSONS FOR DISSEMINATION: Our findings indicate that centralized population health outreach, specifically text messaging, can increase breast cancer screening participation when implemented into routine operations.

IMPLEMENTATION OF STRUCTURED CARE MANAGEMENT-CLINICIAN ROUNDS TO IMPROVE HOSPITAL THROUGHPUT

Catherine Daniel¹; Katie Scally¹; Jennifer A. Chen¹; Stephen Boone^1,2; Chirayu Shah¹; Tony Jawe³; Daniel Alanis⁴; Joslyn Fisher¹. ¹Internal Medicine, Baylor College of Medicine, Houston, TX; ²Emergency Medicine, Baylor College of Medicine, Houston, TX; ³Clinical Care Management, Harris Health System, Houston, TX; ⁴Executive Administration, Harris Health System, Houston, TX. (Control ID #4059062)

STATEMENT OF PROBLEM/QUESTION: Is a structured care management-clinician rounds (CMCR) program feasible and will it improve hospital throughput, as measured through accuracy of estimated discharge date (EDD), overall length of stay, and time of discharge?

DESCRIPTION OF PROGRAM/INTERVENTION: Limited inpatient bed capacity is a substantial problem in our academic, safety-net hospital. There are over 40 hospitalized patients boarding in the emergency center (EC) at any given time. Hospital overcrowding and, specifically, boarding of patients in the EC, are associated with adverse health outcomes. We aim to improve hospital throughput and thus decrease hospital overcrowding by implementing twice-daily, structured rounding between clinicians and care managers. Structured CMCR have been shown to decrease length of stay, reduce readmissions, and improve patient satisfaction.

Prior to our intervention, CMCR at our institution were held inconsistently and without prescribed structure. In this intervention, care management and hospital medicine leadership collaborated to develop a structured CMCR program. Key components of the quality improvement initiative included (1) scheduled CMCR twice daily at specified times and (2) development of a template for the afternoon meeting with 10-questions per patient. Preliminary data was collected in August 2023, structured CMCR were implemented mid-September 2023, and post-intervention data was collected in October 2023.

MEASURES OF SUCCESS: In this project, our primary outcome was feasibility, measured by the percent of teams reporting daily participation in CMCR. The perceived value of the rounds was also measured through survey data. Secondary outcomes included percent of discharge orders placed before 11:00 am, average time of day of discharge, accuracy of EDD, and average overall length of stay.

FINDINGS TO DATE: Preliminary assessment through survey of participants (physicians, case managers, and social workers) suggests that the twice-daily, structured CMCR are feasible. The percentage of respondents who reported meeting five mornings a week (Mon-Fri) increased from 59% to 97%. 68% of respondents reported consistent participation in the afternoon CMCR 5 days per week and another 21% of respondents met 3 to 4 times per week. On a 5-point scale, the majority of respondents rated the usefulness of the rounds as 4 or 5, with the average usefulness of morning rounds rated 4.5 and afternoon rounds rated 3.5.

Since the implementation of structured CMCR, the percent of discharge orders placed before 11:00 am increased from 28% to 31% on direct care hospitalist teams and from 11% to 14% on teaching teams. Observation length of stay decreased from 65 hours to 59 hours while inpatient length of stay increased from 6.77 days to 6.98 days. Average discharge time remained consistent between 12:00-1:00 pm. EDD accuracy improved from 23% to 30%.

KEY LESSONS FOR DISSEMINATION: Twice-daily, structured CMCR are feasible. Early data shows improvement in accuracy of EDD but equivocal impact on hospital throughput as measured through discharge time and length of stay.

IMPLEMENTING A MAILED FIT PROGRAM IN A VA BASED PRIMARY CARE SYSTEM

Kaleb Keyserling¹; K. Paige Gardner¹; Gabriel Monti²; Jenna Anderson¹. ¹Portland VA Medical Center, Portland, OR; ²Oregon Health & Science University, Portland, OR. (Control ID #4060951)

STATEMENT OF PROBLEM/QUESTION: Fecal immunochemical testing (FIT) is an effective method for colorectal cancer screening; however, it requires significant effort and time on primary care to coordinate testing.

DESCRIPTION OF PROGRAM/INTERVENTION: Routine colorectal cancer screening has been shown to decrease disease specific mortality. The United States Preventive Services Taskforce recommends screening for average risk patients between the ages of 45-75. Given its comparable efficacy and the current wait times and higher cost of colonoscopies, the FIT has become the preferred modality of screening in many health care systems. A challenge of FIT has been to ensure adherence to the recommended testing interval. Previous automated FIT programs have been shown to increase screening adherence and potentially cut costs of screening.

In 2022, we established a semi-automated mailed FIT program (MFP) for all VA primary care practices within our healthcare system. FIT kits are mailed from a centralized office to patients the month before their birthday and are followed by an automated reminder phone call one month later. Our program developed a unique query to identify suitable individuals for FIT screening which has gone through multiple iterations and adjustments to appropriately identify individuals for screening, accurately capture previous screening through outside healthcare systems, and help the primary care team more easily facilitate care.

MEASURES OF SUCCESS: Our main outcome measure is the percentage of average risk patients who have obtained appropriate colon cancer screening as defined by VA electronic quality measures. Our process measures include total number of FITs mailed and resulted. Balancing measures include FIT positivity rate and the percent of patients with a positive FIT that have completed a colonoscopy within 6 months.

FINDINGS TO DATE: Since implementing the MFP, the percentage of average risk patients who are up to date on their screening has increased from 50.5% in Aug. of 2022 to 53.9% in Oct. 2023. There is a trend from Apr. to Oct. 2023 with six data points increasing during that time. The number of total FIT results has increased from 6553 to 8390 from 2021 to 2023 with the percentage of positive FITs decreasing from 9.4% to 7.9%. The percentage of positive FITs with a follow up colonoscopy within six months increased from 41% in 2021 to 44% in 2022.

KEY LESSONS FOR DISSEMINATION: The results from our MFP add to the growing evidence that MFPs can improve adherence to colorectal cancer screening recommendations. While there was some concern that implementing the MFP would decrease the percentage of patients with positive FITs obtaining the recommended colonoscopy, this does not appear to be the case.

Our project has brought up several key challenges for further discussion including 1. How best to utilize the EMR to identify appropriate patients for screening. 2. How to collaborate between health care teams to ensure patients obtain appropriate screening. 3 The potential role for a nursing coordinator to help with result communication and care facilitation.

IMPLEMENTING THE THREE-MINUTE FOOT EXAM IN A RESIDENT RUN, UNDERSERVED COMMUNITY CLINIC

Waleeja Rashid¹; Martha Dillon². ¹Internal Medicine, UConn Health, Farmington, CT; ²Internal Medicine, University of Connecticut School of Medicine, Farmington, CT. (Control ID #4065136)

STATEMENT OF PROBLEM/QUESTION: Frequent foot exams in patients with diabetes are essential for identifying loss of protective senses and in a busy primary care setting foot exams can be time consuming and limited by availability of tools such as 10 g monofilament or tuning fork. Compared to the national average, we found a significant care gap in the instances of screenings performed at our underserved, urban primary care resident clinic.

DESCRIPTION OF PROGRAM/INTERVENTION: The aim of this quality improvement project was to increase frequency of foot exams by 80-100% compared to last year by instituting the three-minute foot exam over the course of 6 weeks in a busy underserved, urban resident primary care clinic.

We started by setting an inclusion criterion and conducting chart reviews to document how often foot exams were recorded for each patient over the course of 1 year. Following this, we constructed a dot phrase outlining the three parts to the exam. We reviewed this with residents at the beginning of the study and recorded the use of the dot phrase and documentation of foot exams.

Components of the three-minute foot exam are history, exam and education. We identify modifiable and non-modifiable risk factors of ulcers. The physical exam consists of inspection, palpation and checking for protective senses with Ipswich test. This can replace the monofilament test with nearly similar sensitivity and specificity. Using the index finger to lightly touch the tip of toes, we record if the patient is able to identify the touch. Finally, educating patients to conduct regular foot exams at home and the importance of reporting new lesions to the clinic.

The current secondary intervention will focus on employing standardized and easy to use diabetic plans in visit notes to make documentation more efficient.

MEASURES OF SUCCESS: To evaluate our interventions, we used qualitative measure of percentage of diabetic patients that have had a documented complete foot exam in the past year.

FINDINGS TO DATE: 54% of patients studied had documented foot exams compared to 6.4% of exams recorded last year. Two-tailed T-test: P-vale <0.0001, 95% confidence interval of this difference, from -0.58 to -0.36.

After 10 weeks, charts for an additional five weeks of primary care visits were reviewed. For these additional patients, 17.5% had a foot exam documented in the past year and only a further 8 exams were done.

KEY LESSONS FOR DISSEMINATION: Shortening foot exams to three minutes and reducing need for tools we initially saw an increase in the rate of foot exams done in a busy resident run primary care clinic. This intervention initially increased rates by more than 200% but was not sustained a few months later and did not reach national average levels. Change was hindered by practitioner buy in as well as a high patient no show rate.

IMPROVING DELIVERY OF SEPSIS CARE IN A VA EMERGENCY DEPARTMENT

Jacob Khoury¹; David Beran³; Angela Hamilton⁴; David Ronnenburg³; Caitlin M. Martin Klinger². ¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²Medicine, Southeast Louisiana Veterans Health Care System, New Orleans, LA; ³Emergency Medicine, New Orleans VA Medical Center, New Orleans, LA; ⁴Pharmacy, New Orleans VA Medical Center, New Orleans, LA. (Control ID #4059548)

STATEMENT OF PROBLEM/QUESTION: At our facility, there is low compliance with the Center for Medicare and Medicaid Services Sep-90 bundle, compared to national average.

DESCRIPTION OF PROGRAM/INTERVENTION: At a VA Medical Center in in the Southeastern Region, there were several quarters of low compliance with the Center for Medicare and Medicaid Services Sep-90 bundle, suggesting slow delivery of evidence based sepsis care. This metric includes the timely evaluation of septic patients with blood cultures, labs, and a lactic acid; timely delivery of antibiotics and fluids; timely re-evaluation with repeat lactic acid; and initiation of vasopressors for refractory septic shock. Our scope includes identification, initial management and follow up of sepsis care initiated in the emergency department.

We conducted an extensive problem analysis, including multiple Gemba walks, and interviews with emergency department and inpatient providers, nursing, pharmacists, laboratory, and hospital leadership. We developed a current-state process map and a fish-bone diagram to identify areas to target for improvement.

Numerous fall outs were due to failure to repeat a lactic acid after an initial lactic acid was elevated. We redesigned the lactic acid order, and adjusted the critical value of lactic acid to trigger a call to the nurse for every elevated lactic acid.

Subsequent planned interventions include implementing a sepsis screening protocol at triage, use of a visual sepsis cue in the emergency department tracking system, redesign of the sepsis order set, review of the antibiotics available in the emergency department, and standardized sepsis handoff between emergency department and inpatient nurses and providers.

MEASURES OF SUCCESS: Percentage of patients who are given IV fluids per week in the emergency department who receive IV fluids within 3 hours of presentation

Percentage of patients who are given IV antibiotics (either vancomycin, piperacillin-tazobactam,

azithromycin, ceftriaxone, cefepime, and ampicillin-sulbactam) per week in the emergency department who receive IV antibiotics within 3 hours of presentation

Percentage of patients with an elevated lactic acid per week in the emergency department who have a repeat lactic acid drawn within 6 hours of the first lactic acid draw time

FINDINGS TO DATE: Our baseline repeat lactic acid rate was 29.1%. Following implementation of the electronic medical record changes and the laboratory callback mechanism, the percentage of repeat lactic acid values has remained above the baseline for 8 weeks, with an average rate of 47%.

KEY LESSONS FOR DISSEMINATION: A detailed analysis of the problem is imperative for development of successful interventions. Well designed ordering menus in the electronic medical record can also streamline and standardize the delivery of evidence based care. Sepsis care is complex and difficult to deliver for numerous reasons, including high prevalence of sepsis mimics, difficult time constraints, multiple providers and nurses involved in the care, and handoffs occurring during care delivery.

IMPROVING FOLLOW-UP OF INCIDENTAL PULMONARY NODULES USING A RADIOLOGY-BASED TRACKING SYSTEM AT A SAFETY NET HOSPITAL

Tatyana Nguyen¹; Augusta Alwang¹; Emily Jansen³; Corrin Finnell²; Qiyao Zhang⁴; Mary Clancy⁵; Avneesh Gupta²; Katrina Steiling⁵; Nicholas Cordella¹. ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Boston Medical Center Department of Radiology, Boston, MA; ³Quality and Patient Safety, Boston Medical Center, Boston, MA; ⁴Quality Analytics, Boston Medical Center, Boston, MA; ⁵Pulmonary, Allergy and Critical Care Medicine, Boston Medical Center, Boston, MA. (Control ID #4055313)

STATEMENT OF PROBLEM/QUESTION: How to improve the rate of aherence to follow up imaging for incidental pulmonary nodules using actionable finding feature of radiology-based tracking system

DESCRIPTION OF PROGRAM/INTERVENTION: Our team leveraged an existing Radiology Findings quality improvement dashboard to generate a list of pulmonary nodule actionable findings (AF) that had recommended follow-up due 3 months or less from the date the report was finalized, but who had not completed the recommended follow-up between January 2022 and July 2023. We identified and manually reviewed 62 cases that had pulmonary nodules measuring > 6mm to determine if follow-up or outreach had been performed, and to identify themes related to failure to complete the follow-up imaging recommendation.

We developed an action plan for overdue findings to intervene on all nodules identified on our list, including: 1) Radiology Service Navigator (RSN) follow-up for administrative closure of completed findings and re-outreach of lower acuity findings; 2) Quality and Patient Safety Team (QPS) follow-up for communication of additional information from the manual review with the responsible clinician; 3) Lung Nodule Clinic (LNC) follow-up for communication and documentation of outreach to the responsible clinician to determine whether further evaluation and testing was needed for patients requiring urgent follow-up imaging.

MEASURES OF SUCCESS: We aimed to close care gaps in completing recommended follow-up imaging through our multi-disciplinary action plan involving Radiology, Pulmonary Medicine, and Quality and Patient Safety. We also sought to identify themes related to failure to complete recommended follow-up, including imaging modality on which the incidental pulmonary nodule was detected, clinical locations from which the imaging originated, and whether a Primary Care Provider (PCP) was documented in the medical record.

FINDINGS TO DATE: Our multi-disciplinary action plan reviewed 100% of these cases and identified 14 patients (22%) that already had follow-up elsewhere or had a documented clinical decision to not pursue further follow-up.

A total of 27 (44%) patients had the incidental finding originally detected on chest X-ray.

The Emergency Department (ED) and Outpatient clinics were the most common ordering locations for incomplete follow-up. Among outpatient clinics, imaging orders that detected incidental pulmonary nodules that originated from specialty clinics appeared to be most likely to have not completed recommended follow-up imaging.

A total of 22 patients (35%) without follow-up had no PCP listed in the electronic medical record.

KEY LESSONS FOR DISSEMINATION: The Actionable Findings system is a promising tool to improve the rate of incidental pulmonary nodule follow-up. However, there remains further opportunity to strengthen the safety net for studies originating in outpatient specialty clinics and the ED to ensure timely ordering and completion of recommended follow-up. Further study is needed to assess the adherence to recommended follow-up of pulmonary nodules which are not marked as AF.

IMPROVING HCP DOCUMENTATION ON MEDICINE FLOORS: A QUALITY IMPROVEMENT INITIATIVE

Aphrodite Megaris¹; Elisabeth L. Rosen¹; Hannah Bava¹; Joy McIlvaine²; Lina Miyakawa³. ¹Internal Medicine, Mount Sinai Health System, New York, NY; ²Mount Sinai Health System, New York, NY; ³Division of Pulmonary and Critical Care Medicine, Mount Sinai Health System, New York, NY. (Control ID #4059854)

STATEMENT OF PROBLEM/QUESTION: Improving HCP Documentation on Medicine Floors: A Quality Improvement Initiative

DESCRIPTION OF PROGRAM/INTERVENTION: Advanced Care Planning (ACP) is a crucial part of health care, as it helps guide medical management and decision-making while honoring the patient’s wishes. Among its components, assigning a Health care proxy (HCP) empowers patients in selecting someone to make medical decisions on their behalf when they can’t. HCP's are expected to make medical decisions based on the patient’s anticipated preferences or past discussion disclosing the patient’s wishes. To ensure the recognition of patients’ chosen HCPs, formal documentation with a patient's signature is essential. Enhancing and standardizing HCP documentation practices is of utmost importance for patient-centered care and upholding patient autonomy in moments a patient cannot advocate for themselves. This Quality Improvement initiative aimed to identify and overcome barriers to HCP documentation, targeting a 15% increase in completion rates post-intervention.

MEASURES OF SUCCESS: Multifaceted interventions were implemented to encourage HCP documentation. These included nurse education on initiating HCP discussions and completion of HCP form, integrating the form into admission packets, ensuring availability of blank HCP forms across hospital units including the Emergency Department, personalized weekly reminders via Epic chat for medical residents, and education for medical residents and hospitalists with tipsheets standardizing HCP documentation. Emphasis was placed on documentation for patients admitted to medicine service aged 65 and above and was the focus of our analysis.

FINDINGS TO DATE: The pre-intervention mean rate of HCP completion was 31.93%, increasing significantly to 48.03% post-intervention (p <0.05), comparing corresponding months in 2022 and 2023 (October and November), given interventions in September 2023.

KEY LESSONS FOR DISSEMINATION: The statistically significant increase in HCP form completion is evident, with an immediate surge to 53.87%, followed by a slight decline, expected due to the nature of one-time interventions versus continuous efforts. The sustained increase from baseline suggests successful integration into practice, reinforced by high completion rates in subsequent months. This indicates knowledge internalization among staff, promising for future healthcare settings.

IMPROVING INTIMATE PARTNER VIOLENCE (IPV) SCREENING AND REFERRAL IN AN INTERNAL MEDICINE RESIDENCY CLINIC

Yamini Vepa, Zehra Hussain, Vincent Mack, Connor Holthouse, Zahra Manji. Internal Medicine, Christiana Care Health Services Inc, Wilmington, DE. (Control ID #4064940)

STATEMENT OF PROBLEM/QUESTION: Intimate Partner Violence (IPV) is a condition with severe physical and emotional health consequences and is often under-screened by physicians in primary care practices.

DESCRIPTION OF PROGRAM/INTERVENTION: IPV is a significant public health problem affecting millions in the US, leading to health impacts varying from STDs to death from physical and sexual assault. The USPSTF recommends screening for IPV in all women of reproductive age; however, screening is infrequent among internists, estimated at 6% in one study. We sought to increase the rate of IPV screening during well-woman exams in our internal medicine residency primary care practice. We first surveyed residents, asking them about their current IPV screening practices and barriers to screening. Based on the results of the survey, we developed a 4 part intervention: 1)Didactic education for the internal medicine residents with a focus on sensitive language and time-efficient strategies for screening, 2)Resource badge cards to serve as immediate access, 3)Updated “well women exam” templates with IPV screening reminders, 4)Education and “Quick texts” with the HITS (Hurt, Insult, Threaten, Screen) questionnaire – a brief, time-efficient, validated tool to screen for IPV. We plan to obtain creator consent prior to the use of HITS.

MEASURES OF SUCCESS: Our primary measure of success is the rate of documented IPV screening during well-woman exams. We will also measure the following process measures: resident comfort level with screening documented in post-didactic surveys, use of resource badge cards, updated well-woman quick-text, and documented HITS use during well-woman visits.

FINDINGS TO DATE: Of the 21 well-woman exams completed from November 1, 2023, to November 30, 2023, only six had IPV screening documented. 37/67 residents responded to our survey. The results are as follows: 45.9% of residents reported not having screened any patients for IPV over the prior three months. Most residents (73.1%) reported they DO feel comfortable broaching the topic of IPV with their patients. The most identified barriers to screening were lack of knowledge regarding patient resources, insufficient time, and worry about appropriate language to use. Most residents (81.1%) reported they were unaware of any specific resources for IPV patients.

KEY LESSONS FOR DISSEMINATION: Through the initial steps of our project, we confirmed that baseline screening rates are low and consistent with national trends. Our survey revealed that residents do feel comfortable broaching the topic of IPV but face barriers such as time, appropriate language, or knowledge regarding available resources. We used this information to design tailored interventions as follows: Prioritizing teaching around the efficient HITS screening tool, Specific language to use, and Resource badge cards. Our survey results and low-cost and time-efficient planned interventions are generalizable to other internal medicine residents to improve screening and referral rates at other residency primary care practices.

IMPROVING NALOXONE PRESCRIBING AT DISCHARGE

Ellena Popova¹; Patel Karishma²; Sarah Burbank²; Fiona Ng²; Diana Funk²; Laura Pugh²; Chloe Cattle²; Sushmitha Divakar²; Alexander Logan^3,2. ¹Internal Medicine Primary Care, University of California San Francisco, San Francisco, CA; ²Internal Medicine, University of California San Francisco, San Francisco, CA; ³Division of Internal Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA. (Control ID #4054243)

STATEMENT OF PROBLEM/QUESTION: Opiate overdose deaths continue to rise, including among patients who primarily use non-opioid drugs; hospitalizations are an opportunity to provide overdose risk education and mitigation strategies, including access to naloxone, for patients with all substance use disorders.

DESCRIPTION OF PROGRAM/INTERVENTION: This resident-led quality improvement project aims to increase rates of prescribing naloxone at discharge to inpatients with opioid, stimulant, and/or benzodiazepine use disorders. The intervention will run 8/31/23-6/30/23; included are patients discharged from the Internal Medicine service at an urban academic safety net hospital. Based on an initial gap analysis, we designed a QI intervention consisting of provider education, targeted outreach using performance metrics with peer comparison, and electronic health record (EHR) optimizations.

MEASURES OF SUCCESS: We aim to reach a 75% discharge prescribing rate of naloxone for patients with any substance use disorder (SUD), excluding mono-alcohol, -tobacco, and -cannabis use disorders. We also seek to increase resident confidence in providing overdose prevention counseling measured by pre- and post-intervention surveys.

FINDINGS TO DATE: Our resident pre-survey (N = 42, 23% response rate) showed 59% of residents often or always prescribe naloxone to people with opiate use disorder (OUD) while only 14% of residents often or always prescribe naloxone for patients with non-OUD SUDs. Additionally, 60% do not feel comfortable in discussing overdose prevention methods for their patients with SUD. Main barriers to prescribing were lack of knowledge of who would benefit from a naloxone prescription and forgetting to order naloxone prescriptions, and their preferred learning methods were a shared EHR dot phrase and noon conferences.

In the first three months of intervention (9/23-11/23), 490 patients with SUD have been discharged from our resident teams, with a 6.96% absolute increase in naloxone prescribing relative to baseline (N = 997) (42.2% v. 49.2%, p 0.011), with only the provider outreach interventions currently in place. We anticipate additional impact of planned provider education tools (rollout Dec 2023-Feb 2024), engagement of pharmacists in provider outreach (Jan 2024), and discharge prescribing Best Practice Alerts in the EHR (Spring 2024).

KEY LESSONS FOR DISSEMINATION: Inpatient providers are well-positioned to discuss overdose prevention and prescribe medications to mitigate risk of fatal overdose, especially for underserved populations who often face increased barriers to accessing outpatient care. QI interventions including education, targeted provider outreach, and EHR optimization can improve discharge prescribing rates of naloxone. Additional education for residents on overdose risk factors and overdose prevention counseling is needed.

IMPROVING RATES OF ADVANCED CARE PLANNING IN A RESIDENT PRIMARY CARE CLINIC

Emily Kosinski¹; Amber Bird²; Laura Dingfield¹. ¹Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; ²Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4064976)

STATEMENT OF PROBLEM/QUESTION: How can advanced-care planning conversations be better facilitated between residents and high-risk patients within their primary care clinic panel?

DESCRIPTION OF PROGRAM/INTERVENTION: In our institution, all internal medicine residents are trained in the Serious Illness Care Program (SICP), a care delivery program designed to facilitate earlier and higher-quality advanced care planning (ACP) conversations between physicians and patients. Despite this intervention, as of November 2022 only 12.9% of high-risk patients within resident primary care clinic panels had any ACP documentation within the electronic medical record (EMR). A quality-improvement project was designed and implemented to increase the rates of ACP within two outpatient, resident primary care clinics at a large academic Internal Medicine residency program. A voice-of-the-customer analysis was conducted with a subsection of internal medicine residents (n=20) and attending preceptors (n=15) within the clinics. Thematic analysis identified four main barriers to resident advanced care planning: 1. Time constraints 2. Competing issues to be addressed within clinic visits 3. Difficulty identifying high-risk patients and 4. Difficulty initiating ACP in a non-acute setting. A resource guide was distributed to residents with information on identifying high-risk patients within their panel using EMR dashboard and filtering tools, guide to designating a healthcare proxy within the EMR, and coordinating and documenting a dedicated advanced care planning visit with patients using the SICP framework. Residents received a protected half-day panel management session during an ambulatory rotation to identify their high-risk patients and decide on what next steps would be approrpriate to facilitate advanced care planning for those patients.

MEASURES OF SUCCESS: Residents were surveyed regarding patients identified as high-risk and interventions proposed to address advanced care planning. Our outcome measure will be the percentage of high-risk patients with a healthcare proxy designated. Process measures include percentage of high-risk patients with an ACP note on file. Qualitative feedback from residents was also elicited.

FINDINGS TO DATE: Of the internal medicine residents (n=31) who completed the activity to date, 178 patients were identified as high-risk of significant morbidity or mortality. Of these patients, 9 had a healthcare proxy designated, and 10 had a previous advanced care planning (ACP) note documented. Of the interventions taken, 10 patients were called to discuss healthcare proxy desgination, 10 were sent information on ACP via mail, and 56 were contacted to schedule a dedicated visit to address ACP.

KEY LESSONS FOR DISSEMINATION: This project highlights that educational interventions alone are ineffective at facilitating advanced-care planning within a resident-led primary care clinic. Optimizing workflow and providing dedicated time to address these complex issues are necessary to promote success.

IMPROVING SGLT2I PRESCRIBING IN RESIDENT CONTINUITY CLINIC FOR HEART FAILURE PATIENTS

Adam R. Blaine, Kimiya Nourian, McKenna Eisenbeisz, Trisha Slehria, Amanda Chang, Katrina Soyangco, Casey Hardin, Michelle Miller, Michael Klein, Wendy Fiordellisi. Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #4064085)

STATEMENT OF PROBLEM/QUESTION: In our Resident Continuity Clinic (RCC), only 18.6% of patients diagnosed with heart failure are receiving goal-directed SGLT2 inhibitor (SGLT2i) therapy.

DESCRIPTION OF PROGRAM/INTERVENTION: Heart failure affects over six million people in the U.S. In recent years, SGLT2i medications have emerged as a promising therapy to improve heart failure management, prevent hospitalization, and reduce mortality. The 2022 American Heart Association and the American College of Cardiology guidelines recommend use of SGLT2i medications for both heart failure with reduced ejection fraction and heart failure with preserved ejection fraction, regardless of diabetes status. In the past, cost has been a significant barrier to access for our patient population. With new data published on their benefits, most insurances will cover the medication. In our outpatient residency clinic, we found that only 18.6% of patients with any ICD-10 diagnosis of heart failure are prescribed SGLT2i therapy. Our aim is to increase the prescribing rate by 20% in the next 20 weeks. Our intervention focuses on educating residents and faculty about the benefits of SGLT2i therapy. We will implement an educational intervention as part of a mandatory resident education session held during clinic week for all residents in RCC. Furthermore, an automated email will be sent at 7am on Monday to specific residents at the start of their clinic week and their respective staff. Lastly, a short presentation to the attending physicians working with residents will outline the lack of prescribing and benefits of the medication in this population. Pharmacy resources will be highlighted for staff in case they encounter patients whose insurance does not cover the medication.

MEASURES OF SUCCESS: We collected baseline data for all patients with any ICD-10 diagnosis of Heart Failure from July 1, 2022, to June 30, 2023 and identified how many of these patients were prescribed SGLT2i therapy. We excluded patients with a history of DKA or type I diabetes. We found that only 18.6% of patients with Heart Failure were prescribed SGLT2i therapy. Following our intervention, we will collect data from January 15, 2024 to February 26, 2024, to measure the effects of resident education on prescribing practices. We plan on using this data to complete another Plan-Do-Study-Act cycle before a final data analysis in April 29, 2024.

FINDINGS TO DATE: Only 18.6% of patients in RCC are on goal directed SGLT2i therapy.

KEY LESSONS FOR DISSEMINATION: Heart failure is a common diagnosis, and effective outpatient treatment can help improve patient symptoms, prevent hospitalization, and reduce mortality. With new trials to support their use, insurance access to SGLT2i in more disadvantaged populations has improved. Educating healthcare providers on the newest advances through electronic communication and within the clinic setting benefits patient outcomes through improving adherence to newer, evidence-based guidelines.

IMPROVING STANDARDIZED CARE FOR PATIENTS ADMITTED WITH EATING DISORDERS

Claire Ciarkowski¹; Brenna Brown²; Kelsey Tuttle²; Alyssa Hickert²; Gabriel Fette²; Jen Simmons³; Shegi Thomas³. ¹Internal Medicine , University of Utah, Salt Lake , UT; ²Psychiatry, The University of Utah School of Medicine, Salt Lake City, UT; ³Nursing, University of Utah Health, Salt Lake City, UT. (Control ID #4063595)

STATEMENT OF PROBLEM/QUESTION: Patients admitted with eating disorders receive variable care regarding medical monitoring and behavioral interventions, which can result in unintentional harm.

DESCRIPTION OF PROGRAM/INTERVENTION: Eating Disorders are the third most common chronic disease among young people and anorexia nervosa significantly increases the risk of death among women. Patients who are admitted due to severe malnutrition and low BMI are at risk for acute medical complications including refeeding syndrome and cardiac issues such as arrhythmias and congestive heart failure. These patients are also at risk of self-sabotage behaviors which can lead to prolonged hospitalizations and frustration among staff. On chart review of hospitalized patients with an admission diagnosis of anorexia nervosa, bulimia nervosa, or eating disorder NOS over a 1-year period, we found patients received inconsistent lab monitoring and nutritional supplementation. Additionally, interviews with nursing staff revealed multiple challenges in patient care citing sabotaging behavior in these patients. A multidisciplinary group including representatives from Internal Medicine, Psychiatry, Nursing, Social Work, Risk Management, Clinical Dietician, Information Technology and Quality Consultants was formed. Our goal was to provide consistent, standardized, cross-disciplinary care for patients with eating disorders during acute hospital admissions. To do this, we created an order set which includes clear communication for nursing and guideline driven recommendations on monitoring. Nursing staff on acute care units received an educational module on best practices for patients admitted with eating disorders to match the order set. The order set became available for providers on 12/6/2023.

MEASURES OF SUCCESS: We will monitor order set use in patients with an admission diagnosis of anorexia nervosa, bulimia nervosa, or eating disorder NOS. Outcomes of patients admitted with one of these diagnoses and without the order set will be compared to patients who had the order set used during the admission. Between the two groups, we will analyze the percentage of interventions completed, length of stay, discharge location, follow up provided and 30-day readmission rate. A 1-year follow up survey will be distributed to nursing staff to assess satisfaction on interventions in this patient population.

FINDINGS TO DATE: Baseline analysis of 8 patients admitted with eating disorders from 11/1/2021 to 10/30/2022 had a range in implementation of proposed interventions (11.6%-69.8%, median 53%). The median length of stay was 9.5 days (range 2-44 days) and the 30-day readmission rate was 12.5%. Three patients were discharged to inpatient psychiatry and 5 patients were discharged home with a range of outpatient support.

KEY LESSONS FOR DISSEMINATION: Patients admitted for eating disorders can be challenging to manage. Leveraging a multidisciplinary team to create a standard of care will help improve quality of care, reduce variation in practice and make nursing staff feel more supported in the setting of sabotaging behaviors.

IMPROVING THE ACCURACY OF ASTHMA DIAGNOSIS BY INCREASING THE RATE OF PFT COMPLETION AMONG PATIENTS WITH A LABELED DIAGNOSIS OF ASTHMA THROUGH COMMUNITY OUTREACH METHODS

Fadi Toro¹; Andrei Brateanu². ¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Medicine, CCF, Cleveland, OH. (Control ID #4064323)

STATEMENT OF PROBLEM/QUESTION: Amongst my patients with a diagnosis of Asthma in EPIC, only 45% underwent pulmonary function testing (PFTs) in the past.

DESCRIPTION OF PROGRAM/INTERVENTION: The QI project aims to increase the PFT completion rate from 45% to 65% among patients with a diagnosis of Asthma in EPIC within 3 months using community outreach methods. The setting is an outpatient hybrid academic clinic run by residents. The patient population includes my patient panel and my clinic supervisor's patient panel.

The first intervention includes electronically messaging patients with an active MyChart Status who have a diagnosis of Asthma but no prior PFTs on file. The message provides information on the required actions to schedule an appointment for Pulmonary Function Tests (PFTs).

The second intervention is a reminder message through MyChart for patients who have read the first one but did not schedule their test.

The third intervention will include a quick phone call. It pertains to individuals who, despite having an active MyChart status, have not read the MyChart message. This suggests that they may not necessarily be regular users of MyChart. The third intervention will only be applied if the goal is not reached within two weeks of the second intervention.

MEASURES OF SUCCESS: - Key Performance Indicator (KPI) = # of patients with PFTs out of those with a diagnosis of Asthma

- The aim is an increase in KPI or average % increase in PFT completion from baseline

FINDINGS TO DATE: There was an 8% increase in scheduled PFTs following the first intervention, namely, mass texting Asthma patients with no prior PFTs and with active MyChart Status through EPIC.

The next intervention is re-sending the same text to patients who have read the first message.

If the goal was not reached by the second intervetnion, then the third intervention will be calling patients who have not read the first message.

KEY LESSONS FOR DISSEMINATION: - Mass texting patients through the EMS is a simple yet very effective technique and can significantly improve patients' outcomes

- Asthma is a very common yet overdiagnosed condition. Making sure that patients undergo appropriate diagnostic testing is key to optimizing patients' health

INCREASING BREAST CANCER SCREENING AMONG PRIMARY CARE RESIDENT PATIENTS AT A FEDERALLY QUALIFIED HEALTH CENTER

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 #4064943)

STATEMENT OF PROBLEM/QUESTION: 63% of resident primary care patients at federally qualified health center who were eligible for breast cancer screening were overdue in June 2022.

DESCRIPTION OF PROGRAM/INTERVENTION: Through quality improvement initiatives, we aimed to decrease the percentage of eligible patients overdue for breast cancer screening from 63% to 30% by December 2023. Chart review of 26 patients overdue for screening showed that mammogram scheduling was the biggest barrier to screening. Of the 26 patients, 50% had an active mammogram order, but had not scheduled a mammogram.

We thus decided to target patient scheduling by hiring 2 PA students to contact overdue patients. The PA students contacted overdue patients 3 times over the course of 3 weeks. Patients were sent a HIPAA compliant text message with clinic and radiology contact info if they did not answer the phone. If there was no response via call or text, a patient portal message was sent with radiology scheduling information. Patients were asked if they knew they were overdue for breast cancer screening and then, if interested, given the information to either schedule with radiology or have the researcher schedule for them.

MEASURES OF SUCCESS: Success was measured by successful completion of a screening mammogram, regardless of whether patient or researcher scheduled.

FINDINGS TO DATE: A total of 415 patients of 29 residents and 2 attendings were identified as eligible for breast cancer screening through SlicerDicer query on Epic, 69% (286) of which were overdue for breast cancer screening. 61 of these patients had already scheduled a mammogram, and were not contacted by the PA students.

59% of patients were reached on the first call. Only 25% of text messages were read. 35 messages were sent through the patient portal as a final outreach. Only 3 of the 35 messages were read and no mammograms were scheduled as a result.

The most common reason patients reported not being up-to-date with screening was that they did not know they were overdue (33%). The next most common reasons were not having the time (14%) or knowing how to schedule (11%).

35% of patients asked the researcher to schedule their mammogram. Only 6% (13) patients scheduled mammograms on their own after outreach.

Completion rates were almost double for self-scheduled appointments compared with researcher-scheduled appointments, 34% to 18%, respectively. Self-scheduled appointments were more likely to be rescheduled rather than cancelled, with 6 of 14 self-scheduled appointments rebooked compared to only 2 of 63 researcher booked appointments.

KEY LESSONS FOR DISSEMINATION: Although patients were receptive to researchers scheduling mammogram appointments, patients were half as likely to attend researcher-scheduled appointments. At our institution, mammograms were booked several months out, so future interventions may need more frequent reminders closer to appointment time or the ability to schedule patients much sooner.

Secure text messages and patient-portal communications were not a successful method of outreach for this patient population.

NALOXONE OUTREACH INITIATIVE: A PHARMACIST-LED QUALITY IMPROVEMENT (QI)STUDY

Polly D. Fraga¹; Christine Leduc^1,2; Hyun Joo Lee². ¹General Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA; ²Pharmacy, Lahey Hospital and Medical Center, Burlington, MA. (Control ID #4053824)

STATEMENT OF PROBLEM/QUESTION: There were over 100,000 deaths from opioid overdose in the United States in 2021, and 23% of these deaths involved prescription opioids. The 2022 CDC guidelines recommend co-prescribing naloxone for all patients prescribed over 50 Morphine Miligram Equivalents (MME) daily of opioids. In a Massachusetts academic medical center, an assessment of current opioid and naloxone prescribing trends showed 3% of patients prescribed high dose opioids had a concomitant prescription for naloxone, similar to rates seen elsewhere. In this study, we examine the effect of a QI pharmacy outreach initiative aimed at increasing naloxone prescribing to patients prescribed high dose opioids in a General Internal Medicine (GIM) practice.

DESCRIPTION OF PROGRAM/INTERVENTION: Patients who are prescribed greater than 50 MME/day of opioids without a concomitant prescription for naloxone will be identified via the electronic medical record (EMR). Patients meeting inclusion/exclusion criteria will be mailed a letter introducing the project and informing them to expect a call from a pharmacist. A pharmacist will provide naloxone education to the patient by telephone. If the patient accepts the offer of a naloxone prescription, the pharmacist will send a prescription for naloxone nasal spray to the patient's PCP or designee. The pharmacist will confirm if the naloxone was actually dispensed.

MEASURES OF SUCCESS: The primary endpoint is the percent change pre vs post intervention in patients with a concomitant naloxone prescription who are prescribed ≥ 50 MME daily of opioids. The secondary endpoint is the percent change pre vs post intervention of patients with a confirmed naloxone prescription fill. Additional data collected will include the overall number of naloxone prescriptions, the cost of naloxone, and the reasons for declining naloxone.

FINDINGS TO DATE: Pre intervention data was obtained from the electronic medical record. From September 14, 2023 to December 13, 2023, 39 patients had an opioid prescription for 50-90 MME/day, and zero of these patients had a concomitant naloxone prescription. In the same time period, 63 patients had an opioid prescription ≥ 90 MME/day, and three of these patients had a concomitant naloxone prescription. This means approximately 3% of patients prescribed high dose opiods as defined by the CDC have been co-prescribed naloxone. Participants have been sent the introductory letter and we are starting to contact identified patients directly. We will report additional data on the impact of these letters and pharmacist phone calls.

KEY LESSONS FOR DISSEMINATION: Initial data show the academic practice patterns for appropriate naloxone prescribing do not differ from national data. EMR data can be used in a targeted patient approach to improve naloxone prescribing rates. A pharmacist led program offers advantages in a busy GIM practice. We will present efficacy data on direct pharmacist outreach to patients on high dose opioids who have not yet been prescribed naloxone in increasing the appropriate prescription of naloxone in this at-risk population.

OPTIMIZING TELEMETRY LENGTH OF STAY (LOS): IMPACTING CLINICAL DECISION-MAKING THROUGH SYSTEMS ENGINEERING

Heather Hopkins¹; Chase Houghton¹; Cherinne Arundel². ¹Medicine, Washington DC VA Medical Center, Washington, DC; ²Medical Service, Washington DC VA Medical Center, Washington, DC. (Control ID #4062478)

STATEMENT OF PROBLEM/QUESTION: Telemetry LOS is often longer than medically necessary on the inpatient wards. At our facility only 12% of our acute care med-surg beds are telemetry-capable. Therefore, overutilization of telemetry for continued stay patients often results in admission delays for new patients who require telemetry monitoring. We aim to improve our telemetry LOS by implementing telemetry order sets with built-in provider education and auto-discontinuation features.

DESCRIPTION OF PROGRAM/INTERVENTION: Our facility is a Mid-Atlantic academic VA medical center with 97 acute care med-surg beds and approximately 4,000 inpatient medicine admissions annually. In Feb 2022, telemetry bed availability in the facility decreased from 26 to 12 beds due to nurse staffing shortages. Prior to our interventions, telemetry utilization was reviewed by a flow physician each weekday during interdisciplinary discharge rounds. Telemetry removal orders were communicated by email to the patient flow center, who then communicated with the nursing staff and telemetry technicians.

Multiple interventions were undertaken simultaneously over a one-year period. These interventions were created based off review of baseline data on telemetry LOS and daily telemetry bed availability. Stakeholders, including clinical coordinators, nurses, telemetry technicians, physicians, and EMR specialists met regularly in an interdisciplinary effort to design and implement the following processes:

Created a telemetry order set and incorporated this into the EMR, including built-in physician education for telemetry indications, diagnosis-based ordering, pop-up reminders for daily review of telemetry appropriateness, and auto-discontinuation of orders.

Devised a telemetry tracking system to provide real time awareness of telemetry bed availability.

Implemented nursing educational initiatives to increase the available number of telemetry-trained nurses.

Updated telemetry equipment to enable central monitoring and off-unit transportation.

Increased number of telemetry boxes.

MEASURES OF SUCCESS: Two quantitative measures were assessed before and after initiation of the above interventions. These included the average telemetry LOS (hours/patient) and the average number of available telemetry beds per day. These performance metrics were collected through retrospective chart reviews and the Bed Monitoring System (BMS) board data extraction.

FINDINGS TO DATE: Interventions began in September 2022. Average inpatient telemetry LOS decreased from 97 hours/patient in Aug 2022 to 50 hours/patient in Aug 2023. Average available telemetry boxes improved from 3 (out of 12) per day to 7 (out of 16) per day.

KEY LESSONS FOR DISSEMINATION: Adding diagnosis-dependent tele order sets with auto-discontinuation orders results in improved telemetry utilization for patients.

Educating physicians about telemetry appropriateness optimizes physician level of care decision-making and telemetry resource allocation.

OUT OF SCOPE? COLORECTAL CANCER SCREENING GAPS AND BARRIERS IN A RESIDENT CLINIC

Chanel Varney²; Sachi Oshmia¹; Julia Gamble²; Robin Byrd²; Alex H. Cho³; Joel C. Boggan¹. ¹Medicine, Duke Medicine, Durham, NC; ²Duke University, Durham, NC; ³Medicine, Duke University, Durham, NC. (Control ID #4064691)

STATEMENT OF PROBLEM/QUESTION: Colorectal cancer remains the second leading cause of cancer deaths in the United States and rates of screening exhibit known health inequities. We sought to determine rates of and barriers to screening at a resident clinic with a historically underserved population.

DESCRIPTION OF PROGRAM/INTERVENTION: Post-graduate year (PGY)-2 and PGY-3 residents performed a 2-phase (each half of the Academic Year) audit-and-feedback review of their primary care panels for patients not meeting colorectal cancer screening (CRCS) metrics via electronic health record (EHR) dashboards. In each Phase, residents were given a patient list of patients for whom screening had been ordered but not completed (OBNC) at the time of the report. Residents then contacted up to 3 of the OBNC patients to determine barriers to completion in Phase 1 and possible solutions in Phase 2.

MEASURES OF SUCCESS: Rates of CRCS performance were analyzed at the clinic level and qualitative responses to barriers were categorized thematically.

FINDINGS TO DATE: In Phase 1, 732 patients eligible for CRCS across 22 resident panels were reviewed. Of these patients, 423 (57.8%) had not received CRCS. In Phase 2, 707 patients eligible for CRCS across 20 resident panels were reviewed, with 387 (54.7%) having not received CRCS. Of patients who had not received CRCS, 24 (5.7%) in Phase 1 and 37 (9.6%) in Phase 2 were felt to not require CRCS based on factors such as life expectancy. Overall, 208 of patients without CRCS in Phase 1 (49.2%) and 228 in Phase 2 (58.9%) had had a primary care appointment in the preceding 12 months and 275 (65.0%) and 241 (62.3%) had activated the EHR patient portal. Residents in Phase 1 had an average of 7.1 OBNC patients, while residents in Phase 2 had an average of 9.2. Between audits, the 19 residents who completed both phases saw an average of 5.2 patients for clinic visits who had not received CRCS and ordered CRCS for an average of 6.5 patients. Residents contacted 38 OBNC patients in Phase 1 and an additional 26 OBNC patients in Phase 2. Transportation was the most frequently cited patient barrier to CRCS, followed by time to complete screening. Nine residents reported ordering more stool testing after their first panel audit, while two others reported offering more stool testing. Only 4 patients (15.4%) contacted in Phase 2 wished for additional in-person visits to facilitate screening, while 20 (76.9%) would like colonoscopy preps to be available at the time of ordering CRCS.

KEY LESSONS FOR DISSEMINATION: The majority of patients eligible for CRCS across several resident primary care panels had not been screened based on EHR metrics, although half of these patients had been seen for primary care visits within the preceding 12 months. Roughly 1/3 of unscreened patients had had screening ordered before the time of the initial panel audit, and residents ordered additional screening after participation in this QI project. Patients cited transportation as their most important barrier to CRCS and many would appreciate prep kit availability at the time of ordering screening.

PRESCRIBING EXERCISE - A QUALITY IMPROVEMENT PROJECT TO INCREASE EXERCISE PRESCRIPTIONS IN PRIMARY CARE

Daniel P. Nurse¹; Christina Hermanns¹; Elizabeth Hahn¹; Daniel Cancilla¹; Meghna Nagam¹; Mohammad Alamer¹; Christopher Black¹; Aqieda Bayat¹; Bianca Honnekeri¹; Helene Puzio¹; Jessica Donato². ¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Hospital Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4064520)

STATEMENT OF PROBLEM/QUESTION: Exercise has been proven to be one of the most effective lifestyle changes patients can make to combat chronic diseases and increase lifespan, yet primary care physicians do not routinely prescribe exercise to their patients.

DESCRIPTION OF PROGRAM/INTERVENTION: A quality improvement project was initiated to increase the percentage of patients in the primary care clinics of internal medicine residents prescribed exercise as measured by documentation in the clinic note. Baseline data was collected on 90 patients in the panels of nine internal medicine residents, who were seen for annual physicals or primary care follow-up visits within the prior three months at three ambulatory sites of our large academic medical center. Data included patient demographics, Charleston Comorbidity Index, and whether there was a documented discussion about exercise from their most recent clinic visit. The Key Performance Indicator (KPI) was calculated by taking the number of patients with documentation of exercise discussions in the note assessment/plan divided by the total number of patients seen. Given that most internal medicine residents did not feel they had enough knowledge about how to prescribe exercise, nor adequate resources to develop exercise prescriptions, our initial intervention incorporated the use of disease-specific exercise prescription handouts from the Exercise is Medicine® website (www.exerciseismedicine.org) which have been developed by subject matter experts from the American College of Sports Medicine. To aid in documentation of exercise prescriptions, the residents used a dot phrase in their clinic notes whenever they gave an exercise prescription to their patients as a means of providing access to the resources via a hyperlink and as a prompt for documentation in the assessment/plan of the note.

MEASURES OF SUCCESS: We seek to increase the percentage of patients with documented discussions about exercise in the primary care panels of internal medicine residents by 20% in 6 months.

FINDINGS TO DATE: Baseline data from the initial 90 patients showed an average age of 55.7 years, average BMI of 31, and an average Charleston Morbidity Score of 2.4. Only 15.2% of patients had documentation of a discussion about an exercise plan in their most recent clinic note’s assessment/plan. Post-intervention data collection is currently ongoing.

KEY LESSONS FOR DISSEMINATION: Prescribing exercise in the primary care panels of internal medicine residents is currently low, as measured by documentation in the clinic notes, and represents an important opportunity. We predict that the use of disease-specific exercise prescription handouts from the Exercise is Medicine® website will increase resident incorporation of exercise prescriptions into primary care practice, while also enhancing resident confidence and ability to prescribe exercise. We believe this will be a valuable intervention with high generalizability to other ambulatory practices to increase exercise prescriptions and improve the health of our patients.

REDUCING PATIENT WAIT TIMES AT A STUDENT-RUN FREE CLINIC

Sarika K. Mullapudi, John S. Laue, Carlie Stein. School of Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL. (Control ID #4063533)

STATEMENT OF PROBLEM/QUESTION: Patients seen at our medical student-run free clinic (SRFC) spend an average of 2.5 hours in the clinic per appointment, and surveys conducted at other SRFCs highlight patients’ decreased satisfaction with long wait times.

DESCRIPTION OF PROGRAM/INTERVENTION: We evaluated wait time data from a student-run free clinic in the Southern region which serves under-insured and uninsured patients. We identified that prescribing and dispensing medications adds a significant amount of time to appointments, so we implemented a quality improvement (QI) project to streamline our dispensary protocol with the goal of decreasing patients’ total time in the clinic by at least 10%.

Prior to our QI implementation, lead physicians at the SRFC spent a considerable amount of time manually looking for which medications were available and searching for prescription savings coupons for unavailable medications, which both contributed to long wait times for patients. To address this challenge, we created an updated formulary sheet containing all available medications and dosages at our SRFC, with areas to indicate which medications were projected to run out during the clinic day. The formulary sheet is updated at the beginning of each clinic day and distributed to the physician, student volunteers, and the dispensary room so that providers know what medications are available prior to discussing options with the patient.

MEASURES OF SUCCESS: We collected 2 months of our SRFC patients' total time spent in the clinic using manually recorded entry and exit times from before (n = 100) and after (n = 91) updating our dispensary protocol. We evaluated “normal capacity clinics days” in which at least 3 new patients and 3 returning patients were seen so that an inflated provider-to-patient ratio did not artificially decrease patients’ total time in the clinic in our analysis. The final data set analyzed new patients’ total time in the clinic on a normal capacity clinic day before (n = 26) and after (n = 15) implementing the dispensary protocol, alongside returning patients’ total time in clinic before (n = 53) and after (n = 52) the implementation.

FINDINGS TO DATE: Our SRFC’s new dispensary protocol significantly decreased returning patients’ total time in clinic from an average of 144 minutes to 123 minutes, for a total reduction of 15% (p < 0.05*). The average total time spent in clinic for new patients decreased from 146 minutes to 130 minutes (p = 0.156), which is not significant but may be due to only having collected data from 15 new patient appointments after our protocol implementation.

KEY LESSONS FOR DISSEMINATION: Our streamlined dispensary protocol can be implemented at other SRFCs or limited-resource settings to decrease long patient wait times in order to improve patient satisfaction and overall clinic efficiency. Finding ways to reduce patient wait times is especially important when working with vulnerable patient populations, such as those served by our SRFC. Our next steps include evaluating if decreased wait times correlate with decreased patient walk-out rates.

REELING BACK IN THOSE WHO WERE “LOST TO FOLLOW UP”: AN EFFORT TO DECREASE DISPARITIES IN HYPERTENSION CONTROL IN BLACK/AFRICAN-AMERICAN PATIENTS

Tamara F. Godfrey, Shayla Mitchell Bigelow. Internal Medicine, University of North Carolina System, Chapel Hill, NC. (Control ID #4054293)

STATEMENT OF PROBLEM/QUESTION: Despite system-wide efforts to improve hypertension (HTN) control amongst all patients, the disparities in control widened between Black/African-American patients and White patients in our Internal Medicine clinic at a large academic medical center.

DESCRIPTION OF PROGRAM/INTERVENTION: We identified Black patients that were in the HTN registry, categorized as low-risk (ASCVD score <10% and/or no heart failure, chronic kidney disease, or diabetes), had not achieved goal blood pressure (<140/90), had not been seen in our clinic in at least 6 months, had no future HTN outreach efforts by the population health team planned, and did not have future follow up appointments scheduled. Over the course of seven months there have been three PDSA cycles – each with the main focus of outreach to low-risk Black patients with uncontrolled HTN that had not been seen recently in clinic. Interventions included MyChart messaging and phone calls to patients encouraging them to make a clinic appointment to discuss HTN, and reminders in the appointment notes encouraging the provider to address HTN and social determinants of health (SDOH).

MEASURES OF SUCCESS: After the outreach efforts were completed during each cycle we documented how many MyChart messages were read, how many appointments were made, how many appointments were kept, whether blood pressure was controlled during the appointment, and whether adequate follow up was arranged after the appointment. We also assessed if the number of Black patients with uncontrolled HTN decreased over this period of time, as well as the disparities that existed between this population and White patients.

FINDINGS TO DATE: From the two PDSAs that included MyChart outreach to patients, 32% of a total of 64 patients read the message and 15% scheduled an appointment. From the two PDSAs that included telephonic outreach to patients, 42% of a total of 28 patients were successfully reached by phone and 63% were scheduled for appointments. Unfortunately over the course of five months, from two months after the first PDSA cycle to two months after the third PDSA cycle, the percentage of low-risk Black patients in our clinic with controlled HTN decreased from 68% from 60%.

KEY LESSONS FOR DISSEMINATION: After recognizing the widening disparities between Black and White patients with HTN in our clinic and noticing that many of the Black patients in the HTN registry had not been seen in some time, we focused our efforts on outreach to get these patients back into clinic to discuss their HTN. We learned that telephonic outreach was more successful in getting patients scheduled compared to relying on outreach through the electronic medical record, and despite a number of patients returning back to care the rates of HTN control in our clinic worsened for Black patients. We have secured ongoing staff support for this outreach to continue, but future efforts will also shift to focus on provider and patient education for Black patients that are actively being followed for their HTN, as well as increased screening and addressing of SDOH.

SOMEBODY'S WATCHIN' ME: ASSESSING THE IMPACT OF PATIENT MONITORING ON HOSPITAL DISCHARGE DELAYS

Kyla R. Rodgers, Brandon Temel, Emma Greimann, Sara Settle, Rasimcan Meral, Elizabeth Spranger, Jennifer Stojan. Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI. (Control ID #4060315)

STATEMENT OF PROBLEM/QUESTION: What are the specific barriers that lead to suboptimal patient monitoring practices and subsequent discharge delays to SARs/SNFs in our large university hospital?

DESCRIPTION OF PROGRAM/INTERVENTION: Our large university hospital uses multiple monitoring modalities in the inpatient setting: patient attendants, video monitors (VM), patient rounders (PR), psychiatric nurses, and bed alarms. Skilled nursing and subacute rehabilitation facilities (SNF, SAR) require patients to be free from continuous patient monitoring (attendants, VMs) for 24h prior to discharge (DC). Analysis of hospital data from care manager (CM) reports showed that 26 DCs were delayed in 2023 due to patient monitoring (1% of delays), resulting in an extra 262.1 hospital days (average = 10.6 days/pt). An additional 192 DCs were delayed due to "pending SAR auth," under which monitoring may also be categorized. Resident physicians and CMs report having experienced DC delays due to continuous monitoring at high rates (77.4% and 100% respectively), with more than 50% identifying it as a moderate to severe problem.

MEASURES OF SUCCESS: After deploying strategies aimed to improve communication, documentation, and implementation of alternative monitoring modalities we will re-evaluate DC delays with repeat surveys to providers, CM, and RNs. Additionally, we will complete new data analysis utilizing chart review of DC delay data to see if our interventions have been successful.

FINDINGS TO DATE: We surveyed medicine residents (n=54), faculty hospitalists (n=21), medicine ward RNs (n=62) and found 3 key problem areas. 1. Communication. Patient monitoring is primarily RN implemented, does not require medical team notification, and is not associated with an EMR order. Interdisciplinary rounds are precluded by a lack of geographic wards. 2. Documentation. Only 3% of residents and 19% of faculty hospitalists know how to find RN documentation of active monitoring, and while 98% of RNs report charting in the safety flowsheet, chart review showed that only 37% of VMs and 50% of attendants were documented there. 3. Underutilization of alternative monitoring modalities. Physicians had poor awareness of PRs (2% of residents, 33% of faculty), and 12% of nurses incorrectly believed that use of PRs prevents DC to SNF/SAR. Based on these findings, we are entering the planning phase of a PDSA cycle designed to reduce DC delays due to patient monitoring.

KEY LESSONS FOR DISSEMINATION: This project represents a detailed investigation into intricate problems involving many stakeholders surrounding patient safety, continuous patient monitoring, and discharge delays. Universal themes of communication barriers and documentation difficulties emerged. Our findings, and practical interventions targeting different components of the process, are applicable to large university hospitals across the nation facing similar difficulties.

STANDARDIZING ADVANCED CARE PLANNING IN THE PRIMARY CARE CLINIC: A QUALITY IMPROVEMENT PROJECT

Maryssa Miller¹; Kirby M. Sullivan¹; Hailee Grannan¹; Margot Valme¹; Ornella Kouomegne Simo¹; Jeana Chacho¹; Ivan Berezowski²; Amtul Malik¹; Ryan Pearson³; Courtney Paul¹; Louisa W. Whitesides⁴. ¹Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; ²Medicine, George Washington University Medical Faculty Associates, Washington, DC; ³Informational Technology, George Washington University Medical Faculty Associates, Washington, DC; ⁴Geriatric Medicine, George Washington University, Chevy Chase, MD. (Control ID #4064549)

STATEMENT OF PROBLEM/QUESTION: There is a lack of standardization of Advanced Care Planning (ACP) discussions during Medicare Annual Wellness (MAW) visits at our institution. In addition, there is no standardized way to access a patient’s previous ACP documentation or conversations in our electronic medical record (EMR). Our aim was to improve the documentation for ACP for MAW visits by increasing the utilization of a standardized smart phrase by 15% over 6 months in our institution’s primary care clinic by both residents and attendings.

DESCRIPTION OF PROGRAM/INTERVENTION: We initially worked with information technology (IT) to design a smart link section in our EMR specifically for ACP. The section includes a place for healthcare providers to document end of life planning conversations, healthcare proxy or durable power of attorney, and space to upload advanced directive documentation. To increase utilization of this section, we created a standardized smart phrase that when added to a note automatically transfers information to the ACP section of EMR. To increase the use of this smart phrase and ACP section of our EMR, we designed three Plan-Do-Study-Act (PDSA) cycles. We first held resident-led informational sessions with residents during their ambulatory clinic week with step-by-step instructions to add the smart phrase to their personal MAW visit templates. For the second PDSA, the geriatrics department provided an educational session to residents about ACP, documentation, and the importance of standardization of ACP discussions. Our last PDSA cycle included a resident-led education session for attending physicians on utilizing the standardized smart phrase. We also added the smart phrase to the institution’s standardized MAW template and encouraged the use of this standardized template.

MEASURES OF SUCCESS: We measured the number of times the ACP smart phrase was utilized during visits billed as MAW visits in our institution’s ambulatory clinic every month.

FINDINGS TO DATE: Baseline utilization of standardized ACP smart phrases during MAW visits was 0%. After implementation of the first PDSA cycle, utilization increased to 12.9%. After implementation of the second PDSA cycle, utilization increased to 17.8%, which surpassed our initial goal. Utilization after the third PDSA cycle is still pending at this time.

KEY LESSONS FOR DISSEMINATION: Internal medicine residents receive little education about ACP, which is an essential part of primary care. Having brief educational sessions can reinforce the importance of ACP in the primary care setting. Utilizing standardized smart phrases that are incorporated into EMR templates can increase the standardization of conversations surrounding ACP during MAW visits and improve documentation of advanced directives for patients.

STANDARDIZING DEPRESSION SCREENING THROUGH USE OF THE ELECTRONIC MEDICAL RECORD

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 #4065109)

STATEMENT OF PROBLEM/QUESTION: Universal depression screening increases early depression identification and reduces screening disparities in at-risk populations; despite these benefits, primary care providers often do not screen due to limited time and competing priorities.

DESCRIPTION OF PROGRAM/INTERVENTION: Our academic general internal medicine (GIM) practice consists of 3 urban clinics with 19 faculty providers. Each clinic has access to behavioral health social work. Based on a survey, our group was using different methods for depression screening with varying uptake and follow-up of positive screens. The results highlight a lack of standardization across our group.

To address these gaps, we introduced a QI initiative with the first arm focused on standardization of depression screening in our adult population. This work built on an existing psychiatry depression pilot, which focused on subspecialty clinics. In this pilot, positive screens were forwarded to a designated social work team for follow-up, which we replicated in GIM.

Using a quasi-experimental QI design, we developed a workflow to implement captive electronic medical record (EMR) screening for depression. Patients without a previous history of depression received questionnaires electronically 24-48 hours before their visit if they had no documented screening completed in the last 12 months. A PHQ-9 score over 10 was automatically forwarded to the social work team for support. If the questionnaire was not completed electronically, they were offered in clinic by paper or as a captive questionnaire. Multiple meetings were held starting September 2022 with standardization going live July 2023.

MEASURES OF SUCCESS: - Rates of Screening

- Use of Captive Questionnaire

- Social work follow up for PHQ-9 scores over 10

FINDINGS TO DATE: In September 2022, the initial depression screening rate for GIM primary care clinics was 40.4%. Since that time there has been a slow positive trend upwards to the most recent screening rate of 68.2%. This upward trend started before the use of captive EMR screening for depression and continued after implementation of the standardized screening process. This suggests that sending the questionnaires to patients prior to the visit does not increase completion of the questionnaires.

KEY LESSONS FOR DISSEMINATION: First, captive electronic medical record screening did not seem to increase depression rates dramatically. However, this initiative demonstrated the success of standardizing screening electronically instead of physician- or staff-led processes. This alleviates task list burn out in primary care. Second, while education does not necessarily lead to behavioral change, there was likely an increased awareness around depression screening that helped drive our positive trend - highlighting that discussing a problem can lead to change. Lastly, by partnering with a behavioral health team, we were able to address physician concerns about additional unexpected topics in a time-limited visit. This underlines the importance of a multi-disciplinary primary care team.

STOP THE LABS: A JOURNEY TO REDUCE RECURRING LABS AT AN URBAN ACADEMIC CENTER

Faye E. Reiff-Pasarew, Krystle Hernandez, Sharel Sadud, Adrian Chernyk, Shanteri Shenoy, Vasundhara Singh, Foram Parikh, Nikta Athari Anaraki, Philip Chen, Julie M. Pearson, Benjamin Dempsey. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4063884)

STATEMENT OF PROBLEM/QUESTION: Electronic medical systems have simplified the ordering of lab tests, which can lead to recurrent ordering without much consideration for quality care.

DESCRIPTION OF PROGRAM/INTERVENTION: Excessive laboratory testing can be painful, disturb sleep, decrease satisfaction, increase length of stay, increase transfusions, lead to venipuncture complications, and is labor intensive. Physician trainees often order extraneous labs due to a lack of understanding of what is necessary and fear of criticism from their supervisors. The primary endpoint for our quality improvement project was to reduce the number of total common labs ordered on the inpatient medicine teams in an urban academic center by 10% over six months.

MEASURES OF SUCCESS: Our process measure was the percentage of inpatients with recurrent lab orders (labs ordered for more than one day). We created a “recurrent labs” flag in the electronic health record (EHR), audited patient charts five times a week, and provided feedback to the teams on ordering practices. The study was divided into three phases: Phase 1 (January 3-20, 2023) established baseline data. Phase 2 (January 20 - October 4, 2023) combined chart audits, team feedback, and educational sessions. We distributed mouse pads, chocolates, and handouts containing a QR code linked to an intranet site outlining the initiative. During phase 2 we also surveyed the house staff anonymously to assess barriers in reducing recurring lab orders. Phase 3 (starting from October 9, 2023) broadened the aforementioned interventions to a second site (Site B) and introduced incentives for the team with the fewest recurring lab orders over each two-week period.

FINDINGS TO DATE: Between January 3rd and November 17th, we audited 10,144 charts. The mean percentage of recurrent lab orders on the teaching service at Site A fell from 57% pre-implementation (phase 1) to 42.49% and 17.08% in phases two and three, respectively. At Site B, the mean percentage of recurrent lab orders fell from 55% to 23.76% during phase 3. In the first 6 full months (February-July), the total common lab orders per patient decreased by 14% at Site A over the prior year baseline, meeting our primary goal. Additionally, our Housestaff survey during phase 2 revealed that the most significant barrier to reducing recurring lab orders was the additional workload that is required to check lab orders daily (87%), coupled with the concern over missing information (52.2%). The most frequently recommended approach in the survey to reduce recurring labs was to take the time to discuss lab orders collectively as a team during rounds.

KEY LESSONS FOR DISSEMINATION: Successful strategies to improve lab stewardship in this initiative included educating providers on the harms of unnecessary lab orders, understanding when to order labs, avoiding recurring lab orders, discontinuing unnecessary labs, and discussing the need for labs on morning rounds. While education and constructive feedback improved the rate of recurrent labs, positive incentives were most effective.

STREAMLINING THE WRITTEN PATIENT HANDOFF TOOL: A QUALITY IMPROVEMENT INITIATIVE

Ishaan Dharia¹; Emily Gore¹; Sophie Sohval¹; Yonina Kirsch¹; Edward W. Cytryn¹; Frans J. Beerkens²; Mahima Vijayaraghavan¹; Vinh Nguyen¹. ¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4062777)

STATEMENT OF PROBLEM/QUESTION: A significant challenge to adopting a written handoff tool is the time required to fill it out and keep it updated; with advances in EHR technology and increased accessibility via mobile apps, clinical information may be more accessible and up-to-date in the EHR rather than in printed handoffs.

DESCRIPTION OF PROGRAM/INTERVENTION: The purpose of this quality improvement project was to evaluate where residents search for clinical information in the EHR, with the intent to create and evaluate a more efficient written handoff tool for inpatient care.

This initiative was conducted within an Internal Medicine Residency program at a large tertiary academic medical center where residents regularly use a mobile EHR application. A dedicated handoff section is viewable directly in the EHR and is printable. Data on resident interaction with the current handoff tool and EHR use was collected via an anonymous survey. The intervention included shortening the written handoff template based on survey results and educating residents on the new instrument at the start of each inpatient rotation.

MEASURES OF SUCCESS: Pre- and post-intervention resident surveys and faculty evaluations of the handoffs were conducted. Additionally, handoff completion rates and word counts were assessed at selected time points. Continuous variables were analyzed with t-tests; categorical variables were analyzed with chi-square tests.

FINDINGS TO DATE: 53 residents completed the pre-intervention survey; 82.8% reported only referencing the electronic version of the handoff tool as opposed to a printed version. Most residents reported using the handoff to obtain the following clinical information: patient one-liner (80%), active medical issues (50%), 24-hour events (93.3%), code status (63.3%), key physical exam findings (50%), and next of kin info (53.3%). Meanwhile, patient location (33.3%), active medications (6.7%), recent procedures (16.7%), and lines/tubes/drains (3.3%) were more likely to be referenced elsewhere in the EHR. Based on these results, a shortened handoff tool was created.

48 residents completed the post-intervention survey. Residents reported that the new handoff tool took a similar amount of time to update but was significantly more likely to contain up-to-date information (p=0.002). Post-intervention, more handoffs were updated daily (74% vs. 48%, p<0.001), with shorter handoffs (194 vs. 262 words, p=0.001). Additionally, day shift residents were signing out more patients thought to be at a high risk for decompensation to the overnight senior residents (11.1% vs. 2.31%, p=0.001). Faculty evaluation of handoffs found improved quality and completion rates of patient summaries post-intervention.

KEY LESSONS FOR DISSEMINATION: Streamlining the template for the written patient handoff tool can lead to significantly more updated and shorter handoffs, decreasing the burden of handoffs while also increasing their effectiveness. Advances in healthcare technology, like mobile EHR access, may change how patient handoffs are completed and should prompt reevaluation of current processes.

TAMING THE IN-BASKET – HOW TWO SIMPLE TOOLS REDUCED PORTAL MESSAGE VOLUME IN AN ACADEMIC INTERNAL MEDICINE CLINIC

Nicole Hadeed, Jennifer Meddings, Jessica Ameling, James Henderson, Matthew Bucala, Yvette Salamey. Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #4064060)

STATEMENT OF PROBLEM/QUESTION: To assess the impact of educational initiatives and protocols on alleviating portal message burden in a primary care setting.

DESCRIPTION OF PROGRAM/INTERVENTION: Portal messages are electronic messages patients send to a box within providers' in-baskets through the electronic health record. In the wake of the COVID-19 pandemic, portal message volume in primary care clinics increased by over 50% and has persisted. In-basket management, including portal messages, significantly contributes to physician burnout, and correlates with time spent on in-basket tasks. We identified root causes contributing to inefficiency in managing portal messages and implemented cost-neutral interventions targeting these. Our intervention emphasized high-yield best practice standards for handling portal messages and introduced a "Routing Guide" to clarify the roles and responsibilities of in-basket tasks. The study occurred in an outpatient internal medicine clinic at a Midwest academic health center.

MEASURES OF SUCCESS: Primary outcomes were the number of clinic portal messages per physician clinical full-time equivalent (cFTE) per month and the fraction of portal encounters with physician involvement (or physician touch rate). Secondary outcomes included the number of messages sent by clinic team members with more than one recipient (carbon copy behavior), physician portal engagement time, physician and staff satisfaction, and stress levels related to portal management (measured using surveys).

FINDINGS TO DATE: Portal message volume decreased pre-to-post by 220 fewer messages per cFTE per month at the intervention site than concurrent controls (p < 0.001). The physician touch rate remained stable, while carbon copy behavior decreased by 23 per 1000 messages (p < 0.001). Time in in-basket for portal message work showed a notable reduction of 0.5 hours per month per physician (2.1 to 1.6 pre- versus post-intervention, p = 0.36). Lastly, although survey results did not reach statistical significance, participants at the intervention site expressed more favorable views in post-intervention survey questions related to training for managing portal messages.

KEY LESSONS FOR DISSEMINATION: We identified a gap in training and routing standards for portal messages. We reduced portal message traffic between clinic team members by providing physicians and staff guidance, emphasizing role clarification and routing practices. This led to a notable decrease in redundant routing practices and fewer messages received by physicians. We propose that other practices can take a similar approach in identifying training gaps, clarifying roles, and improving in-basket management to reduce message volume and enhance physician and staff well-being.

USING PATIENT NAVIGATION TO IMPROVE CERVICAL CANCER SCREENING AT AN ACADEMIC GENERAL INTERNAL MEDICINE CLINIC

Madison Witherington, Eric Rosenberg, Sharon Aroda, Dianne Goede. Medicine, University of Florida Health, Gainesville, FL. (Control ID #4063545)

STATEMENT OF PROBLEM/QUESTION: Does patient navigation mitigate barriers to cervical cancer screening for patients and clinicians in an academic general internal medicine practice?

DESCRIPTION OF PROGRAM/INTERVENTION: Our academic general internal medicine practice provides comprehensive primary care including cervical cancer screening. From 1/1/2022- 12/31/22, 74.29% of eligible patients seen in our practice were up to date on cervical cancer screening. Clinicians cite barriers to completing screening such as: additional time needed to complete screening, uncertainty over true screening status due to missing records, limited comfort with a sensitive exam. Patients may be unaware of their need for screening, have other high priority medical concerns for their visit, or feel uncomfortable receiving screening outside of a women’s health clinic setting. We hypothesize patient navigation will help improve screening by communicating with clinicians and patients in advance of the office visit.

Beginning May 1^st of 2023, Our patient navigator queries EPIC weekly to identify patients due for screening and scheduled for an office visit of any type (follow up, urgent, annual). Patients are contacted (MyChart and Phone) and informed of their need for and importance of screening. Clinicians are also notified. Additional appointments are scheduled if needed (female provider requested, more time needed for the screening, patient request, etc). Outside records are requested as needed.

MEASURES OF SUCCESS: Our team partnered with the American Cancer Society to improve the clinic’s screening rate to 80% by 12/31/23.

The rate calculation criteria are aligned with the American Cancer Society guidelines for cervical cancer screening. The denominator consists of all patients eligible for screening (age 21-64) with one reportable medical visit during the specified time frame. The numerator includes eligible patients who had appropriate screening within the last 3-5 years.

FINDINGS TO DATE: The cervical cancer screening rate from 11/1/22-11/30/23 increased to 77.71% (a 3.42% increase). This time interval includes the pre-intervention period to ensure comparable visit volume to baseline for rate calculation. The screening rate during the intervention period alone (5/1/23-11/30/23) is 78.83%, a 4.54% increase. The patient navigator was able to reach 227 of the 551 overdue patients. Of these, 50 patients requested an additional appointment, 37 patients completed their screening during their visit, 73 patients indicated they had outside screening results. Outside records were requested for 41 patients and 15 screening records were received.

KEY LESSONS FOR DISSEMINATION: Patient navigation increased screening rates between 3.42% and 4.54%. Many patients contacted by patient navigation (22%) requested an additional appointment for screening. In the future, a women’s health clinic nestled within an internal medicine clinic could help close this gap. Patient navigation is a promising intervention to increase cervical cancer screening within internal medicine clinics that warrants more research to direct future use.

UTILIZATION OF THE ELECTRONIC MEDICAL RECORD FOR PRIMARY CARE SCREENING

Iqra Kazi, Megan Freeman. Department of Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4055054)

STATEMENT OF PROBLEM/QUESTION: Internal medicine residents aimed to increase the rates of AAA screening in the VA IMC by >15% by April 2023 through standardized documentation of screening requirements and creation of a new screening order set.

DESCRIPTION OF PROGRAM/INTERVENTION: Epidemiological studies of abdominal aortic aneurysms (AAA) show an increased incidence worldwide, ranging from 4.2% to 11% per year. The USPSTF recommends 1-time screening for AAA by ultrasonography in asymptomatic men aged 65 to 75 years who have ever smoked. AAA screening rates remain below 50%. At the Audie L. Murphy Memorial Veterans Affair (VA) Hospital IMC, no standardized template existed for healthcare maintenance. The study team consisted of twenty residents and a faculty team leader. Prior to intervention, the resident team performed an in-depth literature review and created a process map understand existing workflows. Residents reviewed 264 patient charts from July to September 2022 to obtain pre-intervention data: gender, age, smoking status and screening for AAA order. The team leader served as the second reviewer. For planned interventions, the resident team updated documentation to include a mandatory screening section as a visual reminder. Second, the resident team developed and implemented an order set for all primary care screening to decrease barriers to appropriate ordering. Both interventions implemented, and education provided to residents occurred between December 2022 and January 2023.

MEASURES OF SUCCESS: Residents reviewed 409 patient charts from February to March 2023 post-intervention. Data analysis proceeded by creation of run charts for pre- and post-intervention phases. The outcome measure specified the percentage of eligible males who had AAA screening addressed before and after the implemented interventions.

FINDINGS TO DATE: After analyzing data, screening overall increased. There was a higher level of screening with more points above the median than below compared to prior to intervention. However, no definitive shift or trend occurred based on available data.

KEY LESSONS FOR DISSEMINATION: Work within the VA EMR, CPRS, usually requires manual input. The two selected interventions leverage this reality to improve efficient ordering and increase overall compliance during patient encounters. Despite our initial intention of swift implementation, the process extended over several weeks, potentially introducing a limitation to the project timeline and outcomes. Introduction of the order set occurred mid-academic year, when current residents’ habits were more established potentially hindering uptake by all resident physicians. This QI project ultimately showed that creation and implementation of these two interventions in CPRS, given our time frame, resulted in a useful tool for resident physicians to use in the long term. This will help educate residents on what screenings need to be completed using screening guidelines while creating accessibility of information within the patient chart and resident note, leading to quality patient care during each encounter.

UTILIZING A DATA ANALYTICS TOOL AND AN ELECTRONIC HEALTH RECORD (EHR) ALERT TO IMPROVE VACCINATION RATES AND EMERGENCY ANTIBIOTIC USAGE AGAINST ENCAPSULATED BACTERIA FOR PATIENTS WITH ASPLENIA

Nathan Richards¹; Neeraj H. Tayal²; Lauren Kirk³; Jodi M. Grandominico-Bradford⁴; Angela Yurkovich⁴. ¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ³General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ⁴Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4064705)

STATEMENT OF PROBLEM/QUESTION: Overwhelming infection with encapsulated bacteria in patients with asplenia can be quickly fatal, however, the tools to prevent and manage these infections, namely vaccinations and emergency antibiotics, are underutilized.

DESCRIPTION OF PROGRAM/INTERVENTION: Despite having tools to help prevent overwhelming infection from encapsulated organisms in patients with asplenia, these tools are underutilized. The vaccine schedules can be complicated. Multiple doses for some of these vaccines are required to complete the primary series and some require periodic boosters. Additionally, providers are very busy and are often managing a variety of diseases for each patient. They may altogether forget that patients with asplenia require special vaccines that are not part of the routine schedule for adults. Similarly, they may forget to provide these patients with a supply of emergency antibiotics to be used with symptoms of possible serious infection and education to seek immediate medical care in these situations. At our general internal medicine and internal medicine-pediatrics academic practices at a university-based health system in the Midwest, we identified a need to supply providers with support tools to improve care of this population. To better understand the problem locally we utilized Qlik Sense®, a data visualization tool, to develop a report that identifies our patients with asplenia and shows whether these patients are up to date on recommended vaccines against encapsulated bacteria. We also worked with our information technology (IT) team to build an EHR alert that auto populates in the patient’s chart based on medical records documentation so that physicians will be notified at patient visits of vaccines that are due. We then educated our faculty on the new EHR alert and had our outreach nurse begin to systematically contact patients via phone and/or the electronic health portal to help close these care gaps. Our nurse assists in scheduling nurse visits, pending vaccines, pending antibiotic orders, and educating patients on the risk, prevention, and management of overwhelming infection in patients with asplenia.

MEASURES OF SUCCESS: 1. Percentage of patients with asplenia who are up to date on vaccines against encapsulated organisms

2. Number of patients with asplenia provided with antibiotics and/or educated on the management of fever and other symptoms of possible overwhelming infection

FINDINGS TO DATE: At the start of our project in November 2023, we found that a large percentage of our patients were behind on recommended vaccines. Of our 206 patients with asplenia, only 29% were up to date on meningitis ACWY vaccines, 11% were up to date on meningitis B vaccines, 43% were up to date on Haemophilus influenza type B vaccines, and 80% were up to date on pneumococcal vaccines.

KEY LESSONS FOR DISSEMINATION: 1. Developing clinical reporting tools can help practices and providers better understand care gaps in specific populations of patients

2. Patients with asplenia are commonly not up to date on guideline recommended vaccines

UTILIZING IN SITU SIMULATION TO IMPROVE EMERGENCY RESPONSE IN AN ACADEMIC GENERAL INTERNAL MEDICINE CLINIC

Dianne Goede¹; Maritza Plaza-Verduin²; Thomas LeMaster³; Jennifer Zimmerman³; Carol Godwin⁴; Tracy Green⁴; Rosemarie Fernandez⁵; Mary Patterson⁵; Eric I. Rosenberg⁶. ¹Medicine, University of Florida Health, Gainesville, FL; ²Division of Pediatric Emergency Medicine, University of Florida, Gainesville, FL; ³Center for Experiential Learning and Simulation College of Medicine, University of Florida, Gainesville, FL; ⁴UF Health Physicians Group, University of Florida, Gainesville, FL; ⁵Emergency Medicine, University of Florida, Gainesville, FL; ⁶Medicine, University of Florida, Gainesville, FL. (Control ID #4064737)

STATEMENT OF PROBLEM/QUESTION: Does simulation-based team training improve performance in simulated ambulatory clinic medical emergencies?

DESCRIPTION OF PROGRAM/INTERVENTION: Medical emergencies are infrequent in ambulatory internal medicine but do occur up to 8 times per year in a typical ambulatory care practice. Studies report low staff and physician confidence in responding to ambulatory emergencies correlated with unfamiliarity with protocols, professional roles, supply availability, and infrequently applied resuscitation skills. In situ simulations (simulation in the clinical environment) in internal medicine clinics demonstrated actionable gaps in performance. Gaps related to teamwork, activation of response protocols, equipment familiarity, and clinical guideline adherence. This project aims to determine if simulation-based team training can improve performance in simulated ambulatory clinic medical emergencies.

We implemented an emergency response workshop including a didactic presentation and applied team-based training sessions in the clinic setting hypothesizing that it will improve clinician and staff performance during ambulatory emergencies as measured by time to critical action.

Physicians (n=6), advance practice practitioners (APPs; n=1), and nursing (n=3) staff at an academic general internal medicine practice participated in an on-site, one-hour emergency response workshop. The workshop reviewed clinic emergency response protocol and resuscitative equipment specific to the practice. Participants then rotated through three stations practicing resuscitative skills. These stations focused on circulatory support (chest compression quality, Zoll AED use) and airway/breathing support. Over the next month, three in situ simulations were conducted at the clinic to allow all participants to participate in a team-based simulated emergency.

MEASURES OF SUCCESS: Simulations were directly observed by simulation experts and time to critical actions noted.

FINDINGS TO DATE: Data was collected during each simulation session in these areas: Airway/Breathing, Circulation, Defibrillation and Team Dynamics/Teamwork. Post-intervention, the clinical team improved their ability to properly apply AED pads and reduced time to initial shock delivery from a baseline of 8 minutes to a mean of 4.3 minutes. Initiation time to and quality of CPR were improved post-intervention. The time to calling 911 improved from 10 minutes to 1-minute post intervention.

KEY LESSONS FOR DISSEMINATION: The clinical team in an ambulatory clinic improved its performance in responding to ambulatory emergencies by participating in an emergency response workshop, including hands-on training in their typical workplace. In situ simulation offers a unique opportunity to evaluate a clinical team’s emergency response performance within their ambulatory care practice setting. These sessions utilized clinic-specific equipment and allowed a safe space for staff and clinicians to practice their skills in a low-stakes environment. Further study is needed to determine skill decay and the need for training refresher.

“HEY DOC, CALL ME BACK." IMPROVING CLINIC PHONE LINE ACCESS FOR PATIENT SAFETY AND SATISFACTION

Reshma Mohiuddin¹; Ena Mahapatra²; Michael J. Davidovich³. ¹internal medicine, John H Stroger Jr Hospital of Cook County, Chicago, IL; ²Internal Medicine, Stroger J Hosp of Cook County, Chicago, IL; ³Medicine, Cook County Health, Chicago, IL. (Control ID #4026760)

STATEMENT OF PROBLEM/QUESTION: Access to the clinic is an integral part of a patient’s healthcare and satisfaction. Better access to care means less ER visits, better compliance, less missed dosages, and better overall health and well-being. In our primary care clinic, in a safety net hospital, we realized that patients have difficulty contacting our providers via the phone line. We did not have a structure to track the phone calls received and therefore, could not establish accountability of whether these calls were being addressed. It is very important for patients' safety and quality of care that the phone calls are answered and messages are returned in a timely manner. Our objective is to improve patient-provider communication through our phone messaging system by improving access and response time.

DESCRIPTION OF PROGRAM/INTERVENTION: The goal is to have patients’ concerns addressed within 2 business days. To improve our phone line services, we had several interventions: 1. The number of phone operators was increased from 1 to 2, one of whom being a nurse. 2. We decreased the number of phone call transfers before going to voicemail. 3. A phone message tracker was developed to account for each call and record the time to resolve the concern. 4. An assigned nurse was responsible for completing the phone message tracker for the month, triaging, and communicating directly with the provider. 5. A questionnaire was offered to participants who had used the phone line within the past 6 months.

MEASURES OF SUCCESS: Our aim is to decrease response times to patient messages and improve patient satisfaction. The objective is to have 85% of our patient messages responded to within 2 business days. We will be keeping track of the time it takes to respond to a patient call using a response time tracker, which includes when the patient called and when the message was completed. We also are asking our patients to complete a questionnaire regarding their experience on a scale of 1-5. Our aim is to reach an 80% satisfaction rate with our phone services.

FINDINGS TO DATE: Our response time of answering a phone message within 48 hours or 2 business days improved from 64% in August 2022 to 70% by August 2023. Patient reported metrics from the questionnaire on response time within 48 hours improved from 37% in August 2022 to 56% by August 2023. Patient satisfaction improved from 22% being satisfied or very satisfied in August 2022 to 49% by August 2023.

KEY LESSONS FOR DISSEMINATION: With improved access to primary care clinics, patients will have better overall health and wellbeing. Patients will have a greater trust and confidence with their primary care medical home knowing that their messages are being prioritized. The ease and ability to contact the provider should be a fundamental aspect of any healthcare system. Improving access to healthcare should be the cornerstone to any primary care practice. An improved patient experience through building a stronger doctor-patient relationship through trust and understanding should be the goal of any clinic.

Innovation in Healthcare Delivery (IHD) - Social Determinants of Health

ADDRESSING HEALTH LITERACY DISPARITIES: UTILIZING A SINGLE-QUESTION SCREENER TO PROVIDE TARGETED CARE INTERVENTIONS FOR RURAL WOMEN VETERANS

Mariam Jacob¹; Jenny K. Cohen^1,2; Kai Kohlwes¹; Christopher Schou¹; Daniel Greenwood³. ¹General Internal Medicine, San Francisco VA Health Care System, San Francisco, CA; ²University of California San Francisco School of Medicine, San Francisco, CA; ³VHA Office of Patient Care Services, Washington, DC. (Control ID #4062452)

STATEMENT OF PROBLEM/QUESTION: Low health literacy (HL) disproportionately impacts rural, low-income, and marginalized populations and is a driver of health disparities and higher costs of care. Rural women Veterans have poor health outcomes owing limited access to gender-sensitive care, however, we lack data on HL and its impact on this population. To improve the health of rural women Veterans, it is imperative that we better characterize levels of HL and identify strategies to ameliorate low HL.

DESCRIPTION OF PROGRAM/INTERVENTION: To gain insight into baseline HL among rural women Veterans, we conducted phone surveys using a single-question screening tool previously identified by VHA National Center for Health Promotion and Disease Prevention. Calls were made to VHA enrolles residing in rural areas of one VA Health Care System (VAHCS) between 11/27/2023 and 12/14/2023. Veterans were asked “how often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” If the Veteran reported they needed assistance, they were offered resources such as optometry, social work, and assistance with accessing technology. All Veterans were offered information about a women’s virtual support group and/or a call from a clinician. Veterans were also asked to share comments, questions, or concerns; their answers documented.

MEASURES OF SUCCESS: We tracked call attempts, referrals, and comments on a secure dataset.

FINDINGS TO DATE: During a 3-week outreach push, 137 rural cisgender women (n=135) and transgender (n=2) Veterans were called and we successfully contacted 100. Of the contacted Veterans, 60% (n=60) opted-into the HL screen. Of those we screened, 98% (n=59) were cisgender women and 1.6% (n=1) was transgender, age range was 27-95yrs, and average age was 61yrs, the majority served during Persian Gulf War, and average rurality score was 4.9. 75% (n=45) of those screened reported no HL challenges: 44 were cisgendered women, 1 was transgender, and average age was 60yrs. 25% (n=15) of those surveyed reported needing assistance reading written instructions: all were cisgendered women, and average age was 65yrs, 27% (n=4) needed help understanding next steps in care, 13% (n=2) needed help understanding content, and 27% declined resources (n=4). Of the total cohort surveyed, 23% (n=14) expressed interest in a virtual women’s support group and 25% (n=15) requested follow-up from a clinician to discuss unmet care needs.

KEY LESSONS FOR DISSEMINATION: Our pilot suggests that one-quarter of rural women in this small survey report low HL, and that centralized outreach can be used to identify and ameliorate HL barriers. While this study focused on rural women Veterans within one VAHCS, we hope that HL screening implementation and low HL mitigation strategies can be applied more broadly with the goal of improving the wellness of Veterans, and in particular rural women Veterans.

ASSESSING AND ADDRESSING SOCIAL NEEDS IN A GERIATRICS CONSULTATIVE CLINIC

Tatiana Rugeles Suarez^1,2; Andrea W. Schwartz³; MICHELLE MARTINCHEK⁴; Amanda M. Mack¹; Meaghan A. Kennedy⁵. ¹Geriatrics, VA Boston Healthcare System Jamaica Plain Campus, Boston, MA; ²Boston Medical Center, Boston, MA; ³Geriatric Research Education and Clinical Center, VA Boston Health Care System Jamaica Plain Campus, Boston, MA; ⁴GEC, Veterans Affairs Boston Healthcare System, Boston, MA; ⁵Geriatric Research, Education, and Clinical Center, VA Bedford Healthcare System, Bedford, MA. (Control ID #4064838)

STATEMENT OF PROBLEM/QUESTION: How can a social risk screening model be optimized for a Geriatrics Consultative Clinic?

DESCRIPTION OF PROGRAM/INTERVENTION: Though healthcare organizations are increasingly adopting social risk screening as part of routine care, best practices for implementation in geriatrics are unknown. Assessing Circumstances and Offering Resources for Needs (ACORN) is a Department of Veterans Affairs (VA) social risk screening and referral model that identifies and addresses social needs among Veterans. We aimed to adapt ACORN for implementation in an interprofessional, Age-Friendly outpatient VA Geriatrics Consultative Clinic.

MEASURES OF SUCCESS: Quality improvement project guided by the Model for Improvement. Our first Plan-Do-Study-Act (PDSA) cycle focused on workflow development and preliminary piloting with a small sample of older Veterans. We developed an initial workflow based on samples from other ACORN sites and clinic team feedback to leverage existing workflows. We then trained clinic staff and providers to familiarize the team with the screener and workflow. Bi-monthly meetings with social work focused on re-designing the workflow to improve efficiency, reduce redundancy, and improve resource navigation for Veterans. Measures included number of screens completed, time to complete screening, number of positive screens, and resources provided. We conducted a 2-week follow up survey with Veterans regarding their perception of ACORN.

FINDINGS TO DATE: We modified the workflow three times during the first PDSA cycle to incorporate changes recommended by providers and clinic staff during the team training and recurring meetings, and to accommodate staff shortages. During the first PDSA cycle (November 2023), four Veterans in one geriatrician’s clinic completed the ACORN screener, three of whom screened positive. The screener was completed in an average of 10 minutes. Two Veterans screened positive for needs related to access to technology and education on VA benefits. One Veteran reported housing insecurity, noting he would not have discussed this subject without the screener. Three Veterans completed the two-week follow-up survey. The two who screened positive reported being contacted by a social worker. All three veterans surveyed thought the length of the questionnaire was “just right” and that it is “moderately” or “very” important for the health care team to know about older Veterans’ needs. Two Veterans expressed a desire for printed resources.

KEY LESSONS FOR DISSEMINATION: The team training and bi-monthly meetings with social work were key components in developing and refining a workflow for ACORN social risk screening in a Geriatrics Clinic. An initial PDSA cycle demonstrated feasibility and preliminary acceptability among a small sample of older Veterans. Subsequent PDSA cycles will refine the workflow for sustainability and incorporate printed resources based on Veteran feedback.

ASSESSING CIRCUMSTANCES AND OFFERING RESOURCES FOR NEEDS (ACORN): A VETERANS HEALTH ADMINISTRATION (VHA) SOCIAL RISK SCREENING AND INTERVENTION INITIATIVE

Lauren E. Russell¹; Alicia Cohen²; Christopher W. Halladay⁴; Amy M. Donaldson³; Jennifer A. Koget³; Sarah Leder¹; Kathleen Mitchell⁵; Ernest Moy¹; Sydney Ruggles⁵; Jennifer W. Silva³; Brittany Trabaris³; Lisa Wootton³; Meaghan A. Kennedy^5,6. ¹Office of Health Equity, Veterans Health Administration, Washington, DC; ²Primary Care; Family Medicine and Health Service, Policy & Practice, Providence VA Medical Center; Brown University, Providence, RI; ³National Social Work Program, Care Management and Social Work Services, Veterans Health Administration, Washington, DC; ⁴Providence VA Medical Center, Providence, RI; ⁵Research, VA Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; ⁶Department of Family Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA. (Control ID #4062448)

STATEMENT OF PROBLEM/QUESTION: How can VHA better identify social risks and needs systematically and connect Veterans with existing VHA and community resources?

DESCRIPTION OF PROGRAM/INTERVENTION: Policymakers, payers, and professional organizations have increasingly called for health systems to implement initiatives to identify and address social risk factors and social needs among patients. Initially piloted in 2018, Assessing Circumstances and Offering Resources for Needs (ACORN) is a Veterans Health Administration (VHA) social risk screening and intervention initiative that aims to improve outcomes and advance health equity among Veterans by systematically identifying and addressing social risks and social needs in VHA clinical settings.

MEASURES OF SUCCESS: Multi-site quality improvement initiative. In the context of routine clinical care, Veterans were screened across nine social risk domains. Measures include site implementation data (number of sites, settings, modality) and Veteran screening data (prevalence of social risks, resources/referrals provided, sociodemographic characteristics).

FINDINGS TO DATE: Between July 2021-December 2023, 32 ACORN sites completed 11,050 screens. The number of VHA sites engaged in ACORN implementation grew from 5 sites in fiscal year (FY) 2021 to 14 in 2022 to 27 in 2023, and the number of screens performed yearly grew from 166 in 2021 to 1,539 in 2022 to 6,225 in 2023. Settings in which ACORN was implemented varied by site and included primary care, specialty care (e.g., mental health, heart failure clinic, geriatrics), and the emergency department. Screening was also administered by a range of staff (e.g., social workers, nurses, peers) and both in-person and remotely (i.e., phone, video). The mean age of Veterans screened was 67 years [SD 15.8] and 1,242 (11%) were female. 3,300 (30%) were Black or African American, 6,783 (61%) were White, and 336 (3%) were Hispanic or Latino. Overall, 7,586 (69%) screens were positive for >1 social need. The most common positive domains were digital needs (e.g., access to technology) (38%), social isolation/loneliness (29%), food (18%), transportation (15%), housing (13%), and utilities (13%). Among positive screens, 61% of Veterans were provided a resource and/or referral, 5% declined assistance, and 7% reported already receiving services or assistance. The most common types of assistance were providing resources/information (29%) and providing a warm hand-off or consult to social work (19%). A Community of Practice and an ACORN Dashboard were developed in 2023 to facilitate site engagement and collaboration and provide real-time access to screening, sociodemographic, and resource/referral data.

KEY LESSONS FOR DISSEMINATION: It is feasible to screen for social risk factors as part of routine clinical care in VHA clinical settings using a variety of implementation approaches. Interprofessional collaboration, continuous quality improvement, and iterative development of implementation support tools and structures have been critical to ACORN’s growth from a small pilot towards broader VHA implementation.

A STUDENT-LED INITIATIVE TO PREVENT MEDICAID DISENROLLMENT IN HOSPITALIZED PATIENTS DURING REDETERMINATION

Toby Terwilliger, Julia Grigorian, Daniel Barboto, Benjamin Kofoed, Madison Canning. Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4031856)

STATEMENT OF PROBLEM/QUESTION: Beginning June 1, 2023, following the expiration of the Families First Coronavirus Response Act, Georgia began reviewing eligibility for all Medicaid recipients, putting 2.9 million Georgians at risk of losing health insurance.

DESCRIPTION OF PROGRAM/INTERVENTION: Patients with Medicaid admitted to a public hospital were identified using an electronic medical record report. Preclinical medical students received a 1-hour training on Medicaid eligibility in the state of Georgia. Students then met with patients at the bedside to discuss the redetermination process, following a pre-written script to determine the patient's knowledge of the redetermination process. Students assisted patients with accessing the online Medicaid portal and viewing their redetermination date and documents required for redetermination. When possible, students assisted patients with the submission process. Students provided patients with a 1-page handout with follow-up information and resources if their redetermination submission was unable to be completed during the session.

MEASURES OF SUCCESS: We recorded the number of patients that were identified to be at risk for Medicaid loss, as well as the number of patients with whom the students interacted. We documented the patients pre-knowledge of the redetermination process as well as their status at the completion of the student encounter.

FINDINGS TO DATE: We identified 497 patients with GA Medicaid admitted to medical/surgical units at a single public safety-net hospital over a 1.5 month period. Students completed sessions with 197 patients. We found that 121 patients (64%) were unaware that the redetermination process was occurring and more than half had ongoing barriers to redetermination including inability to login to the online portal as well as transient or unstable residential addresses. 52 patients (26.4%) had all barriers to redetermination addressed during the encounter. Qualitatively, students provided informal feedback that the project improved their knowledge of US healthcare systems as well as comfort in patient encounters.

KEY LESSONS FOR DISSEMINATION: A student-led intervention is a potentially effective method to alleviate Medicaid Loss at a public safety-net hospital.

Many systemic barriers including transient housing, lack of internet access, and inaccessibility of the state's online Medicaid portal will require more intensive interventions.

Students gained important knowledge of the nuances of American health insurance and barriers to care, as well as experience communicating with patients prior to formal training during clerkships.

Future projects may expand upon student-led interventions to educate patients on other forms of health insurance including the healthcare marketplaces as well as sociopolitical determinants of health such as housing, drug and substance use, and other wrap-around services.

Further research may focus on the impact of such interventions on the medical education of preclinical students including their understanding of healthcare systems and the impact on patients and the delivery of care.

COMPLEX CARE MANAGEMENT (CCM): BUILDING A MULTIDISCIPLINARY CLINIC TO REDUCE OVERUTILIZATION OF ACUTE CARE SERVICES AMONG MEDI-CAL PATIENTS AT A FEDERALLY QUALIFIED HEALTH CENTER

Angela M. Bassal¹; Kirti Malhotra². ¹Internal Medicine, University of California Davis Department of Internal Medicine, Sacramento, CA; ²General Internal Medicine, University of California Davis Medical Center, Sacramento, CA. (Control ID #4065102)

STATEMENT OF PROBLEM/QUESTION: Multi-visit patients with complex medical and social needs, incur significant healthcare burden due to overutilization of acute care services.

DESCRIPTION OF PROGRAM/INTERVENTION: The Complex Care Management (CCM) clinic is a resident led interdisciplinary clinic which was founded in 2019 at a federally qualified health center to help identify and address care gaps experienced by patients who had high acute care utilization with three or more ED visits and/or hospitalizations over the past 12 months along with unaddressed social determinants of health. Many of these patients with complex health and psychosocial needs fail to receive necessary comprehensive support leading to debilitating diseases from preventable causes, inappropriate utilization of emergency departments, and poor quality of life. Each eligible patient who agrees to enroll, meets with a multidisciplinary team and receives a comprehensive assessment of their medical and psychiatric history as well as their social determinants of health. Interventions include healthcare maintenance, psychiatric care, medication reconciliation, subspecialty referrals, substance use navigation, linkage to community resources, and housing/transportation/food resources. The clinic initially consisted of a few dual trained residents in Internal Medicine and Psychiatry, and now has expanded to include many community partners, substance use resources, and social workers. Over the course of the last few years through a team based interdisciplinary approach and multiple points of contact for patients, we have started seeing a significant increase in outpatient engagement.

MEASURES OF SUCCESS: The number of ED visits and/or hospitalizations after CCM enrollment at 6 months and 12 months.

FINDINGS TO DATE: From January 2021 to December 2022, 91 patients had been enrolled in the program. The overall average ED visits and hospitalizations in the 12 months prior to CCM enrollment was 3.65 and 2.29, respectively. 6 months after CCM enrollment, patients had an average of 0.88 ED visit and 0.46 admissions, and there was an average reduction of ED visits by 60.3% and admissions by 55.7%. 12 months after CCM enrollment, patients had an average of 1.81 ED visits and 1.15 admissions, and there was an average reduction of ED visits by 50.4% and admissions by 49.7%.

KEY LESSONS FOR DISSEMINATION: - Care Coordination can be an effective model utilizing a multidisciplinary team and a biopsychosocial lens to identify and understand important health care gaps in our underserved populations.

- How to build programs that provide impactful care despite being in a resource-limited setting.

EFFECT OF A HEALTH SYSTEM-INTEGRATED CHILDCARE FACILITY ON RETENTION IN CERVICAL CANCER SCREENING

Anisha Ganguly^2,1; Michael E. Bowen³; Kimberly A. Kho⁴; Persephone Tian⁵; Erin Barnett^2,1; Megan McArthur⁵; Robert B. Martin⁴; Bijal Balasubramanian⁶. ¹Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ²Parkland Health, Dallas, TX; ³Medicine, UT Southwestern Medical Center, Dallas, TX; ⁴Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX; ⁵The University of Texas Southwestern Medical Center Medical School, Dallas, TX; ⁶The University of Texas Health Science Center at Houston, Houston, TX. (Control ID #4064641)

STATEMENT OF PROBLEM/QUESTION: Childcare needs pose a barrier to appointment attendance among caregivers accessing preventive care.

DESCRIPTION OF PROGRAM/INTERVENTION: Childcare needs are under-recognized as a social driver of health (SDOH). Childcare needs are especially common among women of childbearing age and most commonly pose a barrier to preventive care, including cervical cancer screening. Logistical barriers to care like unmet childcare needs contribute to disparities in cervical cancer, particularly among patients from marginalized backgrounds. To address childcare barriers to access to care, our safety-net health system partnered with a local community-based organization (CBO) to create a no-cost, drop-off health system-integrated childcare facility for patients to receive childcare services linked to their healthcare appointments.

MEASURES OF SUCCESS: Our health system maintains a data dashboard to monitor patient outreach and enrollment in the childcare facility. To assess the effect of this childcare facility on appointment attendance, we are currently conducting a pragmatic patient-level randomized control trial (RCT) among women with abnormal cervical cancer screening tests awaiting diagnostic work-up in gynecology. The study population is screened for childcare needs related to initial gynecology appointment. The intervention group receives telephone-based navigation and assistance enrolling in the childcare facility. The control group receives standard care (no standardized childcare support, potentially rescheduling appointment). The primary outcome for this RCT is show-rate for initial gynecology appointment. Secondary outcomes include show-rates for follow-up appointments and completion of indicated gynecological procedures for cervical dysplasia. Tertiary outcomes include patient-centered outcomes (PCOs) about experience during appointments and interaction with the health system.

FINDINGS TO DATE: Since the childcare facility was opened in November 2020, 728 patients have received childcare support to attend appointments. Baseline demographics among patients utilizing the childcare facility are notable for a mean age of 32.5 years, 95.9% women, and significant racial/ethnic diversity (54.1% Hispanic and 33.7% non-Hispanic Black; 33.5% Spanish-speaking). Thus far, 14 patients have been enrolled in the cervical dysplasia RCT since the trial launched in 10/2023; recruitment remains in progress.

KEY LESSONS FOR DISSEMINATION: Childcare needs are a relevant but understudied SDOH. Our health system-integrated childcare facility in partnership with a CBO presents a potential intervention to address childcare needs to support access to care.

EVALUATION OF A COMMUNITY OF PRACTICE TO SUPPORT IMPLEMENTATION OF SOCIAL RISK SCREENING IN THE VHA

Sydney Ruggles⁵; Kathleen Mitchell⁵; Alicia Cohen^1,2; Alita Harmon³; Lauren E. Russell⁴; Brittany Trabaris³; Lisa Wootton³; Meaghan A. Kennedy⁵. ¹VA Providence Healthcare System Center of Innovation in Long Term Services and Supports, Providence, RI; ²Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI; ³National Social Work Program, Care Management and Social Work Services, Veterans Health Administration, Washington, DC; ⁴Office of Health Equity, Veterans Health Administration, Washington, DC; ⁵Geriatric Research, Education, and Clinical Center, VA Bedford Healthcare System, Bedford, MA. (Control ID #4063452)

STATEMENT OF PROBLEM/QUESTION: Can a Community of Practice model support broader implementation of a social risk screening and intervention initiative in VHA clinical settings?

DESCRIPTION OF PROGRAM/INTERVENTION: Assessing Circumstances and Offering Resources for Needs (ACORN) is a Veterans Health Administration (VHA) social risk screening and intervention model that has rapidly grown since its initial pilot in 2018. Recognizing the need to efficiently onboard and support new clinical teams longitudinally from pre-implementation to sustainment, we launched the ACORN Community of Practice (CoP) in 2023. We aimed to evaluate participation in and satisfaction with the CoP as well as barriers and facilitators to ACORN implementation.

MEASURES OF SUCCESS: 36 VHA sites participating in the ACORN CoP between January and September 2023 were asked to complete three surveys: 1) ACORN implementation survey; 2) monthly reflection for new sites; and 3) satisfaction survey. Site engagement in the CoP was determined through virtual meeting attendance. Descriptive statistics were used to summarize quantitative survey data. Monthly reflections were analyzed using rapid qualitative analysis.

FINDINGS TO DATE: 36 sites joined the ACORN CoP, 27 of which implemented ACORN by the end of September 2023. 19 sites completed the implementation survey, reporting using ACORN across a variety of clinical settings, staff disciplines, and modalities (e.g., in person and remote). On average, 27 individuals representing 15 sites attended monthly New Sites calls and 37 individuals representing 20 sites attended monthly All Sites calls. 82 open-ended responses were collected from 23 unique sites through the monthly reflection survey. Themes for implementation successes included communication, buy-in from leadership and staff, informatics and data, and support from the ACORN team. Competing priorities, limited staffing resources and buy-in, and coordination with clinical informatics were reported as barriers. Themes related to changes made and goals included process development, staffing changes, and expansion of social risk screening. The 26 satisfaction survey respondents were generally satisfied with the CoP (average overall rating 8/10), with most respondents reporting they were Satisfied or Very Satisfied with the All Sites calls, New Sites calls, technical assistance, and implementation tools.

KEY LESSONS FOR DISSEMINATION: The ACORN CoP facilitated onboarding and longitudinal support for clinical teams implementing social risk screening and intervention. ACORN sites were generally satisfied with the CoP model and implementation support received. Future work will include in-depth qualitative interviews with high and low-uptake sites to better understand barriers and facilitators and optimize support through the CoP. Development of a CoP has supported wider-scale implementation of ACORN across a variety of VHA clinical settings, while fostering knowledge-sharing and collaboration. The CoP model may be a practical approach to facilitate implementation of social risk screening and intervention in health care.

FOOD FOR THOUGHT: AN INITIATIVE TO INCREASE FOOD INSECURITY SCREENINGS AND REFERRALS TO SOCIAL SERVICES AMONG PATIENTS WITH OVERWEIGHT AND OBESITY

Armaan Hasan¹; Arielle Elmaleh-Sachs²; Isaac Dapkins³; Nusrat Jahan¹; Tenzin Desel⁴. ¹Internal Medicine, NYU Langone Health, New York, NY; ²Family Health Centers, NYU Langone Health, New York, NY; ³Population Health, NYU Langone Health, New York, NY; ⁴Internal Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4054083)

STATEMENT OF PROBLEM/QUESTION: Food insecurity is dynamic and prevalent among vulnerable populations, and current screening frequency for social determinants of health (SDOH) in the health care setting may not capture and address this determinant in a timely manner, which in turn limits resources provided as well as impacts health outcomes such as obesity. Given that food insecurity is a known social determinant of health and is also a risk factor for the development of obesity, does screening for food insecurity improve BMI among patients with overweight and obesity?

DESCRIPTION OF PROGRAM/INTERVENTION: This quality improvement project aims to increase screening for food insecurity among patients with a BMI above 25 kg/m² in a community health center in the Mid-Atlantic region with limited disruption to clinical workflow. Initial informant interviews were conducted with clinicians, nurses, counselors, social workers, and IT to understand the current workflow and where there may be capacity to increase screening and referrals while minimizing the disruption to clinical workflow.The proposed intervention includes modifying an existing best practice advisory for counseling patients patients with a BMI above 25 kg/m², by adding a prompt to screen for food insecurity as well. In the proposed workflow, if a patient screens positive, the clinician is prompted to place a referral order to a social services center or counselor embedded within the clinic that can help address the patient's food access barriers, help enroll the patient in SNAP benefits, and aid with several other social services as well.

MEASURES OF SUCCESS: Measures of success for this proposal include an increased number of patients screened for food insecurity by 14% over one year, as well as increased number of referrals to social services centers or community-based organizations, number of screened and referred patients who are no longer food insecure upon re-screening, and long-term improvement in BMI among those who screened positive for food insecurity and were referred to services.

FINDINGS TO DATE: At the clinic, 78% of patients are at or below the federal poverty level. Baseline characteristics included 6,958 patients with a BMI 25 kg/m², of whom 46% underwent an SDOH screening tool at least once between 12/1/22 and 11/30/23 . Of those who were screened, 15% (n= 490) screened positive for a SDOH, and of those, 43% were eligible for a referral to the social services center affiliated with the clinic. Among those eligible, 99.5% were referred; the SDOH screen included employment, financial resource strain, food security, housing, immigration, safety, and transportation, of which 75% (n= 155) of referrals identified food security as a component of the positive SDOH screen.

KEY LESSONS FOR DISSEMINATION: Food insecurity is a widely prevalent and dynamic social determinant of health, and screening for it regularly and addressing it with available resources should be part of a holistic approach to treatment for overweight and obesity, with the potential to improve health outcomes for patients.

IMPLEMENTATION OF A COMPREHENSIVE, PRIMARY CARE PHYSICIAN LED WEIGHT MANAGEMENT PROGRAM IN A FEDERALLY QUALIFIED HEALTH CENTER.

Rebecca Shafer, Raul Chibas Sandoval, Fernando C. Carnavali, Lauren I. Shapiro. General Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4051936)

STATEMENT OF PROBLEM/QUESTION: Despite having a higher prevalence of obesity and its complications, underserved communities often encounter barriers to accessing comprehensive weight management programs.

DESCRIPTION OF PROGRAM/INTERVENTION: We developed and launched a comprehensive weight management program at a Federally Qualified Health Center (FQHC). The literature describes mostly surgery or specialty driven weight management programs, and our program is novel in that it is led by an interest and taking place in a FQHC.

The program utilizes a comprehensive approach to weight management including dietary, behavioral, physical activity counseling in addition to weight loss medication management. Additionally, the program utilizes resources, such as nutrition and behavioral health, that are already well established at the FQHC. Through this novel program, the FQHC expands access to obesity medicine care to underserved populations in the Medicaid space. These patients often have barriers including insurance coverage and access. Any adult medicine patient in the FQHC network can be referred to the program if they meet the criteria, which is Body Mass Index (BMI) over 25. Every patient referred to the program is seen by a primary care physician with obesity medicine training. Patients in the program attend a standardized number of baseline visits over the first 6 months of the program, and then customized visits thereafter in the first year of the program based on their specific needs and outcomes. The program’s primary goal includes clinically significant weight loss, as defined by a loss of more than 5% of total body weight over a period of 6 to 12 months.

MEASURES OF SUCCESS: The assessment of our program will be divided into 5 categories: 1) Physical Exam, as measured by weight, BMI and waist circumference, 2) Biochemical: as measured by blood pressure, lipid profile, hemoglobin A1C, thyroid studies and liver function tests, 3) Psychosocial, as measured by the Beck Depression Inventory 2 scale and rating of stress level, 4) Socioeconomic/Family, questions about family history of obesity, employment status, highest education level, insurance status and social support, and 5) Lifestyle, questions about alcohol, drug and smoking use and sleep patterns.

FINDINGS TO DATE: TBD

KEY LESSONS FOR DISSEMINATION: An FQHC is particularly well positioned to provide care tailoring to the specific needs and circumstances of underserved communities suffering the consequences of obesity. In addition to clinically significant weight loss, the success of the program will lead to improvement in obesity related chronic health outcomes. By integrating obesity treatment within an FQHC primary care setting, we can effectively reach a larger population and provide this specialty service to an at-risk population.

IMPLEMENTATION OF A PRODUCE PRESCRIPTION PROGRAM FOR PATIENTS WITH FOOD INSECURITY IN A PRIMARY CARE PRACTICE

Gianna Aliberti¹; Carter Baughman¹; Son Quyen H. Dinh¹; Ruth-Alma N. Turkson-Ocran²; Stephen Juraschek¹; Katherine Wrenn³; Kelly Graham³; Elizabeth Targan¹. ¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²General Internal Medicine, Johns Hopkins University, Baltimore, MD; ³Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4063450)

STATEMENT OF PROBLEM/QUESTION: Food insecurity (FI) is a growing national problem and a major factor leading to diet-related chronic diseases, including diabetes, hypertension, hyperlipidemia, and obesity. Healthcare institutions and providers are increasingly viewing food prescription programs as a strategy to cover the costs of healthy food and promote better health for patients with FI. However, primary care providers (PCPs) often do not screen for FI, citing lack of time to screen and a lack of knowledge regarding available resources and interventions.

DESCRIPTION OF PROGRAM/INTERVENTION: We identified Medicaid patients with HTN, diabetes, hyperlipidemia, or obesity via population health data at our practice. PCPs of these patients were prompted via email to screen patients for FI with a 2-item questionnaire at an upcoming visit, and qualifying patients were referred to receive a debit card for fresh fruits and vegetables. The novelty of this project is that the debit cards allow flexibility in purchases rather than more limited options at certain food pantries or via food stamps.

MEASURES OF SUCCESS: To assess the feasibility, we surveyed PCPs about their experience with the program and looked at screening and referral rates. We also collected patient experience data and plan to analyze clinical outcomes data regarding blood pressure measurements, hemoglobin A1c, and BMI to explore the effectiveness of this program. The outcomes of this project are expected to directly address a critical need for data around effective programs that address social determinants of health to improve health outcomes among the highest risk patients.

FINDINGS TO DATE: From our needs assessment, we learned that most PCPs in our practice believe screening for FI to be valuable in primary care but are unaware of screening tools for FI or availability of resources, and that PCPs rarely screen for FI citing a lack of time and/or lack of knowledge about available resources. Opinions on the approach to optimize screening practices for FI are mixed: some prefer asynchronous screening, while others prefer screening at the time of the visit. Between July and September 2023, 258 emails were sent to PCPs to screen eligible patient(s) at an upcoming visit. There were 93 total responses; of those, 28 patients screened negative for FI, 34 screened positive, 20 did not keep the appointment, 8 were rescheduled, and 4 indicated that screening did not occur due to lack of time. Ultimately, 27 patients were enrolled in the program. Patient data collection and analysis are in process.

KEY LESSONS FOR DISSEMINATION: PCPs feel that screening for FI is important and a valuable tool in primary care, but major barriers to screening include lack of time, lack of knowledge of available resources and/or interventions, and lack of understanding of who should be screened. Screening for FI can also be limited by provider and patient discomfort with the screening process. A tangible deliverable helped to facilitate screening for FI, as PCPs felt they had an intervention to provide to patients who screened positive.

IMPLEMENTATION OF INPATIENT SOCIAL NEEDS SCREENING IN A LARGE URBAN SAFETY NET HEALTH SYSTEM

Alessandra Calvo-Friedman^1,2; Jenna Lupi²; Kristen Song²; Jeni Clapp²; Komal Bajaj³; Jinel Scott⁴; Sudha Sarode²; Marlee Ickowicz²; Mary Anne Marra²; Kara Simpson²; Hillary Jalon²; Nichola Davis². ¹General Internal Medicine, NYU Langone Health, New York, NY; ²New York City Health and Hospitals Corporation, New York, NY; ³New York City Health and Hospitals Jacobi, Bronx, NY; ⁴Kings County Hospital Center, Brooklyn, NY. (Control ID #4063531)

STATEMENT OF PROBLEM/QUESTION: Healthcare systems will be challenged to rapidly scale screening for social needs in inpatient settings in 2024 to meet CMS requirements in a way that meaningfully identifies and addresses social needs and does not put undue burden on clinical staff.

DESCRIPTION OF PROGRAM/INTERVENTION: In 2024, CMS will require social needs screening of all admitted hospital patients 18 years or older in five domains: food insecurity, housing instability, transportation, utility difficulties, and interpersonal violence (IPV). Pilots were conducted at two large hospitals in September and October 2023 with active participation from Nursing, Social Work, and Quality & Safety leadership. Population Health provided central coordination, tools and guidance. Nursing administered the screener because they interact with every inpatient and have the clinical training to ask about sensitive issues. The system’s standardized screening questions were built into the nursing intake navigators in the EMR. Although CMS does not require an intervention for identified needs, the goal was to provide patients with some resources. For all domains except IPV, resources to address positive needs was automatically printed on the hospitalization discharge paperwork and reviewed by the discharge nurse. Patients positive for IPV were automatically referred to social work. Reports were built to facilitate collection of data without additional work by clinical staff. In 2024, the workflows will be scaled across all 11 acute care hospitals in the system.

MEASURES OF SUCCESS: Screen at least 70% of inpatients in the pilot.

Implement workflows in a way that did not overburden busy clinical staff and meaningfully met patient needs.

FINDINGS TO DATE: Pilot data from both hospitals:

Total #patients admitted: 3158

Total # (%) patients screened: 3139 (99%)

# (%) patients with positive needs:

1+ Need: 441 (14%)

Food: 280 (8.9%)

Transportation: 361 (11.5%)

Housing Insecurity: 169 (5.4%)

Housing Quality: 183 (5.8%)

Physical Abuse: 9 (0.3%)

Verbal Abuse: 13 (0.4%)

QI surveys (#34) conducted with nursing:

Screening took between 1 and 5 minutes.

More education is needed with nurses regarding resources for patients.

Nursing staff generally believe screening questions are important for patient care.

Resource lists are not fully sufficient to meet patient needs

KEY LESSONS FOR DISSEMINATION: 1. Collaboration between Nursing, Social Work and Quality & Safety supported by a central support team with social needs screening expertise is an effective way to implement inpatient social needs screening and referrals.

2. CMS’s allowance of flexibility around specific screening questions is key; utilizing standard questions set by the health system enables effective data tracking and reporting to improve patient care and meet regulatory requirements.

3. It is essential to provide resources to meet patient social needs; a tiered approach may be necessary in which the most urgent needs are routed to clinical staff and other resources are shared through the EMR or discharge paperwork.

INCREASING ACCESS TO TELEHEALTH BY ENROLLING PATIENTS IN THE AFFORDABLE CONNECTIVITY PROGRAM

Bhav Jain^1,4; Kavya M. Shah^2,4; Parth Patel^3,4; Melissa Martínez⁴; Sravya S. Kuchibhotla^1,4; Alister Martin^5,4. ¹Department of Health Policy, Stanford University School of Medicine, Stanford, CA; ²University of Cambridge, Cambridge, United Kingdom; ³University of Connecticut School of Medicine, Farmington, CT; ⁴A Healthier Democracy, Boston, MA; ⁵Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4063826)

STATEMENT OF PROBLEM/QUESTION: Broadband internet is crucial to accessing telehealth services but many low-income households lack access to proper digital access.

DESCRIPTION OF PROGRAM/INTERVENTION: The Affordable Connectivity Program (ACP) is a long-term program with $14.2B in funding appropriated by Congress to increase national broadband internet access. The ACP provides financial aid of up to $30/month toward internet services for eligible households and up to $75/month for qualifying tribal lands, as well as a one-time $100 discount off connected devices. Our non-profit organization, based in the New England and Southern regions, aims to leverage the health sector and bridge the digital divide by connecting patients to the ACP.

To connect patients to the ACP, our team members actively signed up patients for the program in hospital waiting rooms and used a “get out the vote” (GOTV) method to publicize the program. Our team members further encouraged patients to register by advertising the ACP online through text messages and utilizing face-to-face marketing with posters and handouts.

MEASURES OF SUCCESS: Over the course of this thirteen-month initiative, key measures of success include increasing the number of patients screened for the ACP month-over-month, enrolling at least 1000 new patients into ACP, and distributing at least $300,000 in federal benefits.

FINDINGS TO DATE: As of December 2023, our organization has held 95 ACP signup clinics, all hosted in predominantly Black and Brown neighborhoods across two cities in the New England and Southern regions. To date, the organization has screened 9,765 patients and successfully enrolled 1,085 patients through both in-person and digital enrollments from the New England and Southern regions. 520 patients have been enrolled through in-person clinics in the New England region, and 192 patients have been enrolled through in-person clinics in the Southern region. Through the digital enrollment process, 215 patients have been enrolled in the New England region and 158 patients have been enrolled in the Southern region. The total number of patients screened increased month-over-month, from 72 new enrollments in the first month to 115 new enrollments in the last month. An estimated total savings of $390,600 has been distributed to low-income families who signed up for the ACP through our organization.

KEY LESSONS FOR DISSEMINATION: Expanding access to telehealth is an essential step towards achieving quality health care and addressing gaps in preventive health. Our organization's GOTV approach has been effective in increasing enrollments for the ACP across underserved communities in the New England and Southern regions. Of note, the in-person strategy was associated with more enrollments than the digital strategy, suggesting that in-person clinics may serve as a primary site for increasing uptake of the ACP. By expanding this approach to other cities across the country, bridging the digital divide for patients can reduce health disparities and increase access to primary and specialty care for underserved communities nationwide.

IT TAKES A TEAM TO SCREEN A PRACTICE: INSTITUTING SOCIAL DETERMINANTS OF HEALTH SCREENING IN A LARGE ACADEMIC RESIDENT PRACTICE

Elise Rooney³; Daniel J. Coletti¹; Anna Andrews²; Jennifer Verbsky¹. ¹Internal Medicine, Northwell Health, New Hyde Park, NY; ²General internal Medicine, Northwell Health, New Hyde Park, NY; ³General Internal Medicine, Northwell Health, New Hyde Park, NY. (Control ID #4064049)

STATEMENT OF PROBLEM/QUESTION: It is undeniably important to screen patients for social determinants of health, but there are many barriers to effectively doing so in a large academic resident practice.

DESCRIPTION OF PROGRAM/INTERVENTION: Social determinants of health (SDH) impact patient well-being and health outcomes. General ambulatory practices are often faced with difficulties screening for SDH due to limited time, competing priorities, and lack of resources. However, new SDH screening mandates by the the Center for Medicare and Medicaid Services (CMS) make it incumbent upon primary care practices to develop efficient SDH screening workflows while overcoming barriers to success.

At our large academic resident practice, we successfully developed and implemented a novel workflow to screen patients for SDH needs during office visits, utilizing many members of our interprofessional team. Prior to rollout, formative research was conducted including practice meetings with representatives from each team (front desk associate, medical assistant, physician, and social work). These groups brainstormed workflows that would allow participation by each team member while also minimizing work burden. New workflows also identified ways to alert providers to positive SDH screens and attempt to address patient needs in real-time.

In this refined workflow, all patients are screened annually at the time of their comprehensive visit. Positive screens are reviewed by the medical provider and patients are provided with written materials about local resources for the identified need at the point of care. Patients with more complex needs are connected to our social work team for further assessment, individualized referrals, and guidance.

MEASURES OF SUCCESS: We are tracking volume of patients screened, staff adherence to workflows, social needs identified and related medical diagnoses, and social work referrals. Stakeholder focus groups will identify program strengths and needs.

FINDINGS TO DATE: Since program inception in May 2023 we have assessed 1,253 unique patients, mean age =52.71 years (sd=16.58), 63.9% female. We have identified one or more social needs in 272 patients (21.7%) and three or more needs in 80 patients (6.4%). Approximately half of the positive screens (131 patients or 48.2%) requested a social work consultation.

KEY LESSONS FOR DISSEMINATION: We successfully launched a comprehensive SDH screening program utilizing existing resources and using a stepped approach to helping patients with social needs. In this model providers are empowered to assist patients with resources and patients requesting SW assistance receive personalized consultation to address more complex needs. Our model parallels the framework of our SBIRT program for substance abuse, which combines universal screening and increasingly intense support based on patient preference and need. We feel this model of graduated patient support is easily replicable in most practice environments, and effectively addresses patient social needs during a medical appointment in collaboration with interprofessional team members.

THE IMPACT OF A HOSPITAL-BASED FOOD AS MEDICINE CLINIC

Anirudh Prabu¹; Jennifer Bier⁴; Karen Cook⁴; Douglas Einstadter²; Shari Bolen³. ¹Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; ²Internal Medicine, MetroHealth Medical Center, Rocky River, OH; ³Medicine, MetroHealth/Case Western Reserve University, Cleveland, OH; ⁴Institute for H.O.P.E., The MetroHealth System, Cleveland, OH. (Control ID #4062743)

STATEMENT OF PROBLEM/QUESTION: Although many food assistance programs exist to address food insecurity and improve health outcomes, few studies have evaluated the impact of hospital-based food pantries on health outcomes and health care utilization.

DESCRIPTION OF PROGRAM/INTERVENTION: The Food as Medicine (FAM) hospital-based food pantry functions as a healthy choice food pantry, where patients receive up to a 3-day food supply for their entire household every 2 weeks for up to 12 months. A trained coordinator assists patients in selecting medically tailored food choices (e.g., low-salt options for patients with hypertension). A food delivery option is available. Adults are referred from diverse outpatient and inpatient locations when they screen positive for food insecurity and meet other eligibility criteria: 1) hospitalization for heart failure in the last year; 2) hypertension diagnosis and most recent blood pressure >150/110 mmHg; and 3) diabetes diagnosis and most recent A1c >7%. This study includes 570 patients enrolled between September 2018 and May 2023.

MEASURES OF SUCCESS: We assessed baseline and 3-month measures of dietary behaviors (frequency of eating a variety of fruits and vegetables) using a validated dietary checklist in FAM participants. We assessed health outcomes (A1c, systolic blood pressure, weight), health care utilization (ED visits and hospitalizations and hospital charges) using electronic health record (EHR) data comparing 1-year pre- to 1-year post-intervention in FAM participants versus controls using a multivariate model.

FINDINGS TO DATE: Compared to baseline, FAM participants self-reported statistically significant improvements in dietary behaviors, including increased consumption of an increased variety of vegetables and decreased fast food consumption at 3 months . Compared to controls, there were also statistically significant decreases in A1c (-0.4%; -0.6% to -0.2%), number of hospitalizations(-0.2; -0.2 to -0.1), and hospital charges (-$27,898; -$48,453 to -$7,434), adjusted for demographics (age, gender, race, and ethnicity), patient characteristics (insurance status, median income, and median % poverty), clinical variables (heart failure, diabetes, hypertension, body mass index, baseline A1c, and baseline blood pressure) and enrollment in relation to the COVID-19 shutdown.

KEY LESSONS FOR DISSEMINATION: Hospital-based food pantries, like FAM, can improve dietary behaviors, health outcomes, health care utilization and hospital costs for adult patients with high-risk chronic conditions. Future programs should evaluate the effectiveness of these interventions compared to other food interventions such as referral to local food pantries or produce prescription programs.

Innovation in Healthcare Delivery (IHD) - Vulnerable Populations

BEST PRACTICES IN REFUGEE AND IMMIGRANT HEALTH

susan levine. medicine, University of Connecticut, West Hartford, CT. (Control ID #4043701)

STATEMENT OF PROBLEM/QUESTION: Refugees and immigrants are subject to healthcare disparities due in part to a diminished familiarity by internists with some of the unique care needs of this vulnerable population.

DESCRIPTION OF PROGRAM/INTERVENTION: Refugees have unique healthcare needs including recognition and treatment of chronic conditions realted to their country of origin and migration. Knowledge gaps exist between physicians and their ability to treat refugees. An immigrant health clinic embeded in an academic primary care practice offers unique opportunities to bridge these care gaps. Performing CDC-mandated newly arrived refugee assessments and civil surgeon-certified green card exams allows a busy primary care practice to more effectively recognize and treat key conditions encountered in immigrant populations including latent TB infection as well as a variety of parasitic infections and to recognize the need to deviate from US-based guidelines for chronic disease management and cancer screening, incorporating individualized migration specific risk. Internal referrals from primary care colleagues to such a clinic allow a unique opportunity to train up the immigrant health skills of all primary care faculty in the practice. This session will review some of the specific healthcare benefits of an immigrant clinic and provide practical guidance on implementation strategies.

MEASURES OF SUCCESS: Success of this care model is measured in terms of program growth, referrals from local resettlement agencies, the numbers and types of unique conditions identified, completion rates of LTBI treatement as well as an increased awareness among primary care colleagues and internal medicine residents about migration-specific health risks and culturally humble care strategies.

FINDINGS TO DATE: Approximately 2000 patients from 38 countries have been evaluated. In an embeded nurse-run eDOT program 42 patients with LTBI have been treated with a 96% completion rate. The following additional conditions have been identified and treateed: schistosomiasis, ancylostoma, helicobacter pylori, hepatitis B and C, syphilis, familial mediterranean fever, alpha thalassemia, ventricular sepatal defect, malarai, PTSD, B12 and vitamin D deficiency. As a result of the immigrant health clinic other primary care providers within the practice have increased their LTBI screening and regularly refer patients for migration related health consultations.

KEY LESSONS FOR DISSEMINATION: Building an immigrant health clinic offers opportunities to address healthcare disparities and to address migration specific health risks in vulnerable refugee populations.

BEYOND THE CLINIC WALLS: STRATEGIES TO INCREASE ACCESS TO CARE FOR UNDOCUMENTED LATINO IMMIGRANTS

Harita Shah¹; Alejandra Flores-Miller²; Suzanne M. Grieb⁴; Ronald Saxton⁴; Kathleen R. Page³. ¹Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Johns Hopkins Medicine, Baltimore, MD; ³Medicine, Johns Hopkins University, Baltimore, MD; ⁴Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4060635)

STATEMENT OF PROBLEM/QUESTION: Undocumented Latino immigrants face multilevel barriers to healthcare (e.g., lack of insurance, language discordance, fear of deportation) that lead to health disparities, and there is an urgent need for multilevel public health interventions tailored to these diverse populations.

DESCRIPTION OF PROGRAM/INTERVENTION: We present a multilevel intervention model that our community-academic team has refined and expanded to reach undocumented Latino immigrant populations across Maryland. Maryland is home to diverse immigrant populations who live in urban and rural environments, with many individuals from Central American countries experiencing civil unrest and violence. Our model combines community-based services, home-based testing, community health worker navigation via a text messaging platform, and social media campaigns to promote awareness and uptake of affordable culturally-competent health services. Our most recent initiative was the Sin Duda ("Without Doubt") intervention for COVID-19 services and information. We have applied this model to address disparities in HIV prevention and COVID-19 services, and it may be applied to many other relevant health conditions.

MEASURES OF SUCCESS: We used a comprehensive mixed methods approach to evaluate reach of messaging, uptake of services, and barriers and facilitators to care. We measure COVID-19 vaccination and testing data at our community sites, as well as uptake of home test distribution. We collect reach data from online metrics (e.g., social media platforms, website analytics) and cross sectional surveys. We explore barriers and facilitators to care via qualitative interviews with community members and key stakeholders (this in ongoing).

FINDINGS TO DATE: From April 2021-December 2023, we have attracted over 16,000 visitors to the Sin Duda website. 84% of users visited the website through social media, of which 10,185 (64%) were through organic posts on community partner Facebook and WhatsApp groups, followed by 3,306 (20%) from paid Facebook/Instagram advertisements. Survey and online data show that Facebook and WhatsApp continue to be more effective for outreach to the Spanish-speaking undocumented communities we work with, whereas newer platforms such as TikTok have higher reach to younger bilingual populations. We have facilitated free COVID-19 vaccination for over 2,500 individuals at our community-based site in Baltimore, and provided navigation to testing and vaccination for an additional 1,200 individuals. Home-based test metrics and qualitative data collection are ongoing. Early stakeholder interviews have found the intervention to be acceptable and appopriate for the target audience.

KEY LESSONS FOR DISSEMINATION: Community engagement and multilevel interventions beyond clinic walls are key to addressing multilevel barriers to care for undocumented Latino immigrants. Our results shows that community-based and home-based services paired with social media promotion is an effective strategy to address disparities in evidence based care for undocumented populations.

COMBINED TREATMENT OF STIMULANT USE DISORDER AND HIV: IMPLEMENTATION OF A NOVEL CONTINGENCY MANAGEMENT INTERVENTION IN HIV AMBULATORY CARE

Gabriela Steiner²; Stefan Baral³; Elise Riley⁶; Gabriel Chamie¹; Steve Shoptaw⁴; Monica Gandhi¹; Phillip Coffin⁵; Ayesha Appa¹. ¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²University of California San Francisco School of Medicine, San Francisco, CA; ³Johns Hopkins University, Baltimore, MD; ⁴University of California Los Angeles, Los Angeles, CA; ⁵San Francisco Department of Public Health, San Francisco, CA; ⁶University of California San Francisco, San Francisco, CA. (Control ID #4063727)

STATEMENT OF PROBLEM/QUESTION: Assessing the feasibility of implementing a novel contingency management (CM) program that provides combined treatment for stimulant use disorder (StUD) and HIV in an ambulatory care setting.

DESCRIPTION OF PROGRAM/INTERVENTION: Amongst people living with HIV, StUD is linked with higher rates of medication non-adherence and mortality. CM, an intervention involving incentives for measurable behavior change, is first-line treatment for StUD and can support adherence to antiretroviral therapy (ART). However, CM is not widely implemented outside of formal drug-treatment settings and no existing programs award incentives for multiple behaviors, neglecting the opportunity to address syndemic diseases through one intervention.

To optimize implementation of CM in the ambulatory setting and leverage its potential for combined treatment, we designed a novel program that targets stimulant misuse and ART non-adherence through 12 weeks of CM. We evaluated feasibility through an implementation-effectiveness pilot at our institution’s safety-net HIV clinic; we present results collected in September (pilot launch) through November 2023.

MEASURES OF SUCCESS: We evaluate implementation using the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance), emphasizing Reach and Implementation. The primary outcome was proportion of visits attended with the minimum acceptable attendance defined as 50%, to match that of the largest CM study to date.

FINDINGS TO DATE: REACH. Of 22 participants, 50% were referred by providers and 50% were walk-ins (not contacted prior to enrollment). Participants included 50% women (5 transgender). Most were Black (10) or white (7) and half were unhoused (11). Participants reported using methamphetamine (64%, 14), cocaine (45%, 10), and fentanyl (18%, 4). Most participants (77%, 17) were living with HIV, 53% (9) of whom had detectable viral loads in the past year. Approximately two-thirds of the sample (64%, 14) were taking tenofovir. 13 participants attended a visit after enrollment (59%), 7 of whom took tenofovir.

EFFECTIVENESS. Most urine tests were negative for stimulants (78%) and 77% of participants (10) who attended a visit after enrollment provided at least one negative result. Nearly all tenofovir urine tests were positive (96%).

IMPLEMENTATION. Participants who were retained post-enrollment attended 65% of 63 possible visits, cumulative across all returning participants. The average amount incentivized per visit per person, weighted by number of visits, was $14.

KEY LESSONS FOR DISSEMINATION: A novel CM program to treat StUD and optimize tenofovir adherence was feasible to implement in a HIV-prevention and treatment setting. This pilot reached a population with complex sociomedical needs, including high rates of homelessness and viremia; offering walk-in visits was key in reaching this population. Retainment was challenging but higher than other programs targeting similar populations. This CM design could serve as a scalable approach in settings treating marginalized populations.

IMPACT OF PROVIDING CELLPHONES TO PATIENTS EXPERIENCING HOMELESSNESS ON POST-DISCHARGE OUTCOMES

MARTINA A. KNECHEL¹; Jeffrey Bellinger¹; Natalie Blatz¹; Shaina W. Twardus¹; Ross Buerlein²; Matthew Allen². ¹University of Virginia School of Medicine, Charlottesville, VA; ²Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA. (Control ID #4064587)

STATEMENT OF PROBLEM/QUESTION: For admitted patients who are both experiencing homelessness and lack a working phone, can providing a cellphone with temporary data positively impact their post-discharge outcomes?

DESCRIPTION OF PROGRAM/INTERVENTION: The Homeless Consult Service (HCS) is an inpatient consult service led by medical students, founded at our academic medical center in 2021. For patients experiencing homelessness, the goals of HCS are to form longitudinal relationships, address barriers to discharge, facilitate intakes to local shelters, and connect patients to government and community resources. Starting in October 2022, the HCS began a temporary phone program, providing admitted patients who lack a working phone with an inexpensive cellphone and 2 months of prepaid data.

MEASURES OF SUCCESS: Reduction in subsequent admissions and ED visits, increase in follow-up appointment attendance, and improved contact between patients and the health system

FINDINGS TO DATE: Thus far, HCS has provided phones to 30 patients. For those with complete data for the 6 months before and after receiving a phone (n=13), there was a significant decrease in the number of admissions (3.0 vs. 1.7, p=0.04); however, there was no impact on the number of ED visits in this same time period (4.7 vs. 6.9, p=0.4). Regarding appointment attendance, 7/19 (37%) and 9/21 (43%) patients attended their follow-up appointments scheduled with a PCP and specialist, respectively. To better understand why appointment show-rates remained low, we also explored whether these phones were truly improving patients’ ability to be contacted by the health system. In this light, we found a significant difference in the delivery of appointment reminders between those who did and did not attend follow-up appointments. Of the patients who attended, 75% had successfully received an appointment reminder to their temporary phone, while only 33% of the patients who did not attend their follow-up had received a reminder (p=0.01). Reasons for unsuccessful contact, when they could be identified, were variable, including phones being lost or stolen, and failure to accurately update their EMR contact information.

KEY LESSONS FOR DISSEMINATION: The provision of temporary cellphones to patients who lack working phones has the potential to be high-yield and low-cost intervention to reduce the barriers that persons experiencing homelessness face in accessing the healthcare system.

IMPLEMENTATION OF A STUDENT-LED INTERPROFESSIONAL QUARTERLY FOOT CLINIC FOR AN UNHOUSED POPULATION

McKenzie Bremel¹; Adrianna Kayden²; Heather Cassidy¹. ¹School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4055130)

STATEMENT OF PROBLEM/QUESTION: Unhoused individuals benefit from receiving regular preventative foot care services, but many people lack access to this type of care, leading to preventable morbidity and mortality.

DESCRIPTION OF PROGRAM/INTERVENTION: To help address the foot care needs of unhoused individuals in an underserved community, a student-led quarterly Foot Clinic was created in partnership with a local medical school and multiple community-based organizations. The student volunteers who provide basic foot care services at the Foot Clinic consist of medical students, health graduate professional students, and undergraduate health-profession students. Community volunteers include podiatrists, physicians, FQHC administrative staff who schedule follow-up appointments, and leadership from the hosting homeless shelter. Volunteers must complete an online module and in-person training before the start of the clinic to learn how to provide proper foot care. Foot care services include toenail trimming, callous care, wound care, and specialized services provided by podiatrists. The services at the Foot Clinic are provided at no cost to the individuals (guests) who attend the clinic.

MEASURES OF SUCCESS: After the clinic, student volunteers receive an optional exit–survey querying their comfort level with the population they served, the service they provided, and their likelihood of volunteering with the Foot Clinic again. A separate, optional exit survey assessing patient experience is offered to the guests after their visit. All surveys were completed in accordance with the IRB exemption granted by the home institution.

FINDINGS TO DATE: Since 2019, the Foot Clinic has served 431 guests. The guests rate their satisfaction with the Foot Clinic on their exit survey as either “excellent/very good/good/fair/poor”. Amongst all clinics, 87.01% of guests rated the care they received as “excellent”. Guests have also reported that they feel treated with respect, with 87.04% of guests “strongly agreeing” that they were treated respectfully (N=431). The volunteer base was 72% medical students and 27% undergraduate students (N=283). When asked about their motivations to volunteer, the answer selected by 43.3% of respondents was “I have an interest in giving back to the community, and providing preventative care”. 99.88% of volunteers stated they were “definitely” or “very likely” to volunteer again (N=55)

KEY LESSONS FOR DISSEMINATION: A student-run Foot Clinic at a homeless shelter can be mutually beneficial for its volunteer population and the guests obtaining foot care: volunteers receive invaluable medical or premedical training working with individuals experiencing homelessness, and medical care is made more accessible to the clients. The Foot Clinic is a campus-community partnership model that could be replicated in other communities.

IMPROVING IMMIGRANT INFECTION SCREENING

Jordan Cahn¹; Ayesha H. Sundaram¹; Linda Shipton²; Eirini Iliaki²; Anita Mathews³. ¹Internal Medicine, Cambridge Health Alliance, Cambridge, MA; ²Infectious Diseases, Cambridge Health Alliance, Cambridge, MA; ³Family Medicine, Cambridge Health Alliance, Malden, MA. (Control ID #4060285)

STATEMENT OF PROBLEM/QUESTION: The frequency of infectious disease (ID) screening, detection of chronic infection, and prevention of vaccine-preventable illnesses in immigrant populations is insufficient, often leading to delayed diagnosis and complications.

DESCRIPTION OF PROGRAM/INTERVENTION: Inadequate ID screening can lead to chronic complications with devastating consequences. We aim to increase screening for latent and chronic infections and prevention of vaccine preventable diseases in immigrant patients at a safety net academic community hospital, where the population is 20-50% foreign born. Our intervention contains three components: creating an ID screening test smartset, educating primary care providers (grand rounds, resident teaching sessions, and clinic huddles) about the purpose and use of the smartset, and measuring the number of tests ordered pre- and post-intervention. We also created a guidance document on tests to order based on country of origin and migration history. We then will utilize depersonalized data from the electronic medical record to measure the number of tests ordered for each infection before and after our educational intervention. Anonymous surveys of providers pre- and post-educational intervention will assess uptake and knowledge of the screening tests. The ultimate goal is to increase awareness and frequency of ID screening to improve the quality of care for immigrant patients.

MEASURES OF SUCCESS: Pre and post-educational intervention surveys to assess knowledge and uptake of immigrant ID screening.

Anonymized electronic medical record reports on the number of Chagas, schistosomiasis, strongyloides and tuberculosis tests ordered in the year pre- and the year post-educational intervention.

FINDINGS TO DATE: - 69 survey responses pre-educational intervention, all from primary care providers and hospitalists with varied experience from trainees to greater than 10 years.

- More than half of providers report greater than 50% of their patients are immigrants.

- Greater than 80% providers routinely test for HIV, Hep C, Hep B surface Ag/Ab, and tuberculosis as part of routine screening of immigrant patients.

- Only 59% providers include Hep B core Ab in routine screening, which is important for detection of hepatitis B infection. Additionally, 27-45% providers test for Chagas disease, Schistosomiasis, and Strongyloidiasis, which are prevalent in our patient population.

- Providers indicated that infectious disease screening was not something they had previously received education on but would be interested in further guidance and are interested in using a smartset.

KEY LESSONS FOR DISSEMINATION: Primary care providers should consider infectious disease screening in immigrant patients to prevent complications. We have created a smartset integrated into our electronic health record with guidance for providers to provide excellent care to our diverse immigrant population.

PATIENT PERSPECTIVES ON EXTENDING THE CARE TEAM WITH PREMEDICAL STUDENT HEALTH COACHES IN A SAFETY NET PRIMARY CARE CLINIC

Davida Flattery¹; Lilian E. Yao¹; Victoria Lee¹; Anisha A. Ali¹; Leo Vetter¹; Erandi S. De Silva¹; Monica Rowden²; Alejandro Diaz³. ¹Internal Medicine, Alameda Health System, Oakland, CA; ²Ambulatory, Alameda Health System, Oakland, CA; ³Internal Medicine, Alameda Health System - Highland Hospital, Alameda, CA. (Control ID #4023474)

STATEMENT OF PROBLEM/QUESTION: Training volunteer premedical student health coaches to provide self-management support for chronic conditions extends the primary care team, but do patients perceive this model to be acceptable and valuable?

DESCRIPTION OF PROGRAM/INTERVENTION: Housed in a safety-net academic primary care clinic in the California-Hawaii region, this program has 3 key goals; 1) to provide self-management support for patients with chronic conditions; 2) to increase representation in the healthcare workforce by groups that have been historically underrepresented in medicine by recruiting and mentoring health coaches who reflect the ethnic, racial, cultural, and linguistic diversity of an urban patient population, and 3) to inspire internal medicine residents to pursue careers in primary care by providing them with experience in team-based care. 8 students per academic year are recruited and receive 6 hours of training in Motivational Interviewing (MI)-based self-management support. Each is then paired with a resident. Coaches listen for “change talk” during, and close the loop after the office visit, and then provide MI-based self-management support through telephone follow-up. Coaches receive 30 minutes of group case supervision per week by primary care faculty.

MEASURES OF SUCCESS: To determine if patients perceive this care delivery model to be both acceptable and valuable, we administered qualitative (5-point Likert scale) and quantitative survey questions to patients who had received at least 2 sessions of health coaching.

FINDINGS TO DATE: 12 patients completed the survey. Stated advantages of coaches on the care team included; 1) increased clarity about physician recommendations after reviewing them with the coach, 2) increased confidence in carrying out care plans after review with coach, 3) feeling empowered to make healthy lifestyle changes, 4) help navigating the healthcare delivery system, and 5) coach empathy with specific barriers hindering chronic disease self-management. All respondents agreed that the health coach program should be expanded so that more physicians have a health coach on their team. A representative comment included; “I felt the support of having someone care for me besides my doctor. The doctors addressed my concerns primarily through medications, but the way the health coach called me weekly and encouraged me was instrumental to my well-being.”

KEY LESSONS FOR DISSEMINATION: Recruiting and training URiM medical students to serve as health coaches alongside residents in an academic primary care clinic requires minimal faculty time (~10 hours for recruitment, 6 for MI training and 30 min/week for case supervision). This model provides meaningful clinical experience for student coaches, thereby promoting diversity in the healthcare workforce, while giving residents experience in team-based care. Patients indicated that the addition of health coaches is both acceptable and valuable in multiple domains of chronic disease care. This win-win-win care delivery model could be readily applied across a variety of ambulatory care settings.

RESIDENTS’ PERCEIVED BARRIERS TO SAFELY DISCHARGING PATIENTS WHO ARE HOMELESS

Joyce Tiong¹; Michael J. DiLeo¹; Emily Wang¹; Maria Uribe¹; Anjali Aggarwal¹; Rashmi Rode¹; Doris Lin². ¹School of Medicine, Baylor College of Medicine, Houston, TX; ²Internal Medicine, Baylor College of Medicine Margaret M and Albert B Alkek Department of Medicine, Houston, TX. (Control ID #4063209)

STATEMENT OF PROBLEM/QUESTION: What are internal medicine residents’ perceived barriers to providing a safe hospital discharge for patients who are homeless?

DESCRIPTION OF PROGRAM/INTERVENTION: By law, hospitals must provide a safe discharge to all patients. However, this can be challenging for those who are homeless. Our objective was to identify internal medicine (IM) residents’ perceived challenges to and knowledge of resources for safely discharging this vulnerable population.

MEASURES OF SUCCESS: IM residents from a large academic institution completed an IRB-approved survey where they selected components they consider important when discharging patients who are homeless. The answer choices were based on the American Medical Association’s definition of a “safe discharge” and included confirmation of medical stability, safety of the receiving environment, and access to transportation, medications, and follow-up visits. The survey also asked if they had any formal training on this topic. Using a 5-point Likert scale, residents rated their comfortability discharging homeless patients, familiarity with local resources, and the extent to which they could benefit from more education on this topic. At the end of the survey, residents also included feedback on additional resources that would be helpful in caring for these patients.

FINDINGS TO DATE: Nineteen residents participated (response rate=13%). When comparing paired responses for aspects seen as important versus those routinely addressed, answers for “confirming the receiving environment” were significantly different (p=0.002). This demonstrated that while residents acknowledged the necessity of verifying the adequacy of the receiving environment, with 100% selecting it as important, they were often unable to actually do so. With regards to comfort level discharging this population, residents’ median response was a 4, or comfortable. With respect to familiarity with resources, residents rated chemical dependency, drop-in centers, and food pantries the lowest with a median of 2, or “unfamiliar.” Furthermore, 84% (n=16) agreed or strongly agreed that they would benefit from more education on available resources, and 73% (n=14) agreed or strongly agreed that they would benefit from more education on how to discharge homeless patients. Comments on what makes providing a safe discharge difficult included systemic issues, with lack of available resources (n=10), familiarity with resources (n=8), and time (n=5) cited most frequently.

KEY LESSONS FOR DISSEMINATION: Though our study had a low response rate, it provides insight into additional support residents feel they need to safely discharge patients who are homeless. Residents desired formal discharge training and education on community resources, while also identifying systemic barriers that were out of their control. Future directions include creating a training for residents and an infographic with local resources. We feel this is a start to narrowing the knowledge gap for this vulnerable population.

Innovation in Healthcare Delivery (IHD) - Women’s Health, Sex, and Gender-Informed Medicine

ADDRESSING BARRIERS AROUND BREAST CANCER SCREENING

Nimmy Thomas¹; Nicole Huang¹; Sofia M. Ruiz-Castaneda¹; Christina Stull²; Holli Sadler¹; Rajvi Patel¹. ¹Internal Medicine, Ascension Texas, Austin, TX; ²Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4064394)

STATEMENT OF PROBLEM/QUESTION: Does implementation of on-site mammography increase mammogram completion rates for women ages 45-75?

DESCRIPTION OF PROGRAM/INTERVENTION: Breast cancer is the most common cause of cancer among women in the United States and the leading cause of cancer death in this population. Early detection of breast cancer is vital in decreasing mortality rates.

PDSA Cycle 1 of our QI project investigated mammogram screening rates and barriers to screening in Resident Primary Care Clinic at a VA in the Southern Region. We were able to increase mammogram screening rates by 30% from July to December 2022 through direct patient outreach and follow up. Lack of on-site mammography was thought to be the biggest obstacle, leading to delay of completion rates by four months. In March 2023, a mammography technician was hired and the option to complete mammograms on-site became available. With this change, our goal for PDSA cycle 2, was to increase mammogram screening rates and time to completion of mammogram by 30% from October 2023 to April 2024.

MEASURES OF SUCCESS: Mammogram completion rates between October 2023 to April 2024. Time from order to completion of mammogram between October 2023 to April 2024

FINDINGS TO DATE: Ninety-six women were identified as eligible for breast cancer screening with mammography based on the The American Cancer Society’s (ACS) guidelines, recently also adopted by the VA. The ACS guidelines recommend screening women ages 45-75 without a history of breast cancer. The guidelines recommend annual screening for women ages 45-54 followed by biennial screening from 55-74 years. Based on these guidelines, 60 women were identified as up to date on breast cancer screening and 36 women were not up to date. Among the 36 women not up to date, two had breast cancer and were excluded from the study. Furthermore, 6 women were getting mammograms done through their civilian PCPs and 9 women declined screening.

Nineteen referrals for mammograms were placed, if not previously ordered. Patients were notified of the status of their mammogram order and a phone number for scheduling was provided. Support staff provided additional assistance in obtaining release of information from patients to receive results from outside facilities. Three patients have already completed their mammograms and had their results reported. The project is ongoing and we expect to complete the PDSA cycle by April 2024.

KEY LESSONS FOR DISSEMINATION: On-site mammography is a cost-effective way to increase breast cancer screening rates by minimizing coordination delays between patients and different facilities. However, despite having on-site mammography, additional barriers affecting breast cancer screening rates in female veterans exist: fear of radiation or history of sexual trauma. This could be addressed by educating patients on the risks/benefits of mammography. However, more exploration is needed to better understand how to help veterans with a history of sexual trauma feel comfortable with mammography.

A LEARNING HEALTH SYSTEMS APPROACH TO IMPROVING CERVICAL CANCER SCREENING IN THE VA

Elisheva Danan^1,2; Rhonda Groebner⁴; Berdette Berger⁴; Debbie Pestka²; Jessica K. Friedman³; Bailey Van Eyll²; Maren Strootman⁶; Michele Brueshoff⁴; Catherine Hutchison⁴; Jill Finnigan⁴; Anders Westanmo⁴; Amy Gravely⁴; Kristy A. Kapfhamer⁴; Emma O'Brien⁴; Alisa Duran²; Jill Bowman Peterson⁵. ¹Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN; ²University of Minnesota Twin Cities School of Medicine, Minneapolis, MN; ³Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN; ⁴Minneapolis VA Medical Center, Minneapolis, MN; ⁵Women's Health, Minneapolis VA Medical Center, Minneapolis, MN; ⁶Medicine, University of Minnesota Twin Cities School of Medicine, Minneapolis, MN. (Control ID #4054895)

STATEMENT OF PROBLEM/QUESTION: Implementation of a centralized nurse navigation model to improve timely, guideline-concordant cervical cancer screening results management while supporting clinicians and patients.

DESCRIPTION OF PROGRAM/INTERVENTION: Cervical cancer screening results management is essential to reducing cervical cancer morbidity and mortality. In 2020, VA’s Office of the Inspector General cited 48% of inspected VA facilities for inadequate follow-up of abnormal cervical cancer screens – a critical gap in the quality of VA women’s healthcare.

We reviewed 184 VA screening records from January to March 2022, and found 14 management errors (7.6%). We then developed and implemented a centralized nurse navigation “Pap Hub” intervention: trained RNs review all cervical cancer screening results and use guidelines to determine follow-up recommendations, with gynecologist oversight. Nurses then call patients directly with results and enter consults for colposcopy if indicated.

Pre-implementation, 75% of 55 primary care clinicians surveyed at 7 Midwest VA sites were interested in Pap Hub participation. Sites identified lack of demonstration data as a barrier to implementation. Consequently, we pilot-tested the intervention with 2 clinicians to allow for real-time adjustments, then rolled out at a single site, with additional sites added sequentially.

MEASURES OF SUCCESS: We evaluated Pap Hub intervention effectiveness with respect to (1) improving adherence to evidence-based management guidelines, and (2) minimizing time to patient results notification. Implementation outcomes included patient and clinician process acceptability, and patient understanding of recommendations. We assessed outcomes using a combination of electronic health record data, chart audits, structured patient telephone interviews, and a clinician questionnaire.

FINDINGS TO DATE: Pap Hub nurses have reviewed and responded to cervical screening test results for 1,550 patients at 4 sites from April 2022 through November 2023. Effectiveness: (1) We audited 10% of patient records and found an initial Pap Hub management error rate of 3.9% in the first quarter of implementation, which improved and remained <2% for 5 subsequent quarters. (2) Average time from Pap results to patient notification is <24 hours. Implementation: Patients: 95% of 44 patients surveyed felt results were easy to understand; 94% felt the Pap Hub nurse was easy to talk to. The proportion of patients who correctly identified the purpose of Pap testing and follow-up timeline rose over time. Clinicians: 48 clinicians completed the post-implementation survey. 94% were satisfied with the Pap Hub process;100% agreed that the Pap Hub made evidence-based recommendations and responded to results in a timely manner.

KEY LESSONS FOR DISSEMINATION: The Pap Hub is an effective and acceptable approach to cervical cancer screening results management. Implementation with attention to clinical context and iterative feedback from patients and clinicians led to a sustainable change in management of cervical cancer screening results across multiple VA sites.

EXPLORING ADULT PATIENT EXPERIENCES DURING THE FIRST FIVE YEARS OF THE UCHEALTH INTEGRATED TRANSGENDER PROGRAM

Morgan Wharton²; Marie E. Jetté⁴; Kaila J. Harris^5,4; Natalie J. Nokoff⁶; Danielle F. Loeb^1,7; Quin Axelson⁴; Mary P. Mancuso³; Micol S. Rothman⁸; Rita Lee³; Sean J. Iwamoto^8,9. ¹Division of General Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ³Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ⁴Department of Otolaryngology-Head & Neck Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO; ⁵Voice and Speech Laboratory, Massachusetts Eye and Ear, Boston, MA; ⁶Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO; ⁷Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁸Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ⁹Endocrinology Service, VA Eastern Colorado Health Care System, Aurora, CO. (Control ID #4018715)

STATEMENT OF PROBLEM/QUESTION: Our project sought to investigate patient utilization and experience at the UCHealth Integrated Transgender Program (ITP) by assessing 1) services accessed, 2) communication quality, 3) factors contributing to patients exiting the program, and 4) opportunities for improvement.

DESCRIPTION OF PROGRAM/INTERVENTION: ITP was founded in 2017 to provide comprehensive, interdisciplinary care to gender diverse adults.

MEASURES OF SUCCESS: We surveyed ITP patients aged 18+ years who had access to electronic health record messaging. Surveys sent in English included demographics, adapted validated Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions, and free text.

FINDINGS TO DATE: Complete responses were received from 295 out of 1,328 patients surveyed (22%). Most respondents were white (84%). Patients accessed: primary care (65%), hormone therapy (65%), surgery (54%), mental health (38%), OBGYN (28%), dermatology (18%), social work (14%), voice training (14%), infectious disease (7%), other (19%).

Overall, seventy-five percent (range 66%-91%) of respondents awarded the top box score of "Always”, “Yes Definitely”, or “Very Satisfied” across communication domains; 91% of OBGYN patients selected “Always" for “Did your provider explain things in a way that was easy to understand?” Across care logistics domains, 65% (range 55%-91%) of patients awarded the top box score. Urology earned the highest logistic score of “Always” (91%) in response to “Did the staff from this provider’s office treat you with courtesy and respect?”

Fifty-five respondents (19%) indicated that they no longer utilized ITP services. The most common reasons were geographic barriers (20%) and issues with scheduling (20%). Of note, no one reported leaving due to “detransitioning or stopping hormones.”

Patients reported the most dissatisfaction with scheduling. Patients wanted more virtual options and experienced challenges with waiting for procedures, particularly electrolysis, which has downstream effects of delaying surgeries. Several patients expressed dissatisfaction with weight loss thresholds for surgery and desired less reliance on body mass index. Others wanted to see more gender diverse providers and staff.

KEY LESSONS FOR DISSEMINATION: Overall, patients reported high degrees of satisfaction with their care teams at ITP and most often cited geographic and scheduling barriers as reasons for leaving. For our program and others, ongoing patient feedback and discussions can identify variability between departments and opportunities to streamline scheduling processes. Encouraging supportive relationships and diversity among patients, providers, and support staff is essential for positive patient outcomes and experience. Improvements are needed to ensure that patients can smoothly shift their care to more geographically convenient locations. Reviewing opportunities to increase capacity of services could reduce waitlists and improve patient experience. Additionally, recruiting more gender diverse staff and providers can create a more inclusive atmosphere for patients.

TERATOGENIC MEDICATION WORKGROUP: DEVELOPMENT AND IMPLEMENTATION OF BEST PRACTICES FOR PROVIDER COUNSELING, DOCUMENTATION, AND FACILITY OVERSIGHT OF TERATOGENIC MEDICATION PRESCRIPTIONS

Emmanuelle Yecies^2,3; Noelle Hasson²; Kristin To²; Kimberly Ranade¹; Amma Y. Dodi²; Sharisse Cabatic²; Nicole Grant². ¹Women's Health, VA Palo Alto Health Care System, Palo Alto, CA; ²VA Palo Alto Health Care System, Palo Alto, CA; ³Stanford University, Stanford, CA. (Control ID #4064460)

STATEMENT OF PROBLEM/QUESTION: A VA facility audit identified significant gaps in the provision, documentation, and oversight of teratogenic medication counseling, which could result in potentially unsafe prescribing practices.

DESCRIPTION OF PROGRAM/INTERVENTION: In the setting of a system audit, key stakeholders throughout the healthcare system were identified to lead a quality improvement initiative. Representatives from various service lines including Nursing, Pharmacy, Women’s Health, and Clinical Informatics formed the newly created Teratogenic Medication Workgroup, with the explicit goal of developing and implementing best practices for counseling, documentation, and oversight of VA-identified high-risk teratogenic medications. Balancing clinician and pharmacist time with safe prescribing practices, this group developed a novel note template that allows for straightforward and adequate documentation of pregnancy/lactation assessment and appropriate medication counseling by the prescriber- and is easily identifiable for pharmacy review prior to medication dispensing. With leadership and stakeholder support and feedback, this note became required annually for all outpatient teratogenic prescriptions*. To maximize success, members of the workgroup led prescriber education campaigns throughout the healthcare system, followed by targeted re-education efforts based on patterns identified in chart reviews.

*for women of childbearing-age who are able to become pregnant.

MEASURES OF SUCCESS: The workgroup devised an oversight process, with a mix of data audits, chart reviews, and quarterly reports to relevant system-wide committees. All relevant prescriptions are pulled monthly via an automated process to identify those in which no documentation was entered. These charts are then manually reviewed. This process allows for individual education and follow-up, as well as identification of system-wide patterns for which re-education or refining of the intervention might be appropriate.

FINDINGS TO DATE: The percentage of teratogenic medication prescriptions with adequate provision and documentation of counseling improved from <20% to >90% over the innovation’s first year. This improvement has now been sustained for 12+ months and requires minimal resource investment. The success of this intervention has led to numerous VA systems implementing similar processes as well as national recognition.

KEY LESSONS FOR DISSEMINATION: Engagement of key stakeholders within the healthcare system was instrumental to the success of this intervention. Initial implementation required significant outreach to educate all prescribers and pharmacy staff in the healthcare system, but the interdisciplinary input and buy-in has allowed the initial success to be maintained with relatively low resource investment.

Innovation in Medical Education (IME) - Assessment of Learners

MEDICATION RECONCILIATION PREPARATION WITHIN AN INTERNAL MEDICINE TRANSITION TO RESIDENCY COURSE: A QUALITY IMPROVEMENT PROJECT

Julia Marx, Catherine Chen, Mary Bridgeman, Mary O'Connor, Raman Bhalla. Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ. (Control ID #4060700)

SETTING AND PARTICIPANTS: Graduating fourth-year, second-semester medical students were enrolled in an internal medicine transition to residency (TTR) course and asked to complete a medication reconciliation for three patients following high-fidelity simulation experiences mimicking a hospital discharge. Three medication reconciliation coursework submissions were completed over a two-week period.

DESCRIPTION: The Association of American Medical Colleges (AAMC’s) 13 Core Entrustable Professional Activities (EPAs) encompass fundamental clinical activities that all medical students are entrusted to carry out when entering residency training. According to EPA4, learners should be able to enter and discuss orders and prescriptions, including the ability to compose medication orders efficiently and effectively, recognize and avoid errors by attending to patient-specific factors, utilize relevant resources, and appropriately respond to safety alerts. The medication reconciliation skills of our graduating fourth-year medical students during the TTR program were analyzed for accuracy. The cases were open-book and encompassed prescription writing exercises for medications, home services, and follow-up laboratory studies. Answers were discussed in large group format with the students the day after online submission. Across the three prescription writing simulation exercises, the cases progressed in difficulty.

EVALUATION: For the first simulation, 59 student responses were received. A total of 85% and 80% of students correctly identified Medication 1 and Medication 2, with accurate name, dose, route, and frequency. 42% of those students ordered a contraindicated medication. For the second and third exercises, 60 student responses were received. For the second simulation, 95%, 97%, and 80% of students accurately ordered Medication 3, 4, and 5 respectively, with the correct name, dose, route, and frequency. 7% of students for the second simulation prescribed a contraindicated medication. For the third simulation 3, 77%, 18%, and 95% of students accurately ordered Medication 6, 7, and 8, with accurate name, dose, route and frequency. 64% of students prescribed a contraindicated medication for the third simulation.

DISCUSSION / REFLECTION / LESSONS LEARNED: This workshop, which builds off the standards reflected by EPA4, could be easily replicated at other medical schools. The first two simulations were easier than the last, which may account for the decline in medication reconciliation accuracy. The third simulation was designed to have the closest resemblance to real-life scenarios and resulted in the most significant errors in medication reconciliation. Despite initial didactic content, this exercise highlighted application difficulties for students and the need for medical students and residents alike to engage in medication reconciliation with care. In the future, we plan to analyze the types of medication reconciliation errors made.

MYDATA: CENTRALIZED VISUALIZATION OF STUDENT ASSESSMENT DATA TO PROMOTE PRECISION MEDICAL EDUCATION

Verity Schaye¹; Alexa Gatti²; Matthew Polaniecki²; Jillian Lieber²; So-Young Oh²; Mohammad H. Paracha²; Omar Estevez²; Colleen Gillespie³. ¹Division of General Internal Medicine, NYU School of Medicine, New York, NY; ²New York University Grossman School of Medicine, New York, NY; ³PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY. (Control ID #4053354)

SETTING AND PARTICIPANTS: Precision medical education involves delivering the right educational intervention to the right learner at the right time. This requires the collection of longitudinal assessment data and making meaning of that data to make decisions about clinical competence and appropriate precision medical education interventions. Furthermore, an effective program of assessment requires frequent inputs from multiple sources but also needs to be integrative to make competency decisions. We collect a large volume of assessment data on our students at our medical school and in order to promote precision medical education and competency decisions, these data need to be centrally accessible. Here, we describe the development and implementation of MyData, a centralized visualization of student assessment data.

DESCRIPTION: We started with cataloging all of the medical student assessments that are currently being collected across the curriculum. Through an iterative process with feedback from key stakeholders (students, education leaders, education information technology), we ultimately decided on organizing the assessment data using Miller’s pyramid (at the knows/knows how level: medical knowledge exam and quiz data, at the shows level: Observed Structured Clinical Exercise (OSCE) data, and at the does level: Entrustable Professional Activity (EPA) assessment data collected in the clinical environment). We also included the important threads of personal and professional growth, curricular and career experiences, and research. Lastly, data is further categorized by stage in the curriculum (pre-clerkship, clerkship, post-clerkship) so students can visualize how they will be assessed across the curriculum in one place. Once a final prototype was developed, we got feedback from the key stakeholders and iterated on the design before implementing.

EVALUATION: Qualitative feedback from focus groups obtained after the initial launch indicated there was limited student awareness of the extent of MyData’s features. However, students expressed the benefit of centralizing assessment data sources, that MyData has an intuitive layout and is easy to access, and that they felt comfortable using MyData in future coaching meetings. Additionally, students proposed some changes: a simplified view, an opt-in/opt-out feature for data sharing with coaches, and changes to data access based on student’s stage in curriculum.

DISCUSSION / REFLECTION / LESSONS LEARNED: Students found MyData, a centralized visualization of all their assessment data, to be easy to use and beneficial for facilitating coaching and goal setting. There is a need for ongoing development of a communication strategy to clarify uses of MyData throughout the curriculum and new features to improve the user experience and promote precision medical education. We will continue to gather quantitative data and more qualitative data on students’ use of MyData and integrate feedback to improve the user experience.

TAKING NOTE: ASSESSING RESIDENTS’ MEDICAL CHART DOCUMENTATION DURING A POST-DISCHARGE TELEMEDICINE VISIT WITH A STANDARDIZED PATIENT

Elizabeth Hillier⁴; Renee Heller²; Daniel Sartori¹; Sondra Zabar³; Rachael W. Hayes¹. ¹New York University Grossman School of Medicine, New York, NY; ²Division of General Internal Medicine, NYU Langone Health, New York, NY; ³Medicine, New York University Grossman School of Medicine, New York, NY; ⁴School of Osteopathic Medicine in Arizona, A T Still University, Kirksville, MO. (Control ID #4064724)

SETTING AND PARTICIPANTS: 38 Residents in the Internal Medicine (IM) Residency Program participated in a virtual visit at two urban FQHC clinics

DESCRIPTION: The post-discharge period is a vulnerable time for patients as they risk clinical deterioration, readmission and increased mortality. The outpatient follow-up visit is an essential step to obviate preventable problems and ensure an ideal transition. For many patients, virtual visits are more accessible than in-person visits; however, providers may have less experience and training in telemedicine. We analyzed resident chart documentation practices for a work-place based assessment using announced standardized patients (ASPs) during a virtual, post-discharge clinic visit to assess the need for additional documentation training to improve Transitional Care Management (TCM) visit outcomes and future care coordination.

During their regularly scheduled continuity clinic, residents participated in a video visit with an ASP, a 60-year old woman with a history of congestive heart failure (CHF), recently discharged after a hospital admission for CHF exacerbation. Case objectives to document in the medical chart include a concise history of present illness, medical reconciliation, physical exam findings, assessment/diagnosis, comprehensive treatment plan, and patient education and counseling. Researchers created a literature-based post-discharge follow-up checklist to assess charts for accuracy and completeness. One researcher rated all notes with the checklist through an iterative process.

EVALUATION: Overall, residents performed well on basic information gathering: 84.2% of residents provided complete and concise post-discharge updates, and 92% correctly identified medication discrepancies, though only 34.2% of those residents clearly documented . However, patient education and counseling showed lower performance, with 57.9% of residents providing counseling and only 15.8% documenting 2 or more educational items discussed (most often fluid restriction and diet). While all residents included a physical exam section, only 42.5% documented the patient’s lower extremity edema, a chief complaint of this visit. Treatment plans also varied, as 23.7% of residents chose not to adjust medication dosage and instead reassess at an in-person follow-up visit the following week. This suggests that residents either did not recognize the fluid accumulation or did not feel comfortable managing the symptom during a virtual visit. In a post-visit survey, 100% of learners agreed that the ASP visit provided valuable feedback.

DISCUSSION / REFLECTION / LESSONS LEARNED: This study highlighted gaps in resident telemedicine training, both with documentation and symptom management. Additionally, the study demonstrated that residents perceive virtual SP encounters as an effective tool for workplace-based assessment and training.

THE IMPACT OF LONGITUDINAL VOLUNTEERING EXPERIENCES ON MEDICAL STUDENT PROFESSIONAL DEVELOPMENT

Lauren Fleckenstein¹; Margaret S. Bove¹; Timothy Nold¹; Ethan Mathew²; Abhijay Kumar²; Zoha Qureshi¹; Hussien Bazzi¹; Diane L. Levine³. ¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Medicine, Wayne State University School of Medicine, Detroit, MI; ³Internal Medicine, Wayne State University, Detroit, MI. (Control ID #4064406)

SETTING AND PARTICIPANTS: The “***Honors Society” (HS) is a unique organization at a medical school in the Midwest composed of select students who are committed to service and advocacy in their local community. Each year they engage in a partnership of volunteering and fundraising with a local non-profit which is deemed the “Community Partner of the Year (CPOTY).” Students are asked to commit to ten hours of volunteer service with the CPOTY in addition to other fundraising and non-CPOTY community engagement.

DESCRIPTION: Service learning as a part of medical school education has a known impact on development of professional interests, future leadership roles, and future teaching positions. For instance, volunteering has been shown to positively impact retention of empathy in medical students. Our goal was to quantify the impact the bidirectional partnership between the COPTY and HS has on student members. In an environment in which volunteering is highly encouraged and considered a core part of the curriculum, a unique, multi-year honors society can further enhance the impact that volunteering has on students' professional development.

EVALUATION: Prior to their first time volunteering, HS members completed a baseline pre-survey assessing professional development, personal growth, and understanding of community needs, followed by a series of post-surveys after each volunteer event over the course of the year-long CPOTY partnership. N=29 students completed the pre-survey; they expressed a moderate understanding of health issues facing foster youth (average scores ranged from 4.32-6.57), and demonstrated strong motivation to maintain involvement in their community (average scores ranged from 8.31-9.39). Thus far, N=22 responses have been submitted to the post-survey, with responses continuing through March 2024. Preliminary data demonstrates an increase in areas of professional development, personal growth, and understanding of community needs, though more data is required to establish statistical significance.

DISCUSSION / REFLECTION / LESSONS LEARNED: There is an evolving responsibility for physicians to understand their communities and the barriers to care that they face. While many medical institutions engage with their surrounding communities in a variety of ways, HS cultivates a community-focused environment through participation in a longitudinal relationship with the CPOTY. HS grants medical students a platform to reflect upon their professional development, personal motivation, and recognition of community needs, while concurrently enhancing health literacy and access to care within the community. The outcomes of this project will be used to quantify the impact that HS has on its medical students and demonstrate the benefit of incorporating similar honors societies into other medical schools.

Innovation in Medical Education (IME) - Career Development, Professionalism, and Wellness

A MINI-GRANT PROGRAM TO FOSTER SCHOLARSHIP AND JOY-IN-PRACTICE FOR CLINICIAN EDUCATORS

Rebekah Gardner¹; Kiana Beheshtian²; Kate Mayans¹; Kelly McGarry³. ¹Department of Medicine, Alpert Medical School of Brown University, Providence, RI; ²School of Public Health at Brown University, Providence, RI; ³Internal Medicine, Brown University, Providence, RI. (Control ID #4062583)

SETTING AND PARTICIPANTS: Clinician educator faculty in the Division of General Internal Medicine at an academic medical center.

DESCRIPTION: Participation in scholarship is a desire and an expectation for most clinician educators. Time and funding to focus on personally meaningful projects can support career advancement and may contribute to well-being and job satisfaction.

Prompted by a division-wide needs assessment related to scholarship, we created a mini-grant program called Supporting Teaching & Academic Research (STAR) Grants. The grants provide the following: 1) $2,500 for project-related expenses, 2) release from clinic precepting so the time can be directed to project-related tasks, and 3) support and accountability through the grant lifecycle. The grant application is intentionally brief and non-technical and includes the expectation of scholarly output, broadly defined.

We sought to answer the following research questions: 1) is a faculty mini-grant program for clinician educators feasible and acceptable, and 2) is it effective in fostering scholarship and joy-in-practice?

EVALUATION: In the first 2 years of the STAR Grant program, we reviewed 13 applications from 12 different faculty and funded 11 proposals. 6 projects have been completed, and 5 are ongoing. About half of grantees collaborated on their projects with other division faculty; 4 worked with residents and students.

We employed mixed methods to explore the grantee experience and to evaluate the program’s impact. A colleague outside the division administered a brief survey and interviewed all 11 grantees and all three committee members, using a semi-structured interview guide.

We found that, overwhelmingly, grantees were very satisfied with the grant process and felt funding was sufficient. Grantees expressed gratitude that the division was supporting work that was personally fulfilling, and they noted increased job satisfaction due to the grant. Several grantees recommended more support for study design and statistical analysis. In terms of scholarship, grantees thus far have submitted manuscripts, presented abstracts at conferences, and implemented and evaluated new curricula.

DISCUSSION / REFLECTION / LESSONS LEARNED: The STAR Grant program was feasible to implement and acceptable to clinician educator faculty, with a quarter of division members applying for a grant. All grantees agreed that the application process was smooth and that they had a positive experience after receipt of the grant. Faculty reported that the grants allowed them to work on passion projects that they would otherwise not have been able to spend time on and allowed them to meet their scholarly goals. Based on grantee feedback, we plan to incorporate more study support in the post-award period.

This program could be replicated in other specialties and at other academic medical centers, given the low burden of the application process, the relatively low cost, and the downstream outcome of enabling faculty members to increase scholarly productivity while doing work meaningful to them.

A NEW TYPE OF ROUNDS FOR INTERNAL MEDICINE RESIDENTS: REFLECTION ROUNDS

Kirby M. Sullivan, Maryssa Miller, Sarah Conway. Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4064673)

SETTING AND PARTICIPANTS: Internal medicine (IM) residents of all levels who are on inpatient wards rotations or electives are invited to participate in Reflection Rounds over lunch on the first Friday of every month. Sessions are facilitated by an Assistant Program Director in the hospital conference room.

DESCRIPTION: IM residents are invited to reflect on a pre-selected humanistic topic and share these reflections with other residents in a safe environment. Some examples of the topics for sessions were relationships in medicine, gratitude, death of a patient, joy and grief of patient-physician relationships, countertransference, physician suicide and burnout. During these sessions, the facilitator introduces the topic and invites the group to share their thoughts, feelings, and struggles relating to the topic in order to discuss and relate to each other over subjects which are often ignored or dismissed in the hospital setting. These reflection rounds invite the participants to vent frustrations, celebrate successes, and brainstorm solutions to common problems faced by physicians.

EVALUATION: We collected real-time anonymous survey data about residents’ lived experiences throughout medical training. 24% of residents feel they do not set healthy boundaries with patients. The most commonly used word residents used when describing their reaction to their first patient death was “numb.” These results helped set the tone and frame discussions for that session. We also collected data about residents’ experience and perceived utility of incorporating Reflection Rounds into their graduate medical education using a post-experience survey. Of survey respondents, 73% of residents reported that Reflection Rounds has positively impacted them.

DISCUSSION / REFLECTION / LESSONS LEARNED: There is no current ACGME curriculum requirement to incorporate humanistic medicine rounds into IM residency programs. Burnout is a pervasive problem in medicine in general and particularly in medical training, without many tangible solutions. The medical community has lost several resident physicians to suicide over the last few years, which has been very challenging to process for a lot of our institution’s residents and faculty, increasing the timeliness of making medicine humanistic again. In our post-session survey, one resident commented, “I like hearing others’ experiences [be]cause it normalizes mine, and gives me a space to feel and think about them.” One resident responded that stressful and negative emotions brought up during Reflections Rounds could be combated by incorporating actionable responses to these situations. We hope to incorporate real-time feedback like this from IM residents to improve and customize the curriculum to meet dynamic medical trainee needs. We hope this curriculum paves the way for other programs to adopt a version of Reflection Rounds that fits the needs of their medical trainees.

A ONE-DAY COACHING SKILLS TRAINING: EMPOWERING HEALTHCARE PROVIDERS

Andrea Sikon¹; Jordan Alpert²; Elaine E. Schulte³. ¹Dept. of Internal Medicine & Geriatrics, Cleveland Clinic, Cleveland, OH; ²Center for Value-Based Care Research, Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; ³Pediatrics, Children's Hospital at Montefiore, New York, NY. (Control ID #4063984)

SETTING AND PARTICIPANTS: 237 participated in 15 virtual one-day coaching skills courses 2020 to 2023. After each course, participants completed a survey. IRB exemption status was obtained. Questions assessed the perceived value of the course and change in confidence in using coaching skills. Press Ganey® survey question language was used to measure engagement and resilience. A 5-point Likert scale was used asking “How confident are you in…” a variety of variables with the scale ranging from “not at all” to “substantially.”Survey responses were managed using Survey Monkey^®. The Wilcoxon Signed Rank Test compared the pre-post paired samples at a 95% confidence interval.

DESCRIPTION: In 2008, physician leaders created a unique coaching framework and curriculum based on national coaching competencies. The curriculum was designed through a review of the evidence, regular feedback and leaders’ experience as certified coaches. The curriculum objectives are to discern the value of using coaching skills, to explore the relationship-centered coaching fundamentals of deep listening, empathy, reframing for asset-based thinking and language, and to practice these coaching fundamentals. The curriculum is designed to be highly interactive and experiential, delivered by the certified physician leads. Brief didactic segments on coaching skills are paired with small group exercises to allow the participants to experience both being on the receiving end of the skills as well as to practice using the skills. Trained mentor coaches facilitate participant learning in triad with direct observation with real-time feedback. Faculty began delivering the curriculum virtually in 2020 with the same construct using virtual “breakout rooms”.

EVALUATION: 154 completed the survey (65% response rate), and were mostly females (69%), age 30-39 (38%), MD/DO’s (75%), White (61%), and in practice for an average of 13 years. More than 96% of respondents agreed/strongly agreed the training was valuable, relevant, taught coaching skills feasible to implement, enhanced knowledge about coaching, and improved coaching skills. When assessing change in confidence in coaching skills, participants reported a significant improvement across every category. All but one participant (99%) would recommend the course to a colleague or peer. Increased ratings were seen in Engagement: sense of value (3.1 to 3.7); expanded relationships (2.9 to 4.0); meaning in their work (3.4 to 4.0) and Resilience: dealing with conflict (2.8 to 3.6); sense of empowerment (2.8 to 3.9); use of utilize asset-based thinking (2.0 to 3.9). Participants reported increased ability to use coaching skills with colleagues (2.2 to 3.9), patients (2.5 to 3.9) and in their personal lives (2.4 to 3.9).

DISCUSSION / REFLECTION / LESSONS LEARNED: A virtual one-day training is effective to deliver coaching skills that can be used in daily interactions across contexts and can enhance participants’ professional engagement and resilience.

AT A LOSS FOR WORDS: RESPONDING TO PATIENT-INITIATED DISCRIMINATION AND HARASSMENT

Yasmeen Mohammad¹; Neha Wadhavkar¹; Mindy Sobota². ¹Internal Medicine, Brown University, Providence, RI; ²Division of General Internal Medicine, Brown, Providence, RI. (Control ID #4032729)

SETTING AND PARTICIPANTS: An hour-long workshop was given to a group of internal medicine trainees during a scheduled didactic period in two large academic hospitals.

DESCRIPTION: Participants were asked to complete a pre- and post-survey at the beginning and conclusion of an interactive case-based workshop. During the workshop, trainees were prompted to discuss how they would respond to different incidents of patient initiated discrimination or harassment (PIDH).

EVALUATION: A total of 33 trainees completed the pre- and post-survey. Participant demographics were as follows: Females 42.9%, Males 54.3%, and Transgender 2.8%; White 60.6%, Asian 30.3%, and Black 9.1%. A total of 74.4% of participants reported experiencing PIDH and 84.6% reported witnessing PIDH directed at another provider. Among participants, 70.3% reported never having received training in responding to PIDH prior to the workshop. Prior to the workshop, participants reported their ability to respond to PIDH directed at themselves as: 82.0% poor/fair and 18.0% good/very good, significantly different from after the workshop: 21.0% poor/fair and 79.0% good/very good (p<0.001, OR 4.54, 95% CI [2.7-8.3]). Prior to the workshop, participants reported their ability to respond to PIDH directed towards another provider as: 28.2% poor/fair and 71.8% good/very good, significantly different from after the workshop: 18.4% poor/fair and 81.6% good/very good (p<0.001, OR 2.6, 95% CI [1.6-4.1]).

DISCUSSION / REFLECTION / LESSONS LEARNED: Most trainees have experienced or witnessed some form of PIDH. The workshop was effective in helping participants feel more confident in both recognizing and responding to PIDH directed at them or a colleague. As diversity in healthcare increases, similar initiatives should be implemented at multiple levels of medical education. Ultimately, these initiatives will empower all members of interdisciplinary teams to navigate challenging experiences related to PIDH.

ONLINE RESOURCE URL: 1. Roberts, Laura Weiss MD, MA. Belonging, Respectful Inclusion, and Diversity in Medical Education. Academic Medicine 95(5):p 661-664, May 2020. | DOI: 10.1097/ACM.0000000000003215

2. Cooper LA, Saha S, van Ryn M. Mandated Implicit Bias Training for Health Professionals—A Step Toward Equity in Health Care. JAMA Health Forum. 2022;3(8):e223250. doi:10.1001/jamahealthforum.2022.3250

3. Wheeler M, de Bourmont S, Paul-Emile K, et al. Physician and Trainee Experiences With Patient Bias. JAMA Intern Med. 2019;179(12):1678-1685. doi:10.1001/jamainternmed.2019.4122

4. Hock LE, Barlow PB, Scruggs BA, et al. Tools for Responding to Patient-Initiated Verbal Sexual Harassment: A Workshop for Trainees and Faculty. MedEdPORTAL. 2021;17:11096. Published 2021 Feb 11. doi:10.15766/mep_2374-8265.11096

5. Maassen SM, van Oostveen C, Vermeulen H, Weggelaar AM. Defining a positive work environment for hospital healthcare professionals: A Delphi study. PLoS One. 2021 Feb 25;16(2):e0247530. doi: 10.1371/journal.pone.0247530. PMID: 33630923; PMCID: PMC7906333.

BALINT GROUPS FOR PRIMARY CARE RESIDENTS: BUILDING CAPACITY FOR HANDLING CHALLENGING RELATIONSHIPS IN PRIMARY CARE

Susan Hata, Jessica Zeidman, Joshua Ellis, Sarah Kler, Sarah H. Brown, Karen Carlson. Internal Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4064021)

SETTING AND PARTICIPANTS: Balint groups were implemented in the PC track of an internal medicine residency in an urban academic medical center in the Northeast region in the 2020-21 academic year. Twenty one residents participated in their PGY1 year and 14 participated in their PGY2 year.

DESCRIPTION: Balint groups use case-based discussions to explore the patient-physician relationship. In each session, a resident offers a challenging clinical case. After presenting the case, the rest of the group, facilitated by a psychotherapist and a PC attending, reflect on the emotions experienced by the resident, the patient and any others connected to the interaction. Groups occur during academic half days on ambulatory blocks every two months. Attendance at groups is required for PGY1 PC residents and is optional for PGY2 PC residents. Balint groups are not scheduled for PGY3s due to logistics of their schedule. Group discussions are confidential, and residents are not evaluated on their participation. Groups were held virtually during the first academic year (2020-2021), and in person in the years since.

EVALUATION: During the first 2 years of the Balint groups, all participants (14) were sent an anonymous survey in the late spring of their intern year. The response rate was 100%. Seventy-eight percent of residents (11/14) wished to continue the Balint group in PGY2. Of the 3 residents who did not wish to continue participation, long commutes to participate in person were noted to be a barrier.

DISCUSSION / REFLECTION / LESSONS LEARNED: Balint group participants learn to manage the difficult feelings provoked by certain patients, such as guilt, helplessness, sadness, and anger. Normalizing these emotions reduces isolation and imposter phenomenon. The perspective taking involved aids residents in expanding empathy for their own feelings, and for their patients. After Balint discussions, the residents bring an array of new insights into their next patient encounters.

Factors contributing to the success of our Balint groups include the collegial community within the PC residency, and the scheduling strategy for the groups. Aligning the residents’ schedules so that Balint groups occur during time without clinical responsibilities ensures that they can attend and be mentally present. In addition, residents who commit to ambulatory training tracks may be more attuned to the need for relational skills in light of their future career plans, and this may increase engagement in Balint groups.

In the future, we will continue evaluating the groups for satisfaction and feedback. Offering a virtual option may increase the number of residents who desire to continue Balint groups into the PGY2 year.

ONLINE RESOURCE URL: NA

BEHIND THE SCENES: HOUSE STAFF REFLECTIONS ON THE MAKING OF A RESIDENCY PROGRAM

Jenna Guma, Alexander Garcia, Adriem Ortiz, Kevin D'Mello, Rachel Nash. Internal Medicine, Cooper University Health Care, Camden, NJ. (Control ID #4061120)

SETTING AND PARTICIPANTS: Northeastern residency program with internal medicine residents PGY1 through PGY3 involvement.

DESCRIPTION: Of the many changes to the residency recruitment process in the post-COVID era is the utilization of virtual interviewing and program recruitment videos (PRVs). To supplement virtual recruitment, many programs created videos to share opportunities and overall culture of a program with applicants in lieu of an in-person visit to campus. Our residency program recruited residents to design and lead the recruitment video efforts for the 2022 recruitment season. We examined the experience of residents who volunteered to create a PRV to aid their internal medicine residency program in virtual recruitment and how that experience impacted their perception of their program.

EVALUATION: Residents volunteered to work with program faculty to design, plan, film, and edit a PRV for the virtual recruitment season. After the video was completed, a seven-item questionnaire utilizing 5-point Likert Scales and free responses was designed to gather resident feedback about the experience of creating the PRV. The overall experience of residents and their perception of their program was unanimously favorable across all respondents (17/17 respondents).

DISCUSSION / REFLECTION / LESSONS LEARNED: While the COVID-19 pandemic was the impetus for virtual recruitment processes for many GME programs, it is worth exploring how to optimize the effects of these processes as they persist beyond the pandemic. PRV production was perceived quite favorably by involved residents. In our survey, not a single resident expressed neutral, negative, or extremely negative sentiments towards this creative recruitment effort. All participants expressed a positive or extremely positive view towards this effort and all one hundred percent conveyed the desire to be involved again. This project allowed for resident autonomy in creating the PRV, which likely contributed to the positive feelings associated with the activity. The format, interview questions, and photos/videos were all designed and collected by residents. It allowed for creative expression, fostered collaboration among residents and with program leadership, and helped build house staff camaraderie while creating the video. The project left residents feeling very positively toward the program and a lot of pride in sharing their experience with applicants.

Future steps for this project seek to resolve the above flaws in the study as well as utilize resident feedback to continue to involve residents in PRV design for annual recruitment including but are not limited to: involving program leadership and teaching faculty, expanding project timeline to allow residents more time to plan, upgrading video equipment, and interviewing more residents.

KEEP CALM AND CARRY ON: PROMOTING EMOTIONAL INTELLIGENCE AND CONFLICT MANAGEMENT SKILLS AMONG RESIDENTS

Claire Scott¹; Jung M. Seo¹; Jonathan Lim¹; Anita Kusnoor¹; Stacey Rose². ¹Internal Medicine, Baylor College of Medicine, Houston, TX; ²Baylor College of Medicine, Houston, TX. (Control ID #4062297)

SETTING AND PARTICIPANTS: All senior Internal Medicine residents (n~107) participated in the workshop during academic half-day conferences.

DESCRIPTION: This interactive workshop provided an innovative leadership curriculum which used case-based learning and peer-to-peer teaching to improve skills in managing interpersonal conflict. The instructional framework for the curriculum is based on emotional intelligence concepts, which have proven useful for improving communication both within and outside the realm of healthcare. Residents first received instruction on emotional intelligence concepts. They applied these concepts to three realistic case scenarios, including a conflict with a consultant, nurse, and patient. Residents discussed strategies for navigating these challenges in small and large group discussions.

EVALUATION: Pre- and post-session surveys prompted residents to rate how comfortable they felt in managing conflict (“not at all”, “not so”, “somewhat”, “very”, or “extremely”) and provide qualitative feedback. Of the 107 residents who attended the workshop, 52 (49%) responded to the survey. The session was well received by the senior internal medicine residents. In qualitative feedback, they noted the benefits of discussing shared experiences and challenges and collaborating with co-residents to generate solutions. For each of the three cases of managing conflict with a consultant, nurse, or patient, there was an increase in the number of residents identifying as “very” or “extremely” comfortable with managing conflict (48% to 92%, 54% to 90%, and 56% to 86% respectively).

DISCUSSION / REFLECTION / LESSONS LEARNED: Emotional intelligence and conflict management are important skills for practicing clinicians to promote teamwork for effective and optimal patient care. Residents often face conflicts: with other consulting physicians, interprofessional staff, and with patients. The workshop equipped Internal Medicine residents with emotional intelligence concepts and conflict management skills that they can utilize in residency and throughout their career. They can take these skills back to their academic teams to model professional working attitudes and coping skills to resolve conflict. The workshop highlighted constructive behaviors that can improve professional relationships across the spectrum of healthcare to better serve the patients, protect against workplace-related emotional fatigue, and maintain positive working relationships.

REDUCING PAJAMA TIME VIA SIGN OUT WORKFLOW OPTIMIZATION FOR INTERNAL MEDICINE RESIDENTS

Nathaniel Ash¹; Dana Lew¹; Richa Patel¹; Garred S. Greenberg²; Benjamin Dempsey¹; Mahima Vijayaraghavan³; Beth G. Raucher⁴; Vinh Nguyen¹. ¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Montefiore Health System, Bronx, NY; ³Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁴Internal Medicine, Mount Sinai School of Medicine, New York, NY. (Control ID #4064513)

SETTING AND PARTICIPANTS: “Pajama time” refers to time spent on clinical work outside of usual work hours. At our large, urban academic medical center, 160 medicine residents rotate through the general medicine inpatient service, in which they have scheduled duty hours and are required to sign out their patient care responsibilities to the next provider at the end of their shift. We sought to understand the prevalence of pajama time among residents as part of a wellness initiative to address burnout.

DESCRIPTION: We administered a needs assessment survey with 62 responses among residents of all years. 61% of respondents agreed that accessing the EMR after hours negatively impacts their quality of life, and 31% reported spending 5 or more hours per week on the EMR outside of work hours. The leading reasons to access EMR were to check on a patient’s clinical status (81%), prepare for the next workday (66%), and to answer messages (63%) on an EMR-based platform called Epic Secure Chat (ESC). The majority of respondents (87%) stated they would welcome strategies to reduce time spent on the EMR at home. As ESC “chats” can be tracked and quantified, we chose to focus on decreasing pajama time via addressing after-hour EMR messaging. A new workflow to sign out of the EMR after duty hours and leverage features such as forwarding, away messages, availability status and silencing notifications was implemented. The process shared with trainees is available via the URL. We provided education on the workflow via poster, orientations, and email messaging.

EVALUATION: We tracked the number of off-duty ESC chats sent by categorical medicine residents on inpatient rotations from March 2023 through October 2023. From March to May, 40 off-duty chats were sent per week on average, with a weekly range of 26-57 chats. After July 2023, the number of off-duty chats generally increased to an average of 104 chats per week, with a range of 32 to 190 chats. To better understand the increase in messaging, we surveyed a small group of 11 residents on the EMR signout workflow adoption. Only 4 residents utilized the availability status and 1 resident used the away message on ESC. Most residents reported that they were replying to clinical questions sent to them via ESC.

DISCUSSION / REFLECTION / LESSONS LEARNED: EMR messaging platforms facilitate communication, but may also increase the likelihood that residents will review and answer messages during off-duty hours. We saw an increase in messages after July, suggesting that as residents settle into new roles, they are more prone to off-duty communication. This finding points to the importance of providing resources and workflows for residents to disconnect from the EMR after their shift. While adoption of our EMR signout workflow is still low, we plan to continue implementing education for strategies to decrease pajama time in efforts to empower residents to forward messages in off hours knowing appropriate providers will respond to urgent concerns.

ONLINE RESOURCE URL: https://inpatient.careteamapp.com/uploads/EpicChat-Signout-Process.jpg

RETHINKING RESIDENT WELLBEING: USING A VIRTUAL PLATFORM FOR SELF-REFLECTION, DECREASING BARRIERS TO INTERVENTION, AND CRISIS PREVENTION

Urveel Shah¹; Eric Bai²; Andrea Silvas¹; Katherine Shaw^3,1; Talia Robledo-Gil^1,4. ¹Internal Medicine-Pediatrics, Johns Hopkins Medicine, Baltimore, MD; ²Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; ³Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, MD; ⁴Internal Medicine, Whitman-Walker Health, Washington, DC. (Control ID #4064247)

SETTING AND PARTICIPANTS: The wellbeing platform was developed to support a program with 28 residents. After recent years with trainees enduring significant challenges, residents and program leadership expressed a joint interest in strengthening the support system to prevent crises. The design needed to reduce the barrier for seeking help, as our diverse resident body had different thresholds for seeking aid.

DESCRIPTION: The initial stage involved cultivating resident buy-in and creating a shared language of wellness. The initiative was introduced as a structured system to reduce biases associated with different cultures and personalities when seeking help. A color system was created to provide quick assessment of how a resident was doing, with numbers to indicate severity: Red (1-2, Crisis); Orange (3-4, Struggling), Yellow (Stable, 5-8), Green (Great, 9-10). Those who identified as red or orange would trigger a non-punitive meeting with a member of program leadership selected by the resident. This data would be private, as only a limited committee of residents and leadership had access to the data. A wellbeing action plan, akin to an asthma action plan, was filled out for self-reflection. This information was built into a platform that automated features to conserve limited human capital to focus on actually supporting residents. Automated features included monthly check-in notifications and sending emails to pre-identified leadership for residents who selected orange or red to facilitate check-ins. The platform was developed with standard enterprise installations commonly available at large institutions. The platform was designed to have significant non-programmer editability and was easily imported into the resident environment, requiring only minor device configuration.

EVALUATION: Residents were polled prior to intervention implementation on how supported they felt by program leadership. Feedback was obtained at each stage of development, through online surveys and focus groups during noon conferences. Surveys will be conducted towards the end of the year to assess for post-intervention improvement in subjective measures of how supported residents feel.

DISCUSSION / REFLECTION / LESSONS LEARNED: Creation of a “culture of wellbeing” has led to an increase in clinical teams unofficially asking for color-number check-ins, thus increasing awareness of wellbeing in the work environment. Resident feedback has been critical for design. Residents noted that if the check-in sessions triggered by indicating red or orange were seen as additional bureaucratic burdens, then they would not report honest check-ins. They also indicated that selecting the member in leadership who conducts the checks-in is essential for productive conversations, further supporting the importance of diversity in program leadership. More time and data will be required to see if the intervention can significantly reduce the incidence of crises in residency.

ONLINE RESOURCE URL: https://drive.google.com/file/d/1Alj-5O2L02_si3fPo7kV_NArxRkp1HgA

SIGNIFICANCE OF STRUCTURED LEADERSHIP DEVELOPMENT PROGRAMS FOR WOMEN TRAINEES IN MEDICINE: ONE YEAR REVIEW OF THE FWIM TRAINEE LEADERSHIP DEVELOPMENT PROGRAM

Gayathri Krishnan¹; Maria Q. Baggstrom⁴; Abby Spencer³; Rakhee Bhayani². ¹Internal Medicine, Washington University in St Louis, St Louis, MO; ²Medicine, Washington University in St Louis, St Louis, MO; ³internal medicine, Washington University in St Louis, St Louis, MO; ⁴Internal Medicine/Oncology, Washington University in St Louis, St Louis, MO. (Control ID #4063698)

SETTING AND PARTICIPANTS: The Forum for Women in Medicine (FWIM) Trainee Leadership Development Program (TLDP) sponsored by the FWIM and Office of Education is an 8-month longitudinal certificate pathway for women trainees in the department of medicine. The inaugural cohort consisted of 12 trainees. In the second year, we received 24 applications out of which 16 (8 fellows, 8 residents) were selected to participate. Each participant was also paired with a woman faculty mentor to support goal-directed advancement.

DESCRIPTION: Leadership development and mentorship are valuable interventions to advance women in medicine. The FWIM TLDP aims to provide critical leadership skills to our next generation of women leaders to lead effectively. The curriculum covers topics identified as important competencies for healthcare leadership and targets specific skills through interactive workshops that include case-based learning, role-play, reflection exercises and experiential learning (7 sessions with active learning).

EVALUATION: The program outcomes were measured through pre and post course surveys and observed structured encounters. There was a significant gain in self-reported confidence of skills (5-point Likert scale of much better to much worse) surrounding effective communication (100% better), negotiation (91% better), conflict resolution (92% better), developing a professional network (100% better) and leading with empathy (100% better). At the end of the program, 100% of participants had mentors (vs 42% in the beginning) and 83.33% had developed a career development plan (vs 25% in the pre-course survey). 67% trainees were satisfied with the 1:1 mentor sessions. Among others, qualitative feedback about the program included “I learned techniques for asking for things that I deserve, that my team deserves; as well as how to negotiate solutions. A leader is someone who the team looks up to for being able to do said things in a dignified manner, and I feel that I'll be able to implement what I learned”, “it helped me develop a network of women leaders at various stages that I can lean on, provided me excellent examples of good leaders, helped me identify my own strengths and weaknesses and see how to leverage them”, “Leadership is multifaceted and needs development in several spheres; it is not just an innate quality”, “I no longer apologize unnecessarily, I feel that I belong at the table when I'm on a committee or in a room, and I have improved my active listening skills.”100% of the trainees reported they would recommend this program to a colleague.

DISCUSSION / REFLECTION / LESSONS LEARNED: While developing leadership skills is a lifelong process, structured leadership development programs create safe space for connection, networking and learning, and enhanced leadership competencies. Given the success of the first year of the program, the second iteration was launched after incorporating feedback for change from participants.

ONLINE RESOURCE URL: https://internalmedicine.wustl.edu/diversity/forum-for-women-in-medicine/fwim-trainee-leadership-development-program/

THE MENTORSHIP TETRAD: FACULTY MENTORSHIP MULTIPLIED

Anne Cioletti¹; Michael Rubin¹; Molly Conroy². ¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²General Internal Medicine, University of Utah, Salt Lake , UT. (Control ID #4019659)

SETTING AND PARTICIPANTS: In a large academic center associated with a Veterans’ Affairs Medical Center, members of the Division of General Internal Medicine (DGIM) were offered the opportunity to join a mentorship pilot. A total of 12 mentors and 12 mentees volunteered with specific career goals or areas of focus to discuss. Although offered to all DGIM faculty, the focus was on clinician educators.

DESCRIPTION: Participants (n=24) were organized into 6 mentorship tetrads: 2 junior faculty mentees and 2 mid-career/senior faculty mentors each. Tetrads were assigned around mutual professional interests. Except for one tetrad which included the Division Chief, no tetrad included a mentor/mentee match involving a manager/supervisor.

Prior to starting the one-year pilot program, an orientation was held to set expectations for mentors and mentees. Tetrads would meet quarterly as individual groups with in-person meetings preferred. General topics for the meetings were based on the department’s annual faculty evaluation with aims to work on two areas of growth in required domains: clinical, education, research and administration/service. We also intentionally asked whether work/life integration was discussed to normalize the impact of this on professional work.

EVALUATION: All participants were asked to complete a bi-annual survey noting frequency of meetings and both strengths of and opportunities for the program. Surveys were administered at the 6-month and 12-month (17/24 completed) marks; data presented is 12-month feedback. Most (93%; n=14/15) thought this program should continue in the future. Quarterly meetings felt like the right frequency for participants (86%, n=13/15). Topics most frequently discussed during the sessions were professional projects (86%, n=13/15), work-life integration (86%, n=13/15), promotion process (67%, n=10/15), and networking within the institution (47%, n=7/15). Scheduling was reported as the biggest barrier. Two mentees successfully went through promotion, one of whom is now a program mentor, and another is currently in the promotion process.

DISCUSSION / REFLECTION / LESSONS LEARNED: Overall, this program was very successful, with the tetrad system offering multiple modalities of mentorship and perspectives, and, at times, sponsorship, while utilizing few additional resources. Survey feedback was almost uniformly positive. Now in its second year, the pilot has yielded increased interest with 6 tetrads and 2 pentads (2 mentors and 3 junior faculty). This model enhances mentorship opportunities efficiently while creating a pathway for continued mentor access. Further evaluation will help determine if this model can meet the mentorship needs of junior faculty given often limited pools of mid-career and senior mentors.

THE STRUGGLE IS REAL: SUPPORTING RESIDENTS WITH CLINICAL COACHING.

Abhishek Dhar, Nabil Abou Baker. Internal Medicine/Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #4062557)

SETTING AND PARTICIPANTS: Direct observation and feedback in clinical settings can identify resident skills that need improvement. However, these tools are often unavailable both to residents who do not struggle sufficiently to require formal remediation and to struggling residents prior to entering formal remediation- an intimidating process that may be avoided with earlier intervention. In this intervention, we focused on internal medicine-pediatrics residents at an academic center in the midwest. We identified residents early in intern year who were receiving significant, recurrent feedback about areas where improvement was needed.

DESCRIPTION: Step 1: Identify areas for improvement (via oral/documented feedback) and link them to resident milestones

Step 2: Connect with a coach (faculty and/or peer/chief) who works together with the resident to create an action plan (specific to milestones with detailed changes required to advance to the next level and specific timeline for meeting milestones). Coaches will teach the ADAPT (Ask, Discuss, Ask, Plan Together) feedback model with a focus on normalizing that asking for/receiving feedback is part of developing into a skilled physician

Step 3: Identify and acquire feedback from the resident’s supervisors- attendings that have been made aware of the skills that the resident is focused on improving. The coach will also perform consistent direct observations to track the resident's performance firsthand.

This process will be iterative as the necessary improvements will take multiple meetings, adjustments to action plans, and reassessment of progress through direct observations.

EVALUATION: We will collect informal (verbal) feedback given to residents/ coaches in addition to formal end-of-rotation evaluations. Coaches will perform regular direct observations and track progress on ACGME milestones. We will compare changes in end-of-rotation evaluations and ACGME milestones from pre- to post-intervention. We will also record longer term outcomes- whether residents entered formal remediation, whether they successfully achieved the goals of formal remediation if they did enter it, and whether they achieved the milestones necessary to successfully complete residency. To date, 2 residents have completed our intervention (one avoided formal remediation, one entered remediation but successfully achieved the goals and had the remediation plan discontinued), in addition to one who is currently enrolled.

DISCUSSION / REFLECTION / LESSONS LEARNED: With direct observations, we can identify areas of improvement and guide residents to preemptively address them prior to needing remediation. Therefore, it can lead to improvement in performance prior to less frequent, official milestone checks such as biannual clinical competence committee meetings. A framework like this can be utilized across residency programs when areas in need of improvement are identified. Unfortunately, end-of-rotation evaluations are often not completed on time, and this process requires significant time commitment from the coaches.

Innovation in Medical Education (IME) - Chronic Disease Management

LIFE WITH DIABETES: CURRICULUM ON CONTINUOUS GLUCOSE MONITORING FOR INTERNAL MEDICINE RESIDENTS

Britt Marshall¹; Ina Cecilia Flores Shih²; Dylan Stentiford¹; Saria M. Hassan¹. ¹Internal Medicine, Emory University, Atlanta, GA; ²Endocrinology, Emory University School of Medicine, Atlanta, GA. (Control ID #4064995)

SETTING AND PARTICIPANTS: Use of technology in diabetes mellitus (DM) care has been growing over the past decade. Demand and indications for continuous glucose monitoring (CGM) devices has increased as they have been shown to lower hemoglobin A1c and reduce hypoglycemic events. As of May 2023, Medicare has expanded its coverage to include any patients receiving insulin and patients with a history of hypoglycemia. Medicaid and commercial insurances are following suit. With this expansion, many more patients may now qualify for CGMs. Primary Care, including Internal Medicine (IM) resident continuity clinics, are the frontline for DM prevention and management; however, Primary Care Clinics struggle to adopt CGM due to physician and patient barriers. After conducting a needs assessment, it was revealed that there is a paucity of education on CGM in our academic medical center IM residency curriculum in the southern region.

DESCRIPTION: We designed a hybrid curriculum for IM residents at one of our academic medical center resident clinic sites. This included a didactic lecture about CGM indications, interpretation, and ordering logistics on the electronic medical record (EMR) and a self-learning module where IM residents role played a 48-hour period as a patient with DM. They also had the opportunity to voluntarily wear a CGM sensor to monitor blood sugars and learn on how to troubleshoot the sensor and phone application.

EVALUATION: A retrospective pre-post survey was conducted and qualitative comments from the IM residents were collected. Responses were analyzed using a paired samples T-test that demonstrated improvements in CGM-related knowledge (CGM functioning, indications, data interpretation, and ordering on EMR [N=20, p<0.0001]) and subjective confidence in being able to describe CGM monitoring to and fielding questions from patients in their primary care practice (N=20, p<0.0001). A formal qualitative analysis is pending; however, comments from the survey were overwhelmingly positive towards the curriculum and IM residents felt more empathetic to the challenges of DM management.

DISCUSSION / REFLECTION / LESSONS LEARNED: Given the demand for DM management in the Primary Care setting, this targeted, hybrid curriculum shows promise for bridging a gap in our current IM residency education and improving the capability of IM resident continuity clinics to adapt to technological advances in patient care. Although a small cohort with the success of this one site pilot, we are in the plans to expand to the rest of the residency program.

STRENGTHENING MEDICAL TRAINEES’ PATIENT-CENTERED APPROACH TO CHALLENGES WITH ADHERENCE TO COMPLEX MEDICATION REGIMENS UTILIZING SIMULATED FIRSTHAND EXPERIENCE

Amber Thacker, Shelley R. Ost, Jenay A. Powell, Kamron Robinson. Internal Medicine, The University of Tennessee Health Science Center College of Medicine, Memphis, TN. (Control ID #4063882)

SETTING AND PARTICIPANTS: Multiple factors contribute to medication nonadherence including regimen complexity, scheduling, and difficulty with instructions. These barriers can be further amplified in safety-net populations due to socioeconomic issues such as affordability and health literacy. Medical training programs lack tangible learning techniques from which an appreciation for these barriers may be gleaned. We seek to qualitatively examine the utility of a team-based, simulated exercise in adherence to a complex medication regimen for students during the medicine clerkship at an academic safety-net hospital.

DESCRIPTION: Student volunteers on an inpatient rotation are given placebo medications (edible candies) with a complex dosing regimen similar to those of a typical patient with multiple chronic comorbidities. Certain common challenging conditions for patients are simulated. For example, two of the medications are identical in appearance, highlighting the difficulties patients might have differentiating their medications. Some are to be taken with food and others on an empty stomach. Dosing intervals vary from one to four times daily, and very small candies demonstrate the difficulty of small pills for patients with dexterity or vision issues. All are in prescription bottles with labels and common warnings such as “must be taken whole” etc. Participants are to follow the medication instructions then share their experience with a team-based discussion each day and in a written excerpt at the end of the 5-day experience.

EVALUATION: Each morning, participants share challenges as well as solutions and insights from the experience. Their final written summaries are used to gauge the utility of incorporating this exercise as a standard part of the clerkship. Feedback from participants has been very positive overall. Qualitative comments included: “I learned a lot about how complicated it can be to intertwine the worry and planning that goes into taking medications regularly," “It made me understand how important it can be to talk with patients about how to take their medications and try to be mindful of the medications we give them,” and “I changed my progress note wording from ‘noncompliance’ to ‘nonadherence due to cataracts’ for a patient I was already caring for and never thought to ask before this experience.”

DISCUSSION / REFLECTION / LESSONS LEARNED: Real-time simulations of medication regimens help early clinical medical students identify reasons patients struggle with adherence with complex medication regimens. In this way, medical educators can foster empathy and empower medical students to propose ways to improve medication adherence based on their experiences. Medication simulations can be a valuable addition to a general internal medicine inpatient or outpatient rotation.

ONLINE RESOURCE URL: https://docs.google.com/document/d/1OviHs_vKH_vRu3TxilQSmm9XkjVhhN2g/edit?usp=share_link&ouid=104169068570709903682&rtpof=true&sd=true

TEAMWORK MAKES THE HYPERTENSION CONTROL DREAM WORK: A TEAM-BASED MODEL FOR IMPROVEMENT IN HYPERTENSION CONTROL AMONG INTERNAL MEDICINE RESIDENT CONTINUITY CLINICS

Christine Gladman¹; Deanna Zolfo³; Shayla Mitchell Bigelow²; Karen Kimel-Scott². ¹Medicine, University of North Carolina, Chapel Hill, NC; ²General Medicine, UNC Chapel Hill, Durham, NC; ³UNC Health, Chapel Hill, NC. (Control ID #4063801)

SETTING AND PARTICIPANTS: Academic Outpatient General Internal Medicine clinic with 86 internal medicine residents, 28 faculty, three Advanced Practice Providers (APPs), and two Clinical Pharmacist Practitioners (CPPs)

DESCRIPTION: In this academic health system, hypertension control among low-risk patients is defined as last blood pressure less than 140/90 among patients part of a hypertension registry that do not have atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease, Stage 3 or 4, or diabetes or patients age 40-79 with ASCVD risk score < 10%. Historically, rates of hypertension control among patients of resident physicians was worse compared to patients of faculty physicians and APPs (56% vs. 65%, respectively, in June 2022) due to multiple factors: more vulnerable patient panels among resident physicians, challenges of block scheduling with longer intervals between visits, less continuity of care among resident physicians. To improve control of hypertension among patients of resident physicians, we paired six resident continuity clinic teams that were physically co-located together in clinic with specific APPs/CPPs. The remaining four resident teams continued usual care. This specific care team structure allowed for concerted efforts to ensure timely and intensive management of hypertension among patients of resident physicians. Resident physicians are scheduled in clinic every six weeks in the current block schedule, due to separation of inpatient and outpatient duties. An expectation of two-to-four-week follow-up for patients with uncontrolled blood pressure was communicated with emails to providers, signs in clinic, training of clinical staff, and newsletters.

EVALUATION: Implementation of care teams with APPs/CPPs for focused hypertension management in between visits with resident physicians improved rates of hypertension control from 58% in June 2022 to 64% in June 2023. Alternatively, among resident reams that remained unpaired with an APP/CPP, hypertension control improved at a slower rate from 56% to 60%. In the year prior to implementing resident physician and APP/CPP care teams, rates of hypertension control were relatively stagnant and improved by only 2%. Throughout the year, resident continuity clinic schedule utilization did not decrease with implementation of this team-based model of care and remained above 90%.

DISCUSSION / REFLECTION / LESSONS LEARNED: We implemented a system with formal partnering of resident teams with APPs/CPPs to create care teams for patients with hypertension, that fostered intensive control of hypertension among patients with resident physician primary care physicians. This care team model also allowed residents to spend clinic visits focusing on other, complex acute and chronic medical issues of their patient panels, while ensuring a collaborative hypertension management plan with their team’s APP/CPP. Additionally, these resident-APP/CPP teams allowed the clinic to overcome systemic barriers intrinsic to resident continuity clinic.

Innovation in Medical Education (IME) - Clinical Informatics and Health Information Technology

EPIC FOR INTERNS: DESIGNING A PRACTICAL SEMINAR FOR NEW INTERNAL MEDICINE RESIDENTS

Jennifer A. Woodard¹; Alexander Kerschner²; Troy Kenkel²; Paul Stellmacher¹. ¹Geriatrics and Palliative Medicine, Medical College of Wisconsin, Milwaukee, WI; ²Internal Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4064836)

SETTING AND PARTICIPANTS: A recently graduated resident and an attending physician presented to a group of 43 first-year internal medicine residents (interns) at the end of their second month of residency. The goal of the presentation was to introduce efficient chart review and documentation strategies in order to increase resident confidence in the use of the electronic medical record (EMR).

DESCRIPTION: Our internal medicine residency program did not have any existing training targeted at teaching EMR strategies or institution-specific features to new internal medicine residents. Based on our experiences using the hospital EMR system (Epic), we developed a presentation highlighting features unique to our home institution. We reviewed billing requirements, interprofessional staff use of notes, and a survey of prior internal medicine residents assessing the most important components of notes.

EVALUATION: We created a pre- and post-survey intended to capture current comfort with the EMR and the utility of the training. The survey was administered via a QR code for residents to access on mobile devices. The pre- and post-surveys consisted of 6 and 5 multiple choice questions, respectively; each had one yes/no question and the remainder utilized Likert scale.

The response rate was 27/43 (63%) for the pre-survey and 33/43 (77%) for the post-survey. In the pre-survey, 26/27 (96%) interns reported having used Epic during their medical school training. Residents rated their comfort level writing notes in Epic on a Likert scale from 1 to 10 (1 being least comfortable and 10 being the most comfortable) with an average rating of 7.52 (range 4-10). They rated their understanding of components needed in a note for billing purposes on the same Likert scale with an average of 3.96 (range 1-10).

In the post-survey, 32/33 (97%) agreed that this lecture taught them something new. When asked if this lecture made them more comfortable using Epic, 5/33 “strongly agreed,” 23/33 “agreed,” and 5/33 were neutral. When asked if this lecture taught them time saving strategies to use in EPIC, 12/33 “strongly agreed,” 16/33 “agreed,” and 5/33 were neutral. When asked if formalized training for Epic would have been beneficial prior to the start of intern year, 19/33 “strongly agreed,” 11/33 “agreed,” and 3/33 were neutral.

DISCUSSION / REFLECTION / LESSONS LEARNED: Although most interns had previously used Epic, nearly all of them described benefit from near-peer training. Development of an institution-specific, practical approach to the efficient use of the EMR is a generally well-received method of improving efficiency for internal medicine interns. Future studies will evaluate the impact of this talk on changes in efficiency based on time spent in chart review and documentation by internal medicine interns.

INCREASING CONFIDENCE AND EFFICIENCY IN MEDICAL STUDENT NOTES

Michael Houghan¹; Jennifer Passini³; Laura Zakowski². ¹Department of Medicine, University of Wisconsin-Madison, Madison, WI; ²Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; ³Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4060671)

SETTING AND PARTICIPANTS: Third year medical students on inpatient general medicine services at an academic hospital

DESCRIPTION: Third year medical students on our inpatient general medicine service have not historically used a standard note template, and instead copy a note template from a resident physician or start from scratch. Both options are not ideal, as they 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 imbedded help text for students, which automatically populates for students to use in the EHR. The help text guides students in note writing technique and clinical decision making. The goals 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.

EVALUATION: We measured these goals with a pre- and post-rotation survey and summarized data as counts and frequencies with comparisons made using Fisher’s exact test. The level in organizing an assessment/plan endorsed as “confident” increased from 17% to 83% after 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%. Each of these results were statistically significant with 95% confidence intervals.

Additionally, we performed Epic database review to compare note length in student notes in both the pre-intervention and post-intervention periods. Average note character count for both H&Ps and Progress Notes were obtained, and an 11% decrease in character count in progress notes was noted after implementation of the note template. There was no significant change in H&P note length.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our 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 can is an effective teaching tool for perceived proper note writing and enhanced confidence in note organization. Additionally, there was a reduction in progress note length after implementation of note template, which likely correlates with an increase in efficiency in note writing and a decrease in amount of unnecessary information in notes. There was likely no change in H&P note length autopopulated previously documented social history and problem list.

We plan to further evaluate student notes to determine whether they have improved based on subjective attending opinion and objective rubric comparison. This would help us determine if the note template objectively improved organizing an assessment/plan, and reduced unnecessary information.

TAMING THE BEAST: EMR PERSONALIZATION FOR INTERNAL MEDICINE RESIDENTS

Jared Silberlust¹; Elise Ruan²; Peggy B. Leung³; Helene Strauss¹; J. T. Gossey⁴. ¹Internal Medicine, Weill Cornell Medicine, New York, NY; ²Biomedical Informatics, Columbia University Irving Medical Center, New York, NY; ³Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY; ⁴IM, Weill Cornell Medicine, New York, NY. (Control ID #4015196)

SETTING AND PARTICIPANTS: This workshop took place during a morning report hour-long session. Two separate cohorts of internal medicine residents participated in the workshop during their outpatient clinic rotation. Each cohort contained 20 trainees, combining for a total of 40 PGY-1 through PGY-3 participants. The workshop delivery was identical for both cohorts.

DESCRIPTION: To introduce the relevance of EMR workflow personalization in clinical practice, a 60-minute workshop was developed. First, the strong correlation between health IT frustrations and overall provider burnout was described through a discussion of the latest medical literature. Then, the positive impact of EMR workflow personalization on user experience was reviewed. Next, specific personalization strategies were demonstrated through a live EMR walkthrough. Finally, participants were split into groups and tasked with developing their own personalization ideas in competition with other groups. Groups assigned a reporter to share their idea with the rest of the room, and the utility of each idea was discussed.

EVALUATION: Prior to participating in the morning report, residents were invited to complete an optional and anonymous survey containing two nationally validated questions. The first question asked about the overall level of satisfaction that participants felt using their EMR, and the second question asked about the level of personalization that participants perceived to have incorporated in their EMR workflow at the time of completing the survey. Two months after participating, all workshop attendees were invited via email to complete the same survey. Survey data analysis is ongoing. Additionally, six months of EMR audit-log data is being analyzed to determine levels of personalization before and after receiving the intervention. The mean number of order sets, speed buttons, and smartphrases built will be compared in residents who did and did not receive the intervention. Mean total minutes spent on the EMR will also be compared. Audit-log data analysis is ongoing.

DISCUSSION / REFLECTION / LESSONS LEARNED: This 60-minute intervention aimed to introduce a unique perspective of EMR optimization to residents. The contents of this workshop included discussing data regarding potential benefits of personalization, reviewing several specific personalization strategies, and challenging participants to generate and share creative EMR workflows with their peers. The successful completion of the workshop over multiple morning report sessions demonstrates its implementability and practicality as part of a medical resident’s training curriculum. A preliminary review of EMR audit-log data suggests that workshop participants may adopt EMR workflow personalizations at a higher rate than non-participants. Personalizing EMR workflows can allow for improved provider autonomy, proficiency, and satisfaction during the workday. Future directions can involve incentivizing providers to explore personalization opportunities directly within their clinical environments.

Innovation in Medical Education (IME) - Curriculum Development – CME

ADULT CARDIOVASCULAR GENOMICS CERTIFICATE PROGRAM: EFFICACY AND IMPACT ON HEALTHCARE PROFESSIONALS

Bansari A. Rajani¹; Priyanka Vaidya¹; Alana C. Cecchi¹; Christina Y. Miyake²; Vicki Huff³; Dianna M. Milewicz¹; Siddharth K. Prakash¹. ¹McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX; ²Baylor College of Medicine, Houston, TX; ³University of Texas MD Anderson Cancer Center, Houston, TX. (Control ID #4064156)

SETTING AND PARTICIPANTS: The demand for genetic services has outpaced the availability of genetic resources for most clinicians, who are not routinely trained to implement genetic information into clinical decision making. The Cardiovascular Genomics Certificate (CGC) program was designed to train non-genetic healthcare professionals to recognize, assess, and refer adult patients with heritable cardiovascular diseases, which are often deadly if diagnosis is delayed.

DESCRIPTION: The CGC is an asynchronous online course consisting of 24 modules in three tiers of increasing complexity. As learners complete realistic clinical scenarios, knowledge is reinforced by interactive dialogs, quizzes, and tests. We hypothesize that the CGC will increase genomic medicine competencies in this underserved audience and promote the sustained application of genomic concepts to clinical practice.

EVALUATION: All CGC learners complete a pre-course assessment, 5-10 knowledge checks and quizzes in each module, and a post-course assessment. Qualtrics feedback surveys at the end of every module and a course assessment form are required before learners can claim CME credit. In the feedback surveys, learners may consent to be contacted for interviews about their experiences with the course. An additional survey assessing long-term impacts on clinical practice was implemented in REDCap and emailed to learners approximately 6 months after course completion.

The CGC was accredited and made publicly available in September 2022. CGC learners include nurses (24%), nurse practitioners (21%), physicians (16%), and physician assistants. In paired pre- and post-course assessments, learner scores improved by 20%, primarily in recognition of heritable disease, inheritance patterns, and interpretation of genetic tests. A total of 283 learners enrolled in the CGC and completed a mean of 3.8 modules. Thirty-six learners successfully claimed CME credit and earned a mean of 6.4 credit hours. The initial pass rate on module quizzes was 80%. In feedback surveys, learners identified the modular structure and linked resources of the CGC as strengths. Learners rated the course favourably (mean score: 7.9/10), endorsed confidence to use genetic information in clinical practice, and planned to complete new modules as course updates become available. In long-term surveys, learners expressed increased confidence to explain genetic concepts and communicate with patients about their genetic risks and stated that they were more likely to refer patients for genetic testing. Learners agreed that the CGC effectively promotes awareness of heritable disease in their adult patients and plan to recommend the CGC to their peers.

DISCUSSION / REFLECTION / LESSONS LEARNED: The CGC program effectively empowers non-genetic clinicians to master genomic competencies. The CGC promotes collaboration between healthcare professionals to prevent deaths due to heritable cardiovascular diseases, potentially transforming healthcare education and clinical practice.

ONLINE RESOURCE URL: https://go.uth.edu/CVGenomicsCert

ADVANCING PATIENT-CENTERED PRACTICES ADDRESSING PAIN, OPIOID USE, AND RETURN TO WORK IN GENERALIST MEDICAL SETTINGS: DEVELOPMENT OF AN INTERACTIVE CLINICIAN TRAINING

Emma Biegacki^1,2; David A. Fiellin^3,2; Sara Edmond^4,2; Efia James^5,2; Jeanette Tetrault^1,2. ¹Internal Medicine, Yale School of Medicine, New Haven, CT; ²Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; ³Interal Medicine, Yale School of Medicine, New Haven, CT; ⁴PRIME, VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; ⁵Occupational and Environmental Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4065030)

SETTING AND PARTICIPANTS: Acute and chronic pain are common in the workplace and result in lost productivity which can be exacerbated by long-term opioid prescriptions and opioid use disorder (OUD). Clinicians treating injured workers can benefit from targeted training to identify and treat pain and OUD, and support return to work for these patients. A clinician training was developed to enhance clinical knowledge and confidence among prescribing and non-prescribing clinicians treating patients with pain and/or OUD in general medical settings.

DESCRIPTION: The training consists of four modules: treatment of acute pain; opioid use and return to work; treatment of chronic pain; and evaluating, treating, or referring for OUD. Participants complete one hour of self-directed learning and four hours of live, virtual learning with clinician facilitators employing didactic and small group learning exercises anchored by a longitudinal clinical case. Core principles of the curriculum include patient-centered care, shared decision-making, avoiding stigmatizing language, and responsibility of the clinician beyond the exam room. A initial pilot of the curriculum was conducted in 2022. Pilot evaluation data informed revision of curricular content.

EVALUATION: Participants completed a pre- and post-training clinical knowledge survey assessment. The post-training assessment additionally collected self-reported clinical confidence and training satisfaction scores along 5-point Likert scales (completely, slightly, somewhat, fairly, completely), and commitments to practice change resulting from training participation.

DISCUSSION / REFLECTION / LESSONS LEARNED: Forty-two people completed the training in the period encompassing implementation of the pilot (25 participants) and revised trainings (16 participants). Participants enrolled from six states in the U.S., representing 9 prescribing and non-prescribing clinical roles in over 14 clinical disciplines. Among pilot participants, average pre- and post-curriculum knowledge assessment scores were 82% and 88%, respectively. The average self-reported clinical confidence score across all four domains was 3.6/5. The average satisfaction score was 4/5. Among participants who completed the revised training, average pre- and post-curriculum knowledge assessment scores were 74% and 85%, respectively. The average self-reported clinical confidence score was 3.7/5, and the average satisfaction score was 4.3/5. Examples of participants’ commitments to practice change include intent to: apply validated clinical screening tools for pain and OUD; use patient-centered, non-stigmatizing language; and implement evidence-based approaches integrating treatment and return to work planning. Preliminary results suggest positive impact on clinical knowledge, with participants reporting high rates of satisfaction and clinical confidence, and endorsing interactive, case-based learning approaches to improve patient care.This curriculum highlights diverse perspectives in caring for injured workers.

ADVOCACY TO REDUCE PHYSICIAN MORAL INJURY

Zoe Tseng. Brigham and Women's Hospital, Boston, MA. (Control ID #4061480)

SETTING AND PARTICIPANTS: This program took place at Brigham and Women's Hospital in 2023 and involved five attending physicians in the Department of Medicine that were selected based on interest, availability, practice setting, and previous experience with legislative advocacy.

DESCRIPTION: Physicians have been experiencing increasing levels of moral injury. Advocacy can help prevent burnout. Most physicians feel a duty to advocate, and many will at the patient level, but are ill-equipped to make the systemic changes that are most impactful. Learning advocacy skills and having mentorship to hone them may be helpful for physician engagement in advocacy. Being equipped to tackle issues at a systemic level can reduce frustration with the health care system and increase fulfillment in our professional role. This program aims to expose attending physicians to legislative advocacy and provide training and mentorship in this skill at both the state and national levels. Furthermore, this program may reduce physician burnout by training physicians to advocate for structural changes to improve health care for patients.

This program took place in 2023 funded by a grant from Faculty Development & Well-Being program of Brigham and Women’s Physician Organization and took place over 3 months. Five attending physicians were sponsored to attend legislative advocacy trainings targeting the state and federal level organized by the MA ACP Chapter and the ACP, respectively. Training included updates on health care policy and how to communicate effectively with legislators. Virtual mentoring sessions took place before and after each of the training sessions.

EVALUATION: Majority had not received formal advocacy training. Most cited barriers to future participation in advocacy were lack of time, training, and opportunities to advocate. Post-intervention a majority felt moderately to very comfortable with advocating in the government domain. Professional fulfillment and burnout scales did not substantially change pre- and post-program. What did participants like about the program? “We received training and real-life experience to practice and promote Healthcare advocacy.” “I think a big part of the benefit of this program was connecting with other physicians from our BWH community who share the same experiences, hurdles, and views I do.”

DISCUSSION / REFLECTION / LESSONS LEARNED: Although the majority of the physicians had not received formal advocacy training, after this program most of them felt at least moderately comfortable with government advocacy. The most liked aspects of the program were the education and opportunity to meet colleagues. While time was not protected for participation, the funding reduced the physicians’ barriers to getting involved in advocacy and with ACP. Increasing the program duration beyond 3 months could be more likely to lead to changes in professional fulfillment and burnout scales so future iteration of this program will take place over 6-12 months.

IMPLEMENTATION OF PRIMARY CARE GRAND ROUNDS IN A MOUNTAIN WEST VETERAN AFFAIRS HEALTH CARE SYSTEM

Lisa Thompson¹; Sopheap Na¹; Madeline McKeever². ¹General Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²VA Eastern Colorado Health Care System, Aurora, CO. (Control ID #4063198)

SETTING AND PARTICIPANTS: VA Primary Care leaders created virtual one-hour, monthly, CME-accredited Primary Care Grand Rounds available to all Primary Care Providers (PCPs), nursing staff, and pharmacists in a Mountain West VA Health Care System.

DESCRIPTION: VA Primary Care leaders established Primary Care Grand Rounds in 2021 to provide recurrent, evidence-based education on topics relevant to primary care providers, nurses and pharmacists within the local VA healthcare system. The curriculum was developed to promote standardized communication of up-to-date medical education and to reinforce a standard scope of practice for PCPs (including physicians, physician assistants, and nurse practitioners). Moreover, the Grand Rounds were intended to facilitate communication between the Primary Care Service and local subject matter experts from a variety of disciplines by providing an opportunity to review best practices for communicating with and consulting subspecialty teams within the VA.

EVALUATION: Since starting Primary Care Grand Rounds in December 2021, there have been 25 primary care topics covered. Guest speakers have included PCPs and subject matter experts from over ten subspecialties.

After 1 year and 12 Primary Care Grand Rounds lectures, an optional survey was administered to all attendees. Out of 39 responders, 97% agree or somewhat agree that knowledge and skills were updated, the course is relevant to their practice/profession, the teaching strategies and visual aids were appropriate and that they would use this information to improve the medical management of their patients. 94% agree or somewhat agree that they feel more comfortable referring to specialists who have presented at Primary Care Grand Rounds.

Providers were given the option to provide free text feedback as part of the survey. The comments demonstrated that these talks were useful, and providers appreciated the opportunity for CME credits. Ancillary staff, such as nursing, also benefited from these education sessions and one commented it has helped appropriately triage patients. Having protected time to attend these sessions has given PCPs the ability to update clinical knowledge despite busy schedules.

Several subspecialists who presented at Primary Care Grand Rounds also reported benefit. Specifically, they enjoyed the opportunity to engage with PCPs. Some even reported sustained increased interaction with PCPs after their presentations.

The survey will be sent out again January 2024 to continue to evalute this program.

DISCUSSION / REFLECTION / LESSONS LEARNED: After 12 presentations, VA Primary Care Grand Rounds attendees and presenters reported benefits suggesting that this initiative provides relevant education promoting evidence-based practice while improving interactions between Primary Care and specialty services.

Challenges to coordinating the series include protecting provider schedules for a consistent monthly meeting, timely completion of CME documentation requirements, and eliciting attendee feedback.

PSYCHSNAPS: MENTAL HEALTH AND ADDICTION KNOWLEDGE BOOSTS FOR PRIMARY CARE CLINICIANS

Zoe Kopp, Irina (Era) Kryzhanovskaya, Emma Samelson-Jones. Department of General Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4063159)

SETTING AND PARTICIPANTS: Psychsnaps is an electronic curriculum, designed for primary care clinicians and relevant for trainees in psychiatry, family medicine, and internal medicine, aiming to improve frontline clinician management of behavioral health problems. The authors are 3 clinician-educators in a large, academic medicine setting – 1 primary care embedded psychiatrist, 1 addiction medicine specialist and internist, and 1 primary care internist. We have 331 active subscribers. A 6-months-post-launch survey in 6/2023 had a 15% response rate: 75% of subscribers identified as MD/DO and 21% as APPs (NP/PA), with a majority practicing internal or family medicine. 65% practiced in an academic-affiliated medical setting.

DESCRIPTION: As the need for psychiatric services outstrips the number of psychiatrists available, PCPs are the default providers for patients with mental health needs. Their efforts are hindered by a lack of time, resources, and confidence in treating mental health conditions. PsychSnaps is a curriculum of concise (5 minutes or less to read with 1-3 learning points), clinically focused, and accessible lessons, that are free and delivered via email-newsletter every 2 weeks or accessible via website. An informal needs assessment of common psychiatry e-consult questions from primary care informed the initial curriculum.

EVALUATION: PsychSnaps launched in 12/2022. 26 PsychSnaps have been delivered via 5061 email newsletters, with an open rate of 69%. In the 6/2023 evaluation survey, 100% of respondents found PsychSnaps to be clinically relevant, trustworthy, and useful for patient care. 62% referred to PsychSnaps content for clinical decision making at times other than when they first received the newsletter. Survey comments included positive feedback and suggestions for future topics. We will re-evaluate the curriculum in 1/2024.

DISCUSSION / REFLECTION / LESSONS LEARNED: Given the limited availability of psychiatric care, it is imperative that clinicians are both prepared to care for – and continuously engaged in learning about – the diagnosis and management of acute and chronic psychiatric illness. PsychSnaps is a longitudinal curriculum that exposes learners to new content every other week via the newsletter and simultaneously offers easy access to a repository of prior lessons via the website. Our newsletters have been met with enthusiasm. Moving forward, we will expand the topics covered with subspecialty guest authors in adolescent and geriatric psychiatry. We aim to find sustainable funding opportunities and expand subscribers through speaking engagements, conference presentations, and social media engagement. On the website, we will offer a resources webpage, specific verbiage examples for clinicians to use with patients, and ready-made patient instructions that can be modified by the subscriber for their patient population. Finally, we will highlight PsychSnaps as an active teaching tool, one that can be used by subscribers for learners during clinic and after for spaced learning.

ONLINE RESOURCE URL: www.psychsnaps.com

Innovation in Medical Education (IME) - Curriculum Development – GME

AN INNOVATIVE POPULATION HEALTH AND EMR CURRICULUM AT A LARGE ACADEMIC INTERNAL MEDICINE RESIDENCY PROGRAM

Alex Galloway, Dheepa Sekar, Shub Agrawal, Pamela Vohra-Khullar, Britt Marshall, Danielle Jones, Aakriti A. Arora, Dylan M. Baker. Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4064027)

SETTING AND PARTICIPANTS: Health systems are investing in informatics to address patients’ health and align with new quality focused reimbursement models. Resident physicians need training to use these Electronic Medical Record (EMR) tools. Teaching this skill in resident primary care (PC) clinic is challenging due to the time and structure of the ambulatory experience. While EMR tools had been implemented by our health systems, there was no prior curriculum available for residents. We implemented a population health curriculum at a large urban academic internal medicine residency program at three continuity clinic sites.

DESCRIPTION: We first delivered an introductory didactic on EMR population management skills. We then developed a longitudinal asynchronous curriculum for continued skill development. We identified target metrics based on resident learning needs and health system priorities; examples included hypertension, diabetes, and cancer screening. We emailed guides to each resident during their ambulatory week outlining steps to identify patients in need of intervention, and then to send targeted mass messages with recommended plans to those patients. Shared EMR phrases were created by attending leaders to facilitate communication. With the guide, residents collected de-identified data on the number of patients that met criteria for intervention.

EVALUATION: Our evaluation focuses on assessing resident knowledge, skills, and attitudes towards panel management and our curriculum’s impact on patient outcomes. To assess the impact on resident learning we are using surveys. To assess curricular impact on patient outcomes, we are measuring pre-and post-intervention adherence to screening guidelines within the resident clinics and collecting the number of patients identified on each residents’ panel. Our control group are residents who did not opt-into the longitudinal asynchronous curriculum. Preliminary data from the first two blocks suggests most residents are “not at all comfortable” or only “somewhat comfortable” with panel management.

DISCUSSION / REFLECTION / LESSONS LEARNED: The ambulatory setting presents unique challenges for teaching population health. Time constraints, frequent interruptions, and challenges with physician-patient continuity can make panel management difficult to prioritize. Yet, panel management also offers a critical opportunity to teach and assess skills in systems-based practice. We were able to integrate our novel curriculum into the clinic week without a significant increase in dedicated didactic time. The curriculum has also allowed us to create a more detailed assessment of resident skills of systems-based practice and practice-based learning and implementation in the ambulatory setting. Our curriculum does have limitations; barriers include resident time for asynchronous curriculum completion and EMR-based challenges such as accurate identification of PC Physicians. As we continue this curriculum, we are working to integrate more in-clinic time for panel management with attending support.

AN OUTPATIENT CASE-BASED REMOTE LEARNING CURRICULUM FOR INTERNAL MEDICINE RESIDENTS

Hannah Mallaro¹; Brianna B. Valdes^3,4; Elizabeth A. Scharle². ¹Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ³Internal Medicine, Northwestern Memorial HealthCare Corp, Tampa, FL; ⁴University of South Florida, Tampa, FL. (Control ID #4033189)

SETTING AND PARTICIPANTS: Internal medicine residents spend less time in the outpatient clinical setting compared to inpatient service and feel less prepared to treat common outpatient conditions. Formalized ambulatory didactics are a critical way to supplement clinical exposure to increase outpatient knowledge. Remote learning curriculums are an effective and scalable way to deliver content to residents. Our goal was to create an outpatient case-based remote learning curriculum for internal medicine residents at a large urban academic medical center. We hypothesized a case-based remote learning curriculum would be an effective way to improve knowledge and confidence in outpatient medicine.

DESCRIPTION: The study team defined six core ambulatory topics and wrote case-based lessons to review these topics. The six topics were cholesterol management for primary prevention, adult immunizations, breast cancer screening, depression, osteoporosis, and Medicare annual wellness visits. The lessons highlighted ambulatory content, electronic medical record instructions, and clinic workflow tips. All lessons were reviewed by a content expert at the institution for accuracy. Final lessons were loaded into Qualtrics for easy delivery to residents. First year residents completed the curriculum on a rolling basis during their two-week ambulatory rotation. Data was collected anonymously and participation in research was optional.

EVALUATION: Participants were asked to complete pre- and post-curricular assessments to evaluate knowledge of the six ambulatory topics and confidence in aspects of ambulatory medicine. Eleven residents completed their ambulatory rotation in our four-month pilot study. Eleven participants completed the pre-curricular assessment, and four participants completed the post-curricular assessment. The average score improved from 62% on the pre-curricular assessment to 77% on the post-curricular assessment (p=0.051). Self-reported confidence to manage cholesterol for primary prevention, osteoporosis, and Medicare Annual wellness visits on a 5-point Likert scale increased significantly after the curriculum. All students agreed the curriculum was helpful for improving outpatient medical knowledge and a good use of their time.

DISCUSSION / REFLECTION / LESSONS LEARNED: In this small pilot study, our case-based remote learning curriculum improved internal medicine residents’ knowledge and confidence on six core ambulatory medicine topics. The main limitations were the small pilot sample size and the low post-test response rate. We have expanded the curriculum to a larger group of residents this academic year and are implementing strategies to improve the post-test response rate. Our study adds to the growing body of evidence on the use of remote-learning curriculums in residency.

ONLINE RESOURCE URL: https://northwestern.az1.qualtrics.com/jfe/form/SV_a9uTgly0O3WryRg

A RANDOMIZED CONTROLLED TRIAL OF A NOVEL, PLANT-FORWARD CULINARY MEDICINE CURRICULUM FOR CARDIOVASCULAR DISEASE PREVENTION FOR PRIMARY CARE RESIDENTS

Nathan Wood¹; Maya Fussell²; Erica Lowenkron²; Lora Silver²; Erica S. Spatz¹; Dana Small¹; Rosemarie Fisher¹; Donna Windish¹. ¹Yale School of Medicine, New Haven, CT; ²Yale New Haven Hospital, New Haven, CT. (Control ID #4049188)

SETTING AND PARTICIPANTS: All 51 primary care residents at an academic medical center in New England participated in this randomized controlled study. Twenty-five residents were randomized to the intervention group and 26 to the control group.

DESCRIPTION: Both groups participated in a 45-minute discussion of the “Dietary Counseling in Primary Care” chapter of the Yale Office-Based Medicine curriculum followed by a 1-hour lecture on a plant-forward dietary pattern and its impact on lipids, blood pressure, and cardiovascular disease (CVD) risk. The intervention group received 1 hour of culinary medicine instruction in a “virtual teaching kitchen,” cooking together on Zoom and learning strategies for modifying recipes for heart-healthiness. The control group watched 1 hour of videos from the Nutrition Made Clear curriculum. Each group had a 30-minute discussion of how to apply the content to patient care and a 45-minute Q&A session with a registered dietitian.

EVALUATION: Surveys at baseline, immediate post-, and 8 weeks post-session assessed knowledge of how diet affects CVD outcomes and attitudes of addressing nutrition in patient care. Nutrition knowledge was assessed via multiple-choice questions. Confidence was measured on 6-point Likert scales. Attitudes were measured via a subscale of the Nutrition in Patient Care Survey (NIPS).

NIPS subscale scores did not differ from baseline to immediate post in the control group (mean score 33.1 to 34.3, p=0.08) but did in the intervention group (34.7 to 36.1, p=0.04). Nutrition knowledge scores increased significantly from baseline to immediate post in both groups (mean % correct 53.6% to 93.7%, p=0.001 for control vs. 60.0% to 92.2%, p=0.001 for intervention). Residents who “agreed” or “strongly agreed” that they felt confident discussing a plant-forward dietary pattern with patients did not significantly change from baseline to immediate post in the control group (27.3% to 68.4%, p=0.063) but did in the intervention group (8.3% to 73.9%, p<0.001). Percent of residents who felt confident providing patient-accessible dietary counseling for CVD increased significantly in the intervention group (8.3% to 52.2%, p=0.002) but did not in the control group (36.4% to 63.2%, p=0.453).

At 8 weeks post, 96% of all residents reported implementing something they had learned from the curriculum into caring for patients, and their nutrition knowledge scores remained high. All residents said they would recommend the curriculum to colleagues and wanted additional nutrition education.

DISCUSSION / REFLECTION / LESSONS LEARNED: Both culinary medicine and didactics-only nutrition education can be feasible, well-received, and effective in improving nutrition knowledge. Culinary medicine may be superior in improving learners’ attitudes about nutrition and confidence in providing dietary counseling.

As the ACGME considers instituting mandatory nutrition education for residents, similar didactic curricula may be effective, but culinary medicine education may be more potent.

ONLINE RESOURCE URL: rb.gy/mjqfep

ASSESSMENT OF A RESIDENCY RESEARCH TRACK FOR INTERNAL MEDICINE RESIDENTS

Gabrielle Martin¹; Brittany Tran^1,2; Mawulorm Denu³; Mark O'Connor⁴; Mara M. Epstein²; Timothy Fitzgibbons³; Lara Kovell^1,3. ¹University of Massachusetts Chan Medical School, Worcester, MA; ²Medicine, University of Massachusetts Chan Medical School, Worcester, MA; ³Cardiology, University of Massachusetts Chan Medical School, Worcester, MA; ⁴Endocrinology, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4064469)

SETTING AND PARTICIPANTS: Research training during residency promotes scholarship, opens opportunity for future careers, and can sustain research involvement of physician-scientists. With little evaluation of residency research programs, this study was designed to assess the impact of an internal medicine (IM) residency research track on residents’ knowledge and attitudes about research skills. A research track consisting of didactics and close mentorship was designed within the IM residency and implemented at an academic medical center. Interested participants applied for and matriculated into the first cohort of the research track (2022 – 2023). Of the ten participants, five were PGY2 residents and five were PGY3.

DESCRIPTION: Pre- and post-surveys were designed on RedCap and distributed to the first cohort of IM residents. The survey questions, ranked on a Likert Scale of 1-5, evaluated residents’ confidence with specific research skills and how important certain areas of research knowledge are for their career. The pre- and post-surveys were collected one year apart, after participation in mentored research and didactic sessions (100% survey completion). Post-survey responses were compared to baseline responses using a paired t-test.

EVALUATION: High mean baseline scores were observed for writing a manuscript background or discussion, writing/submitting abstracts, and creating oral presentations, while IRB submission, conducting basic analysis, and grant writing had lowest baseline scores. Mean scores increased for IRB submissions (pre-score (SD): (2.6 (1.1), Δ: 0.9), writing study protocols (3.0 (1.2), Δ: 0.6), designing blank tables (3.4 (1.5), Δ: 0.4), writing methods (3.4 (1.0), Δ: 0.5), and designing survey questions (2.9 (1.3), Δ: 0.9) on post-survey responses (all p < 0.05). No significant score decreases were noted.

DISCUSSION / REFLECTION / LESSONS LEARNED: Creation and implementation of research tracks in IM residency programs can improve research skills and overcome barriers to research during residency training. Our study demonstrates the baseline knowledge gaps and the increase in confidence in research skills through completion of research didactics and close mentorship. Future research tracks should provide a comprehensive approach in improving residents’ abilities to develop a research question, to design and execute a study, and to produce a manuscript.

ASSESSMENT OF CLINICAL INTEGRATION OF POINT-OF-CARE ULTRASOUND WITH AN OBJECTIVE STRUCTURED CLINICAL EXAMINATION

Nalinee C. Srisarajivakul-Klein^1,2; Isaac Holmes⁴; Jennifer Dong⁵; Aron Mednick⁷; Deborah Cooke⁶; Michael Janjigian³. ¹Hospital Medicine, NYU Grossman School of Medicine, Long Island City, NY; ²New York City Health and Hospitals Bellevue, New York, NY; ³Medicine, New York University Grossman School of Medicine, New York, NY; ⁴Internal Medicine, New York City Health and Hospitals Bellevue, New York, NY; ⁵Internal Medicine, New York University Grossman School of Medicine, New York, NY; ⁶DGIM, NYU Langone Health, New York, NY; ⁷Internal Medicine, NYU Langone Health, New York, NY. (Control ID #4059373)

SETTING AND PARTICIPANTS: For the past 4 years, we have taught PGY-2 residents basic skills in lung, cardiac, abdominal, and vascular point-of-care ultrasound (POCUS) based on national courses. Current methods of assessing POCUS skills focus on image acquisition and image interpretation without clinical context, however using POCUS for patient care requires the clinician to integrate their findings to a case. We developed an objective structured clinical examination (OSCE) to assess learners’ ability to obtain ultrasound images, simulate their scanning, and integrate images with data from a clinical scenario.

Thirty-seven PGY-2 residents at an urban academic program took the OSCE.

DESCRIPTION: The resident was presented with a patient case, then asked to obtain images from a human model. The preceptor would then show images from the actual patient via slideshow at the location the resident scanned.

The OSCE was scored via a 45-question rubric. Questions pertaining to anatomy were scored on a binary scale (yes/no). Quality of images were scored with a three-point scale (not done, partially done, well done), or ‘not attempted’ if the learner did not attempt the view. After the scans and interpretations were completed, faculty then asked the learner to generate a differential diagnosis and management plan. The two major findings from the case were bilateral pleural effusions and cardiac tamponade.

EVALUATION: In the lung portion of the case, learners focused mostly on the apices. Thirteen percent of learners did not attempt to view the left base, and 21% of learners did not attempt to view the right base; these learners would be unable to exclude pleural effusion. All learners scored a ‘Well done’ or ‘Partly done’ when interpreting clips. Based on these interpretations, they were able to generate 10 diagnoses on their differentials. Of these diagnoses, 5 of them were supported by the information provided. Five diagnoses were not.

All learners elected to scan the heart after receiving information that the patient was in shock. All residents except for one were able to obtain at least one interpretable image of the heart. All residents were able to articulate concern for tamponade except for one. All residents were able to generate a reasonable management plan.

DISCUSSION / REFLECTION / LESSONS LEARNED: This assessment revealed gaps in our curriculum’s ability to help the resident understand how to examine an organ system with POCUS. The major gap is incorrect use of systemic protocols to evaluate certain complaints. In scenarios where the finding is obvious even with one view, residents are able to apply the POCUS information to the case. If our goal is to fully ensure our residents are proficient in POCUS, then further work should focus largely on explicit instruction in scanning protocols. We acknowledge that some residents will self-select out from learning how to obtain ultrasound images. Despite this, our curriculum’s ability to help learners understand how POCUS can be useful and how to apply findings to a case seems to be effective.

BEYOND THE BOOTCAMP: A LONGITUDINAL JUST-IN-TIME CURRICULUM FOR SERIOUS ILLNESS COMMUNICATION AND HANDS-ON PROCEDURE SKILLS

Amanda Shepherd, Lisa Vande Vusse, Lindsay M. Gibbon, Susan E. Merel. Internal Medicine, University of Washington, Seattle, WA. (Control ID #4063734)

SETTING AND PARTICIPANTS: Ongoing intervention in a large academic Internal Medicine (IM) residency program. We evaluated interns participating in one module in the academic years 2020-2022.

DESCRIPTION: Many IM residency programs teach procedures during infrequent “bootcamp" sessions and do not have robust curricula in serious illness communication. We developed a Just-in-Time (JIT) curriculum for both invasive procedures (e.g. paracentesis) and serious illness communication procedures (e.g. leading a family conference). We addressed these topics synchronously across multiple Just-in-Time sessions to combat skill decay, deliver new timely skills immediately prior to a relevant clinical experience, and equally emphasize technical and communication skills. Guiding principles for this intervention are as follows: 1) JIT delivery of skills at an appropriate developmental level, starting in intern year with three workshops per year delivered in a small group on one of the first days of a rotation; 2) Using simulation to teach higher-risk, commonly used skills; 3) Using the highest fidelity simulation possible (e.g. commercial sim models and experienced actors) 4) Giving specific, actionable feedback in a safe learning environment; 5) Deliberate practice model of targeted, task-centered training.

EVALUATION: One hundred four interns participated in our Medical Intensive Care Unit (MICU) JIT workshop in 2020-2022. Interns had little prior experience placing a central venous catheter (CVC) (average 0.2 experiences) and facilitating a family conference (average 2.2 experiences), response rate 77%. Interns rated their self-perceived preparedness on a 5-level scale ranging from “not at all prepared” (1) to “very well prepared” (5). Seventy-two were complete pre-post pairs (69% response rate). Among those respondents, 8% of participants felt “well prepared” or ”very well prepared” to place a CVC and 9% to lead a family conference before the workshop; post-workshop 60% felt “well prepared” or “very well prepared” to place a CVC and 68% to lead a family conference (Wilcox and P pre-post comparison <0.0001). Ninety-four percent of interns “somewhat agreed” or “strongly agreed” that the skills gained from the workshop were a valuable trade-off to missing morning rounds and 100% of interns “somewhat agreed” or “strongly agreed” that practicing these skills at the beginning of the rotation made them feel more comfortable.

DISCUSSION / REFLECTION / LESSONS LEARNED: This workshop led to significant improvement in intern-perceived preparedness for both skills. With the success of the MICU JIT workshop, we adopted this model for procedure teaching and integrated 7 JIT workshops throughout residency with similar improved preparedness and confidence. While this intervention is resource-intensive, it has been fully embraced by residents and our program feels that it offers considerable benefits over other methods of teaching procedures.

BUILDING PRIMARY CARE COMMUNITY, DIVERSITY, AND LEADERSHIP THROUGH A CONSENSUS-BASED RESIDENT COUNCIL

Rachael Sharma¹; Senxi Du¹; Daniel C. Stokes¹; Sophie J. Rosenmoss². ¹Internal Medicine, University of California Los Angeles, Los Angeles, CA; ²Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4064648)

SETTING AND PARTICIPANTS: Volunteer resident leads implemented a Residency Committee (RC) in a primary care track at an academic medical center in California-Hawaii. Monthly meetings included residents across all three years, and quarterly meetings included residents, the Program Director, Assistant Program Directors, and Chief Resident.

DESCRIPTION: Resident satisfaction has been correlated with autonomy in learning, well-designed curricula, and work that promotes professional growth. An open-forum RC allows residents to build leadership skills while working toward initiatives they deem important, such as flexible curricula and diversity of future residency classes. In October 2022, we launched an RC with a consensus-based decision-making model and a horizontal leadership structure. We have used an iterative process to emphasize sustainability, accessibility, collaboration, and impact evaluation. We have developed a system of agenda setting, rotating meeting leads, residency-wide polls, and working groups to meaningfully change the culture and structure of the residency program.

EVALUATION: We collected process measures over time, including number of meetings, resident and faculty attendance, and meeting structure; outcomes measures including number and type of RC-supported projects; and qualitative feedback on residents’ experiences with the RC. The RC has hosted 14 monthly resident meetings and four quarterly joint resident-faculty meetings. Median attendance at resident meetings increased from three individuals in the first six months to five individuals in the second six months.

Working in small groups on projects based on interest, residents have completed seven projects, with six projects ongoing. Noteworthy projects include: (1) restructuring the ambulatory modules curriculum, (2) evaluating the primary care elective curriculum, (3) hosting a health equity-focused information session for program applicants, (4) re-designing the program website, (5) including senior residents in applicant review, and (6) advocating for increased time for resident-selected outpatient rotations.

The RC and its projects have received positive resident feedback. Residents who attended the medical student recruitment session felt rejuvenated reflecting on their and their peers’ passion projects stemming from the RC. Residents reported that the RC has allowed them to advocate for change and reminds them why they chose to train at their institution. RC activities have continued over two academic years despite membership graduation and turnover.

DISCUSSION / REFLECTION / LESSONS LEARNED: From this pilot experience, we found that an RC is a sustainable way to promote program improvement and resident fulfillment. Keys to implementation success include an open-forum meeting structure, resident autonomy to select projects, and faculty buy-in. Future directions include expanding the RC’s project portfolio and enhancing sustainability.

CLINICAL REASONING FOR ABNORMAL FINDINGS AND TESTS (CRAFT): BEST PRACTICES FOR PATIENT SAFETY AND PHYSICIAN WELL BEING

Melissa S. Lee^1,2; Lucas Dreamer^1,2; Scott McGarvey^1,2; Nadia A. Williams³; Olusegun B. Bankole^1,2; Seeta Chillumuntala^1,2; Madhavi Kolla²; Lavonne J. Valembrun^1,2; Hannah Friedman^1,2; Raphael Bergman^1,2; David Little^1,2; John F. Gibbons^1,2; David Stevens^1,2. ¹Ambulatory Medicine, Kings County Hospital, Brooklyn, NY; ²Internal Medicine, SUNY Downstate Health Sciences University, New York City, NY; ³Ambulatory Care - Primary Care, New York City Health and Hospitals Corporation, New York, NY. (Control ID #4064444)

SETTING AND PARTICIPANTS: We sought to improve timely communication of abnormal results to patients by 36 Internal Medicine residents at an urban safety-net resident primary care practice using clinical reasoning tools during dedicated ambulatory administrative time.

DESCRIPTION: Timely review and management of outpatient lab results is demanding. Stakes are high, as lapses can lead to diagnostic delays, resulting in patient harm and physician burnout. While this clinical responsibility is undervalued, it is essential. Effective management requires a) knowledge to identify abnormal tests reliably; b) clinical reasoning to plan next steps; c) communication skills to engage patients in shared decision making; d) accurate documentation.

Residents are less likely than faculty to report results to patients. A developing knowledge base, limited time, and competing clinical demands add to this performance gap.

Faculty designed CRAFT (Clinical Reasoning for Abnormal Findings and Tests) to: 1) recognize abnormal results, 2) triage need for patient/faculty notification, 3) suggest appropriate follow up testing/referrals, 4) select optimal means of outreach, 5) guide communication. Residents learned CRAFT and were assigned 3 hrs/wk for ambulatory result management.

Residents behaviors around in basket management were surveyed. 134 charts were reviewed (67 before CRAFT and 67 after) and evaluated for abnormal result communication (timing, type, clinical reasoning, need for patient/faculty contact).

EVALUATION: Most common abnormal results were new diagnoses of pre-diabetes (n= 62, 46.3%) / diabetes (n=11, 8.2%) and uncontrolled diabetes (n=14, 10.4%).

When comparing self-reported behaviors (unpaired groups),more results were discussed with faculty χ(1) = 4.126, p = 0.042 and documented as in the EMR χ(1) = 8.651, p = 0.003 after CRAFT. Knowledge to manage results (U=420, p=0.004), time for result review (U=354, p=0.001) and confidence in “taking good care of my patients” (U=457, p=0.038) improved. No differences were observed in comfort speaking with faculty, importance for managing abnormal labs, or need for additional help managing results based on Mann-Whitney tests.

Initially, documentation of abnormal lab communication occurred 48% (32/67) of the time; compared to 73% (49/67) after CRAFT. Results communicated through the EMR changed from 6% (4/67) to 49% (33/67). Phone calls were more commonly used; 7% (5/67) initially vs 16% (11/67). Fewer waited until follow up to disclose results 34% (23/67) vs 7% (5/67). More residents documented clinical reasoning, χ(1) = 10.05, p = 0.002.

DISCUSSION / REFLECTION / LESSONS LEARNED: Cultivating clinical reasoning, communication skills and building rapport outside scheduled clinical encounters should improve patient relationships, enhance professionalism, and improve resident well being.

CRAFT improved communication of test results by giving residents the tools and time to connect in informed and meaningful ways.

CREATING AN INTERACTIVE AND PRACTICAL HEALTH POLICY AND ADVOCACY CURRICULUM FOR RESIDENT PHYSICIANS

Apoorva Ram¹; Beret Fitzgerald¹; Megan Mayer^1,2. ¹Internal Medicine, University of Colorado, Denver, CO; ²Department of Medicine, VA Eastern Colorado Health Care System, Aurora, CO. (Control ID #4064378)

SETTING AND PARTICIPANTS: The intended audience is internal medicine residency faculty interested in developing a health policy and advocacy curriculum, irrespective of program size or academic affiliations.

DESCRIPTION: As schools and residency programs create more advocacy curricula¹, we must create effective engagement methods. Residents lack confidence in health policy and advocacy but want to engage^2,3 and two-thirds of practicing physicians report participating in civic engagement.⁴ This underscores the many calls to advance advocacy and health policy in medical education^5–8, including from the ACGME.⁹ Curricula to fill this gap vary widely in scope and effectiveness,^1,10–14 with little data on the most effective way to teach.¹

Our curriculum covers health policy basics, payment models’ effects on costs and patient care, immigrant health, and advocacy. Our novel approach to teaching advocacy includes a broad advocacy framework, a hands-on workshop, and an online toolkit. The workshop mimics a longitudinal advocacy project "on fast forward”. For example, small groups are given a problem statement: “unequal access to diabetes medications”. They choose two out of three pre-determined options to begin their project and receive a handout summarizing that choice. They create a “one-pager” and action items. This creative workshop aims to improve engagement and retention of material, improve residents’ comfort with health policy and advocacy, and promote advocacy projects.

EVALUATION: We created a needs assessment based on existing policy and advocacy curricula in medical education^{2,3,19–22,10,11,13–18} and expert review to address normative, prescribed, expressed, and unperceived needs within our program.²³ Questions addressed the importance of training in health policy and advocacy, desirability and comfort with content, and likelihood and preparedness of conducting advocacy.

83 residents (response rate of 43%) completed the survey between 7/3/23 - 8/14/23. Curriculum content was chosen by pooling the two highest responses to specific content areas on a likert scale. All residents felt it was important to receive training in the basics of healthcare policy and advocacy. However, 38% were “not at all” prepared to advocate for a specific policy issue on a patient’s behalf, and 49% were unlikely to research a problem rooted in public policy for a patient they were caring for. We plan to conduct post-test surveys assessing initiation of advocacy projects and improvement in preparedness.

DISCUSSION / REFLECTION / LESSONS LEARNED: This group explored residents’ policy and advocacy interests and created a novel curriculum. Further innovation and evaluation of teaching methods are needed to identify the most effective ways to inspire and support the future physician workforce.

*Full reference list, corresponding to in-text citation, available on request.

ONLINE RESOURCE URL: https://www.dropbox.com/scl/fo/djwxbtdqeqklebf9s916r/h?rlkey=wzi8hu3spz3zngofro1tlzwg0&dl=0

DESIGN AND IMPLEMENTATION OF A POPULATION HEALTH CURRICULUM FOR INTERNAL MEDICINE RESIDENTS IN A PRIMARY CARE CONTINUITY CLINIC

Kevin Chang, Ilana R. Yurkiewicz, Kim F. Chiang, Anuradha Phadke. Medicine, Stanford University School of Medicine, Stanford, CA. (Control ID #4061012)

SETTING AND PARTICIPANTS: An academic medical center residency primary care clinic, consisting of 55 internal medicine residents, 21 attendings, and serving 4398 patients.

DESCRIPTION: We implemented a new population health curriculum in May 2023 to increase resident education as part of the ACGME core competency of systems-based practice. We layered the curriculum into an existing continuity clinic block rotation, a 2-week full-day primary care rotation for residents.

Our didactic objectives included:

1. Analyzing population health data for patient panels.

2. Utilizing EHR tools to address care gaps and learn panel management.

Through our instructional materials and with one hour of protected time daily, residents conducted the following exercises:

1. Coordinated care: Using EHR reports, residents identified patients with high care gaps and worked with clinic staff to arrange appointments.

2. Metric-specific outreach: Residents used training guides to conduct metric-specific outreach to their patient panels.

3. Post-curriculum survey: Residents reported numbers of patients seen, provided examples of meaningful patient encounters, and offered curricular feedback.

EVALUATION: In the first six months, we observed increased engagement in population health among the 13 participating residents. All were able to complete the three exercises. On average, residents saw 2-3 of their own high care gap patients in clinic during the rotation. In some cases, follow-up with these patients was arranged post rotation.

Qualitative feedback from the post-curriculum survey was consistently positive. Residents appreciated learning EHR tools for panel management, such as viewing of population health dashboards, bulk messaging, and data abstraction. Another common theme was an appreciated opportunity for motivational interviewing. One resident counselled a patient on tobacco cessation by phone and ultimately initiated varenicline. Another resident counseled a patient on cervical cancer screening and helped a previously reluctant patient undergo a Pap smear.

DISCUSSION / REFLECTION / LESSONS LEARNED: We identified several factors crucial to implementing a novel population health curriculum for residents. One was time; residents found having uninterrupted time devoted to panel management to be crucial in maximizing this curriculum. Another was providing specific task-oriented directions; residents appreciated having training materials that provided framework for how to approach each metric. Understanding panel management logistics then allowed trainees to extrapolate their learning to other arenas of population health.

Feedback from residents also consistently highlighted the importance of EHR training specific to population health and has called for the inclusion of such EHR training into the broader primary care resident curriculum. Future work includes development of a population health EHR toolkit and expansion of opportunities for residents to collaborate with care coordination personnel in the greater healthcare system.

DEVELOPING FUTURE LGBTQIA+ HEALTH LEADERS THROUGH SKILLS-BASED SEMINARS

Son Quyen H. Dinh¹; Eli Goldberg³; Justine Monthony-Eaton⁴; Lisa MacVane⁴; Jennifer Potter². ¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Harvard Medical School, Boston, MA; ³Beth Israel Deaconess Medical Center, Boston, MA; ⁴Fitchburg Family Medicine Residency, University of Massachusetts Chan Medical School, Fitchburg, MA. (Control ID #4063893)

SETTING AND PARTICIPANTS: An LGBTQIA+ Health Graduate Medical Education (GME) Task Force was formed as part of the development of an LGBTQIA+ Health Fellowship at an academic medical center. This task force, composed of over 25 physicians, researchers, and public health specialists across 10 specialties, developed a list of seminar topics via iterative consensus. Expert faculty were designated for each topic and created seminar outlines with learning objectives, agendas, active learning modalities, and pre- and post-seminar work. Over one year, trainees participated in 22 interactive seminars and produced portfolios of scholarly deliverables.

DESCRIPTION: Seminars incorporated longitudinal curricula about health equity and disparities; research methods; community engagement; health program development; health education; quality improvement; leadership development; and health policy and advocacy. Trainees completed preparatory work including readings, audio/video recordings, and online learning modules. Seminars were 2.5 hours long and incorporated learning formats including lectures, expert panels, small-group discussions, and simulations such as a quality improvement process flow analysis and a group peer review. Seminar post-work produced scholarly deliverables as detailed below.

EVALUATION: One fellow and three PGY3 residents participated in the seminar sequence and provided qualitative feedback after each seminar using a “Keep/Toss/Create” format. Trainees completed longitudinal health equity leadership projects and produced scholarly deliverables including an elevator speech, pitch deck, small grant proposal, foundational LGBTQIA+ health curriculum, LGBTQIA+ health program budget, mentored peer review, clinical quality improvement project, presentations, and publications.

DISCUSSION / REFLECTION / LESSONS LEARNED: Qualitative feedback from trainees highlighted the strengths of the seminar curriculum including the development of practical skills for future careers, valuable mentorship, and a wide range of topics. Identified areas for improvement were reassessing the feasibility of deliverables given time constraints and streamlining preparatory work. Future development of the seminar curriculum will involve ways to individualize the learning to each trainee’s interests. These seminars reflect the importance of advanced curriculum outside of clinical training to cultivate leadership skills to promote LGBTQIA+ health equity.

DEVELOPMENT OF A RESIDENT-DRIVEN COMMUNICATIONS CURRICULUM TO NAVIGATE CHALLENGING CONVERSATIONS

Geralyn Palmer, Sarah L. Floden, Kelsey Holbert, Amir Forati, Sara Johnson, Jeremy Smith. Department of Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4031109)

SETTING AND PARTICIPANTS: Four workshops were conducted in 2022 and in 2023, each workshop with 8-9 participants and 3-4 Internal Medicine faculty or fellow facilitators. A total of 26 Internal Medicine interns in 2022 and 29 in 2023 participated.

DESCRIPTION: A resident-driven pilot curriculum was implemented in 2022 which included a short pre-reading and a one hour in-person session comprised of didactics, a standardized patient (SP) demonstration, and partner practice. Resident feedback indicated interest in further practice through SP encounters; therefore, the 2023 curriculum was revised to include three SP encounters. The 2023 sessions were composed of 30 minutes of didactics and 90 minutes of SP encounters. The didactic session introduced communication microskills including the SPIKES and NURSE mnemonics. Each SP encounter included ten minutes for the encounter and ten minutes for feedback. SP clinical scenarios included (1) discussing a probable new malignancy diagnosis, (2) calling a family member overnight regarding clinical deterioration, and (3) caring for a distressed patient with chronic back pain. Interns were divided into groups of two to three and rotated through each encounter. Feedback was standardized to include perspectives from the SP and observing interns. In addition, the observing faculty/fellow mentor used a communications rubric developed for these sessions to provide feedback and facilitate discussion.

EVALUATION: Survey data was collected before and after each workshop, with participants providing responses on a Likert scale. Visual analysis of 2022 survey results by bar plot indicates an observed increase in confidence related to navigating challenging conversations. However, the Wilcoxon signed-rank test revealed no statistically significant difference (Z=5.0, p=1.0). Among the 26 interns, seven (29.2%) suggested further interactive practice in future sessions. Visual analysis of 2023 survey results by bar plot demonstrates a comparable increase in both confidence and comfort. However, like the 2022 results, this was not statistically significant (Z=5.0, p=1.0; Z=4.0, p=0.715). Notably, 100% of 2023 respondents felt this session should be continued for future years.

DISCUSSION / REFLECTION / LESSONS LEARNED: We trained interns to navigate challenging conversations while experts and peers provided real-time feedback. This was a well-received communication skills workshop, with 100% of individuals recommending continuation for the future. While analysis of the pre and post session surveys demonstrated a trend towards improvement in both confidence and comfort, this was not statistically significant, likely due to small sample size. Cost and protected time were perceived barriers to successful project implementation but were addressed with grant funding and dedicated didactic time from the residency program. Future directions include disseminating curriculum to other residency programs within our hospital system, creating a directory of interested faculty mentors, and expanding fellow facilitator involvement.

EMERGENCY MANAGEMENT IN INTERNAL MEDICINE: PILOT EDUCATIONAL PROGRAM

Jacqueline Savage^1,2; Patrick LaBuff³. ¹Medicine, Hartford Hospital, Hartford, CT; ²Medicine, University of Connecticut School of Medicine, Farmington, CT; ³Emergency Management, Hartford Hospital, Hartford, CT. (Control ID #4019072)

SETTING AND PARTICIPANTS: Tertiary care hospital setting with Internal Medicine residents and established emergency management department.

DESCRIPTION: Working with our emergency management department at one of our main teaching sites, we drafted a half day curriculum on the basics of emergency management. Our goal was to introduce the topic, its utility and application in healthcare as well as how internal medicine physicians are a critical component of incident management. This was delivered in a 1 hour lecture. This lecture was then followed by a 1.5 hour table top excercise in which the trainees were walked through a real world incident and go through the steps of emergency management to prepare, respond, and recover.

EVALUATION: We performed a pre and post-test with each session delivered. Out of 74 PGY-2 or 3 trainees, 84% have had no education in emergency management and only 27% of them have heard of emergency management as a component of healthcare. After the training, 88% requested more training on the topic to include hands on simulation as well as interdisciplinary training with fire, police, ems etc. 81% of respondents felt that residency programs need a disaster team on standby and 93% of them said "yes or maybe" when asked if they would volunteer to participate on the disaster team.

DISCUSSION / REFLECTION / LESSONS LEARNED: As internists, disaster and emergency planning are not a standard part of our core curriculum in medical school or residency training. As a result many internal medicine physicians do not find themselves well equipped to handle a large casualty or disaster events. Mass casualty events have grown exponentially in the United States with as many as 686 mass shooting incidents in 2021 alone as well as more complex domestic cases. There are also increasing natural disasters with higher magnitude storm surges due to recent climate change trends. It is critical to equip our physicians with a common language and strategies to be able to assist in a way which is helpful beyond the care at the bedside. Our Emergency Medicine colleagues have been integrating disaster management as part of their standard training for years. They must be able to "understand and apply the principles of disaster and mass casualty management including preparedness, triage, mitigation, response, and recovery." Our pilot educational series elevates our resident’s education to become more familiar with emergency management topics. Our next evolution of the pilot is scheduled to then take the knowledge gained and apply it to a simulated critical incident event and reinforce the concepts learned in preparedness, mitigation and response. Our data shows that our learners see the need and understand the reality of the world we practice medicine in and want to be prepared to lead in the response when the time arises. We hope to set the model for future programs to incorporate emergency management into their undergraduate and/or graduate medical education.

EVALUATING A SERVICE-LEARNING CURRICULUM IN AN INTERNAL MEDICINE RESIDENCY PROGRAM

Ines M. Robles Aponte, Maria H. de Miguel, Justine Phifer. Medicine, Columbia University, New York, NY. (Control ID #4060328)

SETTING AND PARTICIPANTS: All internal medicine residents at an urban academic medical center primarily serving a low-income, Hispanic/Latino patient population. The initiative is led by an interdisciplinary team including primary care physicians, nutritionists, and members from the local community.

DESCRIPTION: Social determinants of health (SDOH) have a significant impact on health outcomes. The Accreditation Council for Graduate Medical Education has emphasized the importance of residents understanding the SDOH of the populations they serve. Service-learning has demonstrated potential in teaching SDOH in non-medical fields. It combines community service with academic instruction to provide learners with practical experiences while addressing community needs. However, there is a lack of evidence supporting the implementation of service-learning in graduate medical education (GME). We aim to understand resident experiences and perspectives on the impact of service-learning and whether it informs their future practice.

Our institution conducted a Community Health Needs Assessment that identified food insecurity, substance use disorders, and housing insecurity as prevalent issues among our patient population. In August 2023, we implemented a service-learning curriculum that focuses on these issues. Primary care physicians, nutritionists, and community leaders collaborated in designing and implementing the curriculum.

First and 2nd year residents participate in activities related to food insecurity and nutrition. They attend didactic sessions, take a neighborhood walking tour, and volunteer at a food pantry. Third-year residents learn about substance use and housing insecurity through lectures, visits to harm reduction facilities, and health talks at homeless shelters.

EVALUATION: By the end of this academic year, 144 residents will have completed the service-learning activities. Following completion, residents will be invited to voluntary focus groups using a semi-structured interview guide. The questions will align with the transformational learning theoretical framework, which examines how experiences contribute to shifts in learners' beliefs, values, and perspectives. We will explore experiences and attitudes toward SDOH.

DISCUSSION / REFLECTION / LESSONS LEARNED: Service-learning has been shown to have a transformative effect on students in areas outside of medicine. The full scope of the impact of integrating service-learning into GME to more fully understand the social determinants of health has not been captured in previous research. Focus groups with analysis of resident responses using qualitative research methods can explore a broader range of experiences and reactions. We anticipate that the insights gained through this study will establish the value and inform the design and implementation of future service-learning programs in the field of GME. Key lessons learned include the importance of flexibility and open communication in fostering successful long-term partnerships with members of the community.

EVALUATION OF A LONGITUDINAL, MULTI-MODAL CURRICULUM ON THE IMPACT OF CLIMATE CHANGE ON POPULATION AND INDIVIDUAL HEALTH IN THE PRIMARY CARE TRACK OF AN INTERNAL MEDICINE RESIDENCY: LESSONS FROM RESIDENT FOCUS GROUPS

Mehul Tejani, Irene Liu, Madhu Manivannan. Medicine, Emory University School of Medicine, Decatur, GA. (Control ID #4065000)

SETTING AND PARTICIPANTS: There is a growing movement to teach medical trainees and residents about the effects of climate change on human health. Open-source databases of curricular content and research on the implementation of curricula have increased integration of climate & health content into medical school and residency education, though few programs have evaluated a dedicated, longitudinal curriculum for internal medicine residents. While some research has assessed medical students’ attitudes on these integrated curricula, little is known about the resident perspective. Our study used focus groups to investigate primary care track internal medicine residents’ evaluations of a longitudinal, multi-modal planetary health curriculum.

DESCRIPTION: The authors conducted focus groups with the first group of third-year internal medicine residents on the primary care track who completed the longitudinal planetary health curriculum. The curriculum was designed to start with basics on climate change, how it affects human health, what steps can be taken in the clinic, and finally expanding to advocacy for systems and policy change. The focus groups assessed residents’ perspectives across five domains focusing on design and impact of the curriculum. The authors analyzed focus group transcripts using an inductive thematic content analysis approach.

EVALUATION: All (n= 8) third-year internal medicine residents on the primary care track at an academic hospital participated in two focus groups. Four major themes were elicited from the focus groups, with strengths and weaknesses of the curriculum identified in each. Residents appreciated transitioning from foundational concepts in climate and health to more nuanced concepts that built upon previous content as well as tangible action items to incorporate climate-informed guidelines in patient care. Residents desired increased opportunities to receive direct feedback from preceptors regarding content and quality of climate counseling to patients as well as more information about advocating for greener health systems at individual patient, healthcare system, and local county levels.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our study offers rich perspectives from internal medicine residents on the most impactful aspects of an integrated planetary health curriculum. Future curricula should include concrete takeaways to inform clinical patient encounters, avenues to advocate for more climate-resilient healthcare systems, and continued opportunities to learn about planetary health. Given the growing understanding of the impact of climate change on health, this study confirmed the desire amongst trainees to obtain education on the topic. The information obtained will be used to expand the program to all categorical residents. It may also serve as a basis to inform faculty development programs to address educators' gaps in knowledge to help better teach our learners.

FACULTY CHALLENGES IN INTEGRATING POCUS INTO AN INTERNAL MEDICINE RESIDENT CLINIC

Zachary Boggs¹; Rachel H. Kon²; Christopher Thom⁴; James R. Martindale³. ¹Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA; ²Medicine, University of Virginia School of Medicine, Charlottesville, VA; ³Medical Education, University of Virginia, Charlottesville, VA; ⁴University of Virginia School of Medicine, Charlottesville, VA. (Control ID #4063435)

SETTING AND PARTICIPANTS: Internal Medicine Resident Clinic, Supervising Faculty

DESCRIPTION: Point-of-Care Ultrasound (POCUS) has been integrated into daily practice in emergency medicine. Within Internal Medicine (IM), there have been similar curricula on POCUS in the hospital setting, but few institutions have introduced POCUS into the primary care setting. One cause for slow adoption in ambulatory setting is the large gap between faculty experience and learner interest. Our study assessed the utilization of POCUS into a IM resident clinic after hands-on faculty training. We held two optional hands-on POCUS training sessions for our resident continuity clinic attendings including a didactic on abnormal scans. Emergency department faculty led these workshops with standardized patients. One week after the training, participants were asked to complete a survey to assess attitudes and self-efficacy. An Epic smartphrase was developed to document POCUS exams and track utilization.

EVALUATION: 12 out of 15 clinic attendings participated in at least one of the sessions. All 12 completed the survey. Prior POCUS exposure was minimal. 92% of faculty thought POCUS would be at least moderately helpful in clinic. Half of participants felt comfortable operating the handheld ultrasound after the training. Those that attended both hands-on sessions felt more comfortable in operating the ultrasound (U=29, p=0.042). The majority felt they would at least use POCUS to assess post-void residuals and skin pathology. Fifty percent felt they would be willing to practice POCUS with residents and give feedback using direct observation. Prior ultrasound training was not significantly associated with perceived use of POCUS more than once weekly (χ2, 1, n=12, p=0.157), comfort in using the ultrasound (U=21, p=0.309), or comfort evaluating residents (U=21, p=0.335). Only 5 unique attendings used the smartphrase in the 8 months post-training for a total of 30 occurrences. Only 3 individuals used the smartphrase more than three times.

DISCUSSION / REFLECTION / LESSONS LEARNED: Integration of POCUS in an IM resident clinic has been challenging, despite multi-day faculty training. There was high interest and engagement in the training, and most thought POCUS would be helpful at our clinic. However, self-reported confidence was lacking after the training, and there was minimal evidence of POCUS utilization by most participants as captured by the smartphrase. Interestingly, prior POCUS training did not correlate with more comfort in using POCUS in practice, though study power was limited. Our study suggests that similar resident clinics should provide more training to select faculty with high interest as designated POCUS “champions.” Although it is reasonable to expose all clinic faculty to POCUS, it is not realistic to train the majority to competence. In the future, we will encourage additional training for interested “champions.” We have begun outpatient POCUS training for the residents and hope this will encourage further clinical integration.

HOW TO DESIGN IT SO THEY WILL COME: A MULTICENTER STUDY OF A GAMIFIED JOURNAL CLUB FORMAT

Steven Allon¹; Alan Baggett⁶; Benjamin Hayes⁵; Preston Seaberg³; Jesse Faulk⁶; Reem Al-Dallal⁴; Amna Anees³; Ryan Kraemer². ¹Medicine, Vanderbilt University Medical Center, Nashville, TN; ²Medicine, University of Alabama at Birmingham, Birmingham, AL; ³Internal Medicine Charleston Division, West Virginia University, Morgantown, WV; ⁴The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX; ⁵Northside Hospital Inc, Atlanta, GA; ⁶UAB School of Medicine Huntsville, Huntsville, AL. (Control ID #4023722)

SETTING AND PARTICIPANTS: Residents at five US internal medicine residency programs engaged in a 12-month gamified journal club curriculum between July 2018 and June 2023.

DESCRIPTION: Each program adopted a 12-month gamified journal club format featuring 1-2 orientation sessions and 6-10 monthly competition sessions. Before implementation, each program utilized a traditional journal club format in which one resident presented a critical appraisal of a faculty-assigned article.

In the orientation phase, residents were introduced to the format, practiced conducting a literature search, and learned the foundations of critical appraisal. Subsequently, residents were divided into two competing teams.

For each competition, 2-4 residents from each team were chosen to participate. Two weeks before, groups received an email with a patient scenario and a clinically relevant question. Each group selected a unique empirical study to answer the question. In the 1-hour competition, each group critically appraised its study and discussed its applicability to the patient scenario. A faculty discussant led a critical review and provided a brief didactic on a biostatistical topic relevant to the studies (e.g., blinding versus allocation concealment). Didactic topics were drawn from a 30-item concept map developed by the authors, aligned to the five-step model of evidence-based practice as defined by the Sicily statement.

A winning group was selected for each session and awarded a nominal prize. A cumulative score was tallied for the larger competing teams. At the end of the academic year, residents from the winning team received a meal catered by the program and/or an inscription on a rotating novelty trophy.

EVALUATION: Participants were surveyed before and after the intervention. The authors developed a de-novo survey to assess engagement dimensions on a Likert-type scale. A paired samples t-test was conducted to compare baseline and post-intervention responses.

The response rate was 65.2% with paired responses from 107 residents. Residents reported significant improvements in most engagement dimensions, including the perceived value of journal club (p<0.001), increased pre-session article reading (p=0.001), and enhanced confidence in literature searches and critical appraisal presentations (p<0.001). In one program (n=25), the survey was repeated annually for three years, demonstrating sustained but attenuated improvements in item-level responses.

Two programs (n=61) used the Berlin Questionnaire to assess critical appraisal skills, demonstrating an increase from 34.3% to 39.9% in correct responses after the intervention (p=.02).

DISCUSSION / REFLECTION / LESSONS LEARNED: Our results demonstrate that a gamified journal club format led to short-term and lasting improvements in resident engagement, coupled with modest gains in critical appraisal skills. Outcomes were consistent across programs diverse in size, schedule structure, and university affiliation.

ONLINE RESOURCE URL: https://drive.google.com/drive/folders/13Z358tmwfKcQ7Zf3TxDlfkgnibInrlsD?usp=sharing

IMPACT OF A PILOT WOMEN'S HEALTH CLINIC IN A CATEGORICAL INTERNAL MEDICINE RESIDENCY

Zaina Siraj¹; Isam Albaba⁴; Michelle R. Kobou Wafo³; Megan R. Gerber^1,2. ¹Albany Medical College, Albany, NY; ²Albany Stratton VA Medical Center Albany, Albany, NY; ³Department of Medicine, University of Wisconsin System, Madison, WI; ⁴Pulmonary and Critical Care, Lewis Katz School of Medicine at Temple University, Philadelphia, PA. (Control ID #4064033)

SETTING AND PARTICIPANTS: Medium-sized Categorical Internal Medicine Residency in Upstate New York

DESCRIPTION: Cervical cancer screening is a critical internal medicine (IM) competency, but many residencies struggle to provide training on this and other women's health topics. We identified this deficiency in our program along with high referral rates to gynecology which can create barriers to screening for women. Our quality data demonstrated a 14% gap in cervical cancer screening rates between Medicaid and commercially-insured women.

In response, we developed a pilot women’s health clinic (WHC) to enhance resident training and improve access to care. Patients overdue for cervical cancer screening were identified through electronic quality data. During the pilot phase (academic year 2022), the WHC provided routine women’s health care within the scope of IM, most referrals were for pap smears. Each session consisted of 1:1 time with IM faculty, and use of the "Limbs and Things" Female Pelvic Trainer which enabled residents to practice pap testing and bimanual exams before seeing patients.

EVALUATION: Prior to the pilot, we surveyed IM residents (72% response rate, n=25), regarding perceptions of women’s health training and clinical skills using a 5-point Likert scale. Results revealed a need for training; 85% of residents had never performed pap smears, 94% gave a score of 2 or less out of 5 when asked about amount of women’s health training in the program, and half reported not receiving any training during residency.

During the pilot, we saw 50 patients (mean age 52, 51% overdue for cervical cancer screening). Patients expressed high satisfaction with being seen at their usual site of care.

The post-survey (85% response rate, n=26) demonstrated improved access to women’s health education and increased confidence in management. 47.4% reported performing at least 2 pap smears, and 68% gave a score of 3 or more out of 5 for the amount of women’s heath training in the program. The proportion of residents reporting non-receipt of women’s health training decreased to 22.7%.

DISCUSSION / REFLECTION / LESSONS LEARNED: The pilot WHC in our IM residency practice was a first step to bridging gaps in both patient care and resident education. We expanded cervical cancer screening and reduced the screening disparity between Medicaid and commercially-insured women to 8% as resident and attending physicians began to offer cervical cancer screening during routine care sessions (outside the WHC). The mean age of 52 indicates that our WHC served women at highest risk for cervical cancer who were not in usual care with gynecology specialists.

The survey results suggest increased resident competency in women’s health management. Additionally, increased resident engagement in cervical cancer screening during routine health maintenance exams minimized the need for specialized healthcare visits and reduced patient wait times. The next WHC phase will continue the same model with a focus on certifying residents to train and support those who are not yet competent.

IMPACT OF STRUCTURED POCUS TRAINING DURING INTERNAL MEDICINE CLERKSHIP AND RESIDENCY TRAINING

Barath Rangaswamy¹; Sulaiman Karim²; Kelly Trinh²; Meron Tesfaye²; Lutfor Nessa³; Srikanth Mukkera^4,3. ¹internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²school of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ³Internal Medicine, Texas Tech University Health Sciences Center Permian Basin, Odessa, TX; ⁴Rheumatology, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX. (Control ID #4064922)

SETTING AND PARTICIPANTS: We are a single campus US medical school. This study evaluated the impact of POCUS ( Point of Care Ultrasound ) training we implemented in the rheumatology elective of IM ( Internal Medicine ) clerkship and residency training. Ten medical students and 25 IM residents participated in this training.

DESCRIPTION: Structured, hands-on POCUS training was introduced in the office based rheumatology elective during academic year 2022-23 as a curriculum development initiative.

EVALUATION: Third and fourth-year medical students, along with first-year internal medicine residents who finished their rheumatology elective completed voluntary online surveys assessing their confidence and comfort with POCUS. The survey utilized a 5-point Likert scale questionnaire of 14 questions. We used Fisher’s exact to compare responses and set α = 0.05 a priori for hypothesis testing.

The survey,completed by 25 residents and 10 medical students, found 84% of residents and 90% of students rate POCUS training as valuable or very valuable. Both groups exhibited greater confidence in identifying knee joint effusion (average scores: 3.5 for students, 2.6 for residents), in contrast to their confidence levels with various ultrasound techniques and pathology identifications. Confidence was lower in hip ultrasounds (2.20 for students, 1.68 for residents) and chondrocalcinosis identification (2.20 for students, 1.76 for residents). Among the participants, 28% of residents and 70% of medical students reported receiving prior informal POCUS training in settings such as the ICU, ER and ward rotations. Previous POCUS education correlated with significantly higher comfort levels, with average scores of 2.86 for students and 2.30 for residents, compared to 2.69 and 1.91, respectively, for those without POCUS education (P-values: 1.11e-09 for students, 1.09e-12 for residents).

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DISCUSSION / REFLECTION / LESSONS LEARNED: Point of Care Ultrasound (POCUS) has emerged as a vital tool in diagnosing rheumatological disorders, detecting osteophytes and joint effusion. Its integration in rheumatology electives during IM clerkship and residency remains limited. While traditionally, POCUS education is focused in pre-clinical years, its incorporation into clinical year training remains less established, reflecting a relative paucity in the literature. This gap underscores the need to consider POCUS education as a potential tool to enhance the clinical skills of medical trainees. The survey results highlight the value of POCUS training in clinical education, as both medical students and residents rate it highly. Notable variations in confidence across different ultrasound procedures were observed, especially in hip ultrasounds and knee chondrocalcinosis identification, indicating training gaps. Analysis revealed POCUS experience prior to training in the rheumatology elective significantly enhances confidence and comfort in both groups, reinforcing the need for early, comprehensive, and targeted POCUS training in medical curricula to address proficiency gaps.

IMPLEMENTATION OF HOSPITALIST ELECTIVE FOCUSED ON VISITING EXTERNAL RESIDENT PHYSICIANS

James T. Boothe, Phillip Wagner, Sonia Dalal. Department of Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4058537)

SETTING AND PARTICIPANTS: Our innovation was implemented at an urban tertiary academic medical center. This hospitalist elective is focused on providing visiting PGY-3 Internal Medicine resident physicians from external institutions with the opportunity to be immersed in the work of an academic adult hospitalist to both help prepare them to be competitive applicants for early-career academic hospitalist faculty positions and to be more professionally prepared for stepping into that clinical role. Our innovation especially provides a venue for PGY-3 trainees at community-based residency programs to experience the practice of inpatient medicine within the medically complex, well-resourced setting of a major academic referral center.

DESCRIPTION: We implemented a 4-week clinical elective for PGY-3 Internal Medicine resident physicians rotating from residency programs external to our own tertiary teaching hospital. The elective involves two principal components. Firstly, the elective puts the rotating resident directly onto an inpatient Hospital Medicine service where the resident works one-on-one under the clinical supervision of a faculty academic hospitalist. In this setting, the resident is given a very high degree of autonomy (compared to a typical inpatient teaching service with multiple levels of trainees involved) in order to simulate the daily work of an attending physician. And secondly, the elective includes didactics, seminars, and workshops focused on topics relevant to the early-career academic hospitalist. These topics of focus are: High-value care, Antibiotic stewardship, Hospital economics, Inpatient coding/billing & reimbursement, Medicine consults & perioperative medicine, Interfacility triage & utilization management, Discharge & post-hospitalization planning, and Contract negotiation & career development for the hospitalist.

EVALUATION: This innovation will be evaluated via pre/post surveys of the elective participants. This is expected to aid us in improving on the elective based on feedback. Additionally, we will follow up with elective participants after they have completed residency training to track their post-residency career outcomes.

DISCUSSION / REFLECTION / LESSONS LEARNED: The role of the academic hospitalist arose in response to the needs of academic medical centers and their associated medical schools and Internal Medicine residency programs. While the career of the academic hospitalist can be attractive to many resident physicians, the barrier to entry into an academically-focused hospitalist position for an early career internist can be quite imposing for a variety of factors, such as training at a community-based residency program or having limited experience in more autonomous inpatient care. Our innovation has successfully demonstrated that an elective focused on Hospital Medicine as an academic discipline and career path can garner interest and participation from trainees based in a wide range of residency programs – from small community-based programs to tertiary well-resourced academic programs.

IMPLEMENTING AND ASSESSING AN IMMIGRANT MEDICINE EDUCATIONAL CURRICULUM AT AN ACADEMIC URBAN INTERNAL MEDICINE RESIDENCY TRAINING PROGRAM

Neha Saini¹; Laura Sirbu²; Shwetha Iyer³; Yuting Deng¹. ¹Internal Medicine, Montefiore Medical Center, New York, NY; ²EMPH, Icahn School of Medicine at Mount Sinai, New York, NY; ³Internal Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4063406)

SETTING AND PARTICIPANTS: Many U.S. cities have large immigrant populations, and this number continues to increase. Previously collected data from our residency program, an academic urban internal medicine residency, demonstrated most residents do not feel confident in screening immigrant patients for certain health conditions. Previously, as part of a longitudinal project, a comprehensive immigrant health educational curriculum was developed & implemented. We assess the impact of this curriculum on attitudes and knowledge of residents in our program.

We developed two 90-minute didactic sessions delivered during ambulatory curriculum blocks to 40 resident physicians between 2021-2023. The content of the curriculum included evidence-based screening recommendations for immigrant patients and focused on latent tuberculosis, hepatitis B, parasites, and mental health conditions.

DESCRIPTION: We conducted a baseline assessment of residents’ attitudes and knowledge prior to curriculum delivery, and again six months after completion of curriculum delivery to compare changes in attitudes and knowledge. The pre-intervention and post-intervention surveys were identical and administered using Qualtrics, a web-based survey platform. All responses were anonymized using a 5-digit code. The survey questions were composed of 12 attitude and 12 knowledge-based questions. The attitude-based questions used a 5-point Likert scale and were assessed using a Wilcoxon signed rank test. The knowledge-based questions were in multiple-choice format and compared as an aggregate and analyzed using a T-test.

EVALUATION: The study included 31/40 total respondents (70%), of which 26 pre-survey and post-surveys were linked for analysis from four cohorts. There was a statistically significant increase in overall confidence in screening (p <0.001), and specifically for TB (p <0.001), hepatitis B virus (p <0.001) and parasitic infections (p <0.001) 6 months after curriculum delivery. The attitude-based questions as an average had an increase from 3 to 3.8 (P <0.0001), indicating an increase in resident confidence after receiving this curriculum.

Similarly, there was a modest increase in overall knowledge scores from 64% to 69.6% (P =0.34). There was not a statistically significant change in knowledge response in the domains of parasitic infections, tuberculosis, or global epidemiology of disease. The largest increase in knowledge was seen in regards to hepatitis screening and infections, from 50% to 66.7% correct (P =0.0035).

DISCUSSION / REFLECTION / LESSONS LEARNED: Most residents do not receive formal training in caring for immigrant populations and do not feel confident in their knowledge. We found overall knowledge scores across cohorts at baseline were appropriate, and not significantly impacted by the intervention, however confidence in caring for immigrant patients increased significantly after receiving the educational curriculum. A formal comprehensive immigrant health curriculum should be adapted and expanded at residency training programs.

IT’S IN OUR LANE: PREPARING INTERNAL MEDICINE RESIDENTS FOR ROLES AS CLINICIANS AND POLICY ADVOCATES FOR FIREARM INJURY PREVENTION

Joel Burnett¹; Katherine Iossi^2,1; Ryan Kane³; Kelsi Manley¹; Patricia A. Carney¹. ¹Medicine, Oregon Health & Science University, Portland, OR; ²General Internal Medicine, Portland VA Medical Center, Portland, OR; ³Duke Medicine, Durham, NC. (Control ID #4035103)

SETTING AND PARTICIPANTS: University-based internal medicine (IM) residency program; 34 IM residents from 2022 to 2023

DESCRIPTION: With an average of 134 firearm-related deaths per day in the United States in 2021, firearm-related injury and death are important public health issues. Because physicians are trusted sources of information for both patients and policymakers, physicians’ engagement in firearm injury prevention may include roles as clinicians as well as policy advocates. Although leading U.S. medical organizations call for clinical and policy advocacy training in firearm injury prevention, these skills are not widely taught in academic medical centers. We developed an eight month, longitudinal curricula on clinical and grassroots advocacy skills training around firearm-injury prevention. Thirty-four PGY1 IM residents participated in the curricula, which included monthly, one-hour, faculty-led workshops from August 2022 to March 2023. Workshops used active learning strategies, such as role-playing, to engage learners. Workshop topics included: introduction to advocacy, gun violence epidemiology, clinical risk assessment and patient counseling, messaging for advocacy, legislative advocacy, social media advocacy, and Op-Ed writing.

EVALUATION: We used an anonymous survey, administered after each workshop, to assess learner perceptions on the effectiveness of the curriculum in teaching actionable skills that address clinician and policy advocate roles in firearm injury prevention. The survey included open ended and multiple choice questions using five-point Likert scale. Response rates ranged from 59% to 100% for each workshop. Eighty percent of participants rated the session on physicians as advocates as extremely effective, which was the highest rated session. For each workshop in the series, more than 70% of respondents agreed that the workshop was effective or extremely effective at teaching actionable skills.

DISCUSSION / REFLECTION / LESSONS LEARNED: IM residents are open and eager to learn about their role as physician advocates and their roles in preventing firearm injury. They responded well to active learning activities and wanted more opportunities to learn and implement the skills they learned, especially as it relates to having conversations with patients about firearm safety and how best to use social media, legislative activities, and op-ed writing to influence policies. Moving forward, we plan to revise our evaluation of learners in order to assess the impact of the curriculum on learners' attitudes, knowledge, and intention to engage in policy advocacy and firearm injury prevention.

JUST ASK THE EXPERT: LEVERAGING INTERPROFESSIONAL PANEL NAVIGATOR CONTENT EXPERTS AND A HYBRID WORKSHOP DESIGN TO EFFECTIVELY TEACH POPULATION HEALTH PANEL MANAGEMENT ACROSS DIVERSE CLINICAL SITES

Anna L. Golob, Saul Fassler, Whitney Harper, Nikki Zarling, Genevieve Pagalilauan. Medicine, University of Washington School of Medicine, Seattle, WA. (Control ID #4062810)

SETTING AND PARTICIPANTS: At our large, multi-site academic internal medicine residency program, fewer than half of residents reported being familiar with resources to conduct panel management. To address this gap, we designed and implemented a population health panel management (PHPM) workshop curriculum. Our initial learner cohort included first- and second-year primary care track residents across multiple affiliated clinic sites.

DESCRIPTION: The PHPM workshops are two-hour sessions delivered during outpatient rotations two to three times yearly. Residents meet at their continuity clinic sites with a faculty member or chief resident and a panel navigator (PN), a non-physician content expert in PHPM workflows and resources. The sessions begin with an all-site virtual orientation, including a brief overview of PHPM principles and a succinct didactic on the chronic disease or preventive health metric of focus for session. Next, at each clinic site, facilitators highlight key EHR data resources, review clinic-specific workflows, and teach the residents how to access their own continuity clinic panel data. Residents then have protected time to review their panel data and enact action plans for patients identified to have care gaps, with support from faculty and PNs. Lastly, residents report out which high yield resources and practices they will utilize going forward.

EVALUATION: Residents evaluate each PHPM workshop immediately following the session. The workshops have been very positively received by residents thus far, with a 4.72 mean overall teaching effectiveness rating on a 1-5 scale (N=25). Representative comments include “This session should be offered to every single resident…it was so incredibly helpful” and “Definitely include this early on in the R1 year.” Our program also studies the resident continuity clinic learning experience twice yearly via anonymous survey, including a resident self-assessment of PHPM knowledge, skills, and practice patterns. We plan to study trends in resident self-assessment of PHPM activities as we continue to implement this curriculum for all our residents.

DISCUSSION / REFLECTION / LESSONS LEARNED: Learning to effectively conduct PHPM supports residents in achieving multiple ACGME core competencies, including Practice Based Learning and Improvement and Systems Based Practice. Furthermore, it is a core outpatient care skillset that improves quality and equity of care. Our hybrid workshop design leverages virtual large group learning to teach key principles about PHPM and specific disease states, and in person small group learning to teach individualized workflows for each clinic’s EHR, interprofessional team dynamics, and patient population. We found the most success in these sessions by partnering with both site-specific faculty and chief resident champions as well as non-physician Panel Navigator content matter experts. Next steps include the continued expansion of this curriculum to include all residents across all clinical sites affiliated with our training program.

LEARNER-DRIVEN FEEDBACK: A FEASIBILITY STUDY OF A MINI-CEX INTERVENTION TO INCREASE DIRECT OBSERVATION AND FEEDBACK IN THE AMBULATORY SETTING

Asmita Gatoo³; Kain Kim²; Dheepa Sekar¹. ¹Medicine, Emory University School of Medicine, Atlanta, GA; ²Internal Medicine, Emory University School of Medicine, Atlanta, GA; ³Emory University School of Medicine, Atlanta, GA. (Control ID #4060692)

SETTING AND PARTICIPANTS: We implemented an observation and feedback model based on mini-clinical evaluation exercises (CEX) for residents in an urban primary care clinic that cares for an underserved population with complex medical and social needs.

DESCRIPTION: The ambulatory learning experience is often limited by time and clinical pressures, especially with regards to observation and feedback. Mini-CEXs have shown to improve feedback and learner confidence. However, implementation is difficult in the ambulatory setting due to faculty-resident ratios and learner hesitation about disrupted clinic flow. Additionally, the mini-CEX model overlooks self-regulated learning, which acknowledges a learner’s role in the feedback continuum for insight that is essential for developing lifelong learning. We combined mini-CEX with facilitative coaching in a direct observation and feedback model for the ambulatory setting that promotes self-regulated learning. To fit within a busy resident clinic, we focused on single skill for each observation. The feedback model employs a facilitative approach that asks the learner to identify an anticipated challenge, participate in a coaching dialogue before the encounter, and receive focused observation and feedback.

EVALUATION: We assessed the model for feasibility of implementation and resident experience. Resident experience was captured through qualitative content analysis of free-text responses. During October 2022 to June 2023, 18 faculty and 11 residents completed surveys out of a total of 36 assigned observations. Faculty provided feedback immediately after the visit or at the end of clinic shift 76.5% and 23.5% of the time, respectively. With regards to clinic flow, 14.3% and 28.6% of residents reported that the direct observation changed the patient interaction and affected clinic flow, respectively. All faculty stated it would be feasible to continue observations, and 85.7% of residents stated they would like direct observations in the future. Emerging themes show that residents found the pre-encounter discussion most helpful in honing patient communication skills and anticipating challenges, and that the goal-driven nature of the encounter was reflected in the specificity of the feedback. One resident remarked that they were nervous about time, but the observation was ultimately feasible and very helpful.

DISCUSSION / REFLECTION / LESSONS LEARNED: This learner-driven mini-CEX pilot for the ambulatory setting was perceived to be feasible by both faculty and residents who completed the exercise, but only about half of direct observations were completed. While we focused on a learner-driven model to foster engagement, we found that faculty encouragement was important in successful completion. Need for faculty encouragement likely reflects learner hesitation to initiate direct observations. Residents that did complete the exercise note pre-encounter reflection and highly specific feedback as useful features in this model and would seek similar direct observation and feedback opportunities in the future.

LIFTING RESIDENT CONTINUITY: STRENGTHENING RELATIONSHIPS BETWEEN PATIENTS AND RESIDENT PHYSICIANS

Karen Kimel-Scott, Christine Gladman. Medicine, University of North Carolina, Chapel Hill, NC. (Control ID #4064901)

SETTING AND PARTICIPANTS: Academic Outpatient General Internal Medicine clinic with 86 internal medicine residents on an X+Y schedule with separate four weeks of inpatient and two weeks of outpatient responsibilities.

DESCRIPTION: We implemented a systematic overhaul to our resident continuity clinic to a team-based model in 2021. Since then, we have worked to improve resident physician continuity with their empaneled patients to improve the experience of both residents and patients. We implemented resident schedule changes including: a stable cadence of full day clinic sessions and routine day of the week (every outpatient week resident has clinic on the same day with the same team including clinical staff and attending). Most importantly, clinic templates are available for scheduling by May, for the whole academic year with simple templates for ease of input. Key clinic operations changes included: scheduling of follow-up appointments by co-located team clinical staff who worked closely with resident physician teams and their patients and could ensure appointments in appropriate time intervals, growth of resident panels through online scheduling mechanisms, and routine patient portal outreach every six months to those who had not been seen in over one year.

EVALUATION: We measured resident physician continuity as the percentage of total completed visits with their empaneled patients which improved from 47% in December 2022 to 69% by December 2023. During the same time period, resident physician schedule utilization was measured as the percentage of available appointments scheduled which was steady at 90%. Ambulatory workload was measured as an average of 5.4 visits out of 6 available visits per session adjusted for new patients counting as two visits. A balancing measure of the no show rate was steady at 10%. There was a steady increase in the average patient panel size for residents from 73 in December 2022 to 85 in December 2023, showing 16% growth of empaneled patients.

DISCUSSION / REFLECTION / LESSONS LEARNED: We implemented several measures focused on improving resident physician continuity despite barriers that limit resident physician continuity with their patients in a block schedule. Continuity was a lagging measure as we demonstrated earlier increases in schedule utilization and worked to build panel sizes so that the quantity of empaneled patients was appropriate for the quantity of resident clinic sessions. It remains to be seen if the experience of better empaneled patient continuity increases the rate of residents choosing outpatient general medicine careers.

MAKING WAVES AT A COMMUNITY-BASED PROGRAM WITH A POCUS FOCUS

Haley Clay, Waldo J. Santiago Colberg, Jordan Nickols. Internal Medicine, East Alabama Medical Center, Opelika, AL. (Control ID #4024093)

SETTING AND PARTICIPANTS: The setting was a new commuity-based IM residency program and involved PGY-1 and PGY-2 residents.

DESCRIPTION: Point of Care Ultrasound (POCUS) is becoming standard across Internal Medicine (IM) training programs. In 2020, a survey conducted by APDIM reported only 63% of respondents had a formal diagnostic POCUS curriculum. When compared to community programs, university-based programs were more likely to implement such a curricula by a statistically significant margin. In our study, we aimed to develop a POCUS curriculum in the second year of a new community-based program utilizing the PEARLS diagnostic approach. PEARLS includes 6 views: Parasternal (long and short axis), Epigastric, Anterior lung, Right upper quadrant, Left upper quadrant, and Suprapubic. Over a twelve-month period, we incorporated five didactic lectures, five skills-based simulations and encouraged utilization of ultrasound on rounds. Knowledge was assessed with a written pre-test and post-test; image acquisition was assessed with a final practicum. Additionally, we evaluated the challenges faced by community-based programs.

EVALUATION: Goals included developing a curriculum with definable objectives, teaching residents to obtain and interpret basic images with POCUS, and addressing barriers to implementation. Knowledge base was assessed with a written pre-test and post-test; image acquisition was assessed with a final practicum. A 22% score increase was seen in pre-tests vs. post-tests. Image acquisition on the final practicum varied due to a variety of factors including interest and participation in a non-mandatory curriculum. Of 90 total views tested (15 residents, 6 views each), 48 (53%) demonstrated competence. Of those, 38 (42%) achieved “gold standard” images requiring no image adjustment. Of the six systems examined with the PEARLS method, the cardiac and epigastric had the lowest scores.

DISCUSSION / REFLECTION / LESSONS LEARNED: In our first year, we addressed barriers that community-based programs face to start a POCUS curriculum such as trained faculty, device acquisition, and developing a culture that encourages use of POCUS in daily practice. At the end of our curriculum, we had an overall improvement in written test scores. We had variable data in the practicum assessment due to a variety of reasons, mostly being lack of consistent participation in the sessions. We have altered the curriculum to include a three-tiered approach to POCUS based off the varying interest levels of our residents (basic knowledge, limited proficiency, and POCUS champions). We also included online modules and longer hands-on sessions. Additionally, we completed a POCUS pocket guide for easy reference. Through refinement of our curriculum by resident and faculty feedback and acknowledging our areas for improvement, we are making waves at developing a successful POCUS curriculum at our community-based program.

ONLINE RESOURCE URL: https://drive.google.com/file/d/1aPSgT5TFq9c4jhMFftkbg_Mlviw6wJm7/view?usp=sharing

MEDICAL STUDENT DIDACTIC SESSION: WORKING WITH LIMITED ENGLISH PROFICIENCY PATIENTS

Kathleen B. Dussan¹; Sarah Yentz¹; Jennifer Stojan¹; Margaret Dobson². ¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Family Medicine, University of Michigan, Ann Arbor, MI. (Control ID #4037486)

SETTING AND PARTICIPANTS: With ongoing dramatic rise in international migration, and recognition that limited English proficiency (LEP) patients face many health care challenges and health disparities, and that LEP patient comprehension, and outcomes improve when cared for by bilingual providers and/or professional interpreters, we planned an intervention to improve medical student experience and facility in working with interpreters. We sought to introduce non-English speaking mock patient history taking to the typical didactic experience and to integrate phone interpreters into the medical education around working with LEP patients.

DESCRIPTION: The “Working with an Interpreter” session was a 90-minute session during one of the “Doctoring” small group sessions in the first year of medical school. "Doctoring" is part of a longitudinal medical school course focusing on both clinical skills as well as addressing ethics, health disparities, bias, and humanism in medicine.

This session was divided into 2 parts: 60 minutes of didactics regarding best practices for working with an interpreter and a 30-minute interactive exercise with a mock patient and phone interpreter. We recruited mock patients, faculty who were fluent in a language other than English, to act as the patients for this exercise. The first half of the session was interactive didactics, including shared review of a video. The second half of the session included students taking clinical histories of mock patients in languages other than English through use of the University hospital’s telephone interpreter service.

EVALUATION: Students filled out a pre and post session evaluation either by paper evaluation form or an online survey link. Following the session, students were more likely to report that using a family member to interpret was not recommended (p<0.05). Prior to the session, 50.5% felt it was unacceptable to have a family member interpret for a LEP patient. After the session, this increased to 68.5%. Students' confidence in taking a history using a telephone interpreter improved (p<0.05). Prior to the session 27% of students felt extremely or moderately confident in obtaining a HPI for a patient who requires an interpreter. After participating in the session, this increased to 72%.

DISCUSSION / REFLECTION / LESSONS LEARNED: Accrediting bodies like the Accreditation Council for Graduate Medical Education (ACGME) have established requirements regarding cultural competency training for medical learners. Learning to successfully work with interpreters to overcome language barriers can improve health disparities. Our innovative, practical curriculum meets the goals of teaching medical students the skills to work successfully with trained professional interpreters, while giving them an immediate opportunity to implement this with non-English speaking patients. Continued opportunities, like our curriculum, will help with decreasing language barriers, increase students’ cultural competency, and hopefully lead to decreased health disparities in their future medical practice.

NEEDS ASSESSMENT FOR DEVELOPING AN AMBULATORY INTERNAL MEDICINE URGENT CARE CURRICULUM

Kiersten Brown¹; Jessica Valente². ¹Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC; ²General Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC. (Control ID #4048830)

SETTING AND PARTICIPANTS: Wake Forest Baptist Medical Center - Internal Medicine Residents

DESCRIPTION: Background: In ambulatory internal medicine, there is an increasing need for urgent care appointments where physicians need to be able to evaluate and treat acute care conditions in the clinic setting. In developing curricula to train Internal Medicine residents, there are very few resources that assess how prepared residents feel to treat urgent care complaints and teach on urgent care topics. There are also very few resources on how to develop and implement an urgent care curriculum for internal medicine residents. Our goal for this project is to assess the need for an urgent care curriculum in internal medicine training and to specify what areas of education should be particularly emphasized.

EVALUATION: Methods: Our internal medicine residents rotate through a four-week urgent care block where the senior residents have the role of precepting interns and teaching on urgent care topics. To assess the needs of an urgent care curriculum (as no current curricula is currently implemented during this rotation), we surveyed the residents with a 6pt Likert scale assessment (1=strongly disagree, 2=disagree, 3=somewhat disagree, 4=somewhat agree, 5=agree, 6=strongly agree). This survey was structured to assess resident comfort level with the outpatient preceptor role, management of urgent care complaints, ability to perform procedures in the urgent care setting, and satisfaction with teaching in the ambulatory setting.

Results: Twenty-three participants completed the survey with the majority being upper-level residents. Overall, residents felt most confident in managing the following urgent care issues: acute care medical complaints (70%, 16/23) and hospital/ED follow-up visits (74%, 17/23). Approximately 52% (12/23) felt confident in managing acutely decompensated chronic diseases in the urgent care setting. In regard to performing procedures like joint injections, incision & drainage, or wound care in the urgent care setting, the majority of residents did not feel confident in these skillsets (70%, 16/23). These results were similar even when asked if residents first knew where in the clinic to look for procedural supplies.

DISCUSSION / REFLECTION / LESSONS LEARNED: Conclusions: Overall, our results indicate that the residents would benefit from an urgent care curriculum, especially in regard to performing procedures in the clinic and managing acutely decompensated chronic diseases. Our next step is developing curricula that focuses on 1) Resident as Teacher preceptor model in the urgent care setting, 2) improving knowledge in treating common urgent care complaints, 3) providing instruction on urgent care procedures and wound care, and 4) managing acute decompensation of chronic diseases in an urgent care setting.

NOVEL CURRICULA IN REFUGEE HEALTH

susan levine¹; Helena Kennedy Collin². ¹medicine, University of Connecticut, West Hartford, CT; ²Medicine, Boston Medical Center, Boston, MA. (Control ID #4043698)

SETTING AND PARTICIPANTS: student, resident and fellowship curricula at two academic centers

DESCRIPTION: Refugees have unique healthcare needs specific to their country of origin, migration patterns, and immigration statuses; however, knowledge gaps exist among primary care providers. Given LCME and ACGME requirements on cultural humility and health care disparities training, refugee health curricula offer unique opportunities for programs to address these gaps and for trainees to develop skills needed to serve immigrant populations.

We will describe two successful initiatives across two different academic health centers- one focused on resident and student education and the other on fellowship training. The student curricula include problem based and team based learning sessions (PBL and TBL) as well as a week long immersion course. In the PBL and TBL sessions students are given background materials and then complete in class exercises where they explore the unique health care determinants of refugees, learn strategies to investigate endemic health risks, and explore differentials of common complaints taking into account migration history. Similar topics are covered in a week-long immersion course. Resident curricula include dedicated refugee health sessions within a series of case based tropical medicine webinars embedded in a global health (GH) track as well as longitudinal patient care opportunities. Webinar topics include the epidemiology of global migration as well as screening of newly arrived refugees. Other track components include skill building simulation exercises. The fellowship curricula are embedded within a 2 year preventative medicine residency framework. Through a mixture of didactics and experiential learning, fellows learn to deliver multidisciplinary refugee care in both academic and community-based settings while developing leadership skills required to address health disparities on a population health level.

EVALUATION: A pre and post knowledge assessment of the student immersion course demonstrated a 74% increase across a variety of content areas of cultural humility, domestic screening, latent TB and other migration specific infections, chronic disease management and trauma assessment (n=20). GH track residents' pre and post assessment knowledge scores increased by 50% in all refugee health content areas (n=12). Fellowship assessments include quarterly Individual Development Plans, which assess progress in key research, clinical, and academic milestones (n=1).

DISCUSSION / REFLECTION / LESSONS LEARNED: The material presented along with supplemental handouts will allow attendees to apply learner specific milestones within the domains of GH, cultural humility, migration specific screening, health equity, public health and trauma informed care to their institutional curricula.

PORTABLE CURRICULUM ON PATIENT SAFETY EVENTS AND ROOT CAUSE ANALYSIS FOR INTERNAL MEDICINE RESIDENTS

Kathryn Leyens^1,7; John Szymusiak^4,7; Benjamin Sprague³; Melinda Hamilton⁶; Andrew Buchert⁷; Dylan Yang⁴; Neha B. Etherington²; Scott D. Rothenberger⁵; Jonathan Lin⁸; Allison DeKosky². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Medicine, UPMC, Pittsburgh, PA; ³Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁴Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁵Medicine, University of Pittsburgh, Pittsburgh, PA; ⁶Pediatric CCM, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA; ⁷Pediatric Hospital Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA; ⁸University of Pittsburgh, Pittsburgh, PA. (Control ID #4064005)

SETTING AND PARTICIPANTS: Our curriculum on patient safety events (PSE) and root cause analysis (RCA) was individually completed online by all categorical UPMC internal medicine residents. Designated time was provided prior to two outpatient clinic sessions to allow for completion. The curriculum including immediate pre- and post-surveys were completed during summer 2022, with secondary post-surveys completed approximately eight months later to evaluate for retention.

DESCRIPTION: The Accreditation Council for Graduate Medical Education (ACGME) emphasizes the importance of identifying, reporting, and evaluating PSE. Our needs assessment comes from both our local and national ACGME Clinical Learning Environment Review (CLER) visits, demonstrating the need for a standardized curriculum on PSE and exposure to RCA. The curriculum consists of three online interactive modules that aim to help residents develop the knowledge, skills, and confidence to accurately recognize PSE, create quality PSE reports, and understand the evaluation through the ideal process of RCA. Module 1 focuses on types of PSE and important features to include in PSE reports through the introduction of the I-SAFE mnemonic. Module 2 includes the participants, components, and process of RCA. Module 3 consists of a simulated, ideal RCA. The curriculum was hosted on a local website and remained password protected for the duration of the study.

EVALUATION: Resident attitudes, knowledge, and skills were assessed through pre-, immediate post-, and delayed post-surveys. Response rates were 60.3%, 40.4%, and 16.5%, respectively. Skill was evaluated by having learners write a PSE report. Pre- and post-surveys were linked by a unique identifier which allowed for paired analysis. Results within these domains were stratified into three composite scores: overall, PSE, and RCA. There was a significant improvement in attitudes for all composite scores immediately following the curriculum. There was also a long-term benefit in overall attitudes following implementation of this curriculum, although with loss of confidence over time in the attitude overall and RCA composite. There was a significant improvement in overall knowledge and PSE score immediately following the curriculum. There was an improvement in the RCA composite, although this was non-significant. There was no significant retention of knowledge. There was a significant improvement in the skill of writing a PSE report immediately following the curriculum; however, there was no retention of this skill over time.

DISCUSSION / REFLECTION / LESSONS LEARNED: This curriculum addresses both a local need as well as an ACGME requirement for resident education. The results of our surveys demonstrated that while there was an overall improvement in attitude, knowledge, and skills immediately following the curriculum, these improvements were not retained over time. Next steps will be to utilize the results from this study to make the necessary modifications to our curriculum to ensure our residents have lasting knowledge within this domain.

PROCEDURE TRAINING WORKSHOP: ENHANCING RESIDENT EXPERIENCE AND ENTHUSIASM FOR ULTRASOUND-GUIDED BEDSIDE PROCEDURES

Cynthia Zheng, Ibrahim yusuf Abubeker, Sarah Freeman. Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI. (Control ID #4064888)

SETTING AND PARTICIPANTS: An end-of-year survey of internal medicine interns in a New England program found few felt comfortable independently performing bedside ultrasound guided procedures including paracenteses, lumbar punctures (LP), and central venous catheter (CVC) placements. To improve resident confidence and competence, a procedure training workshop (PTW) was created.

DESCRIPTION: All PGY-1 and PGY-2 residents were assigned to attend a half-day PTW at a simulation center. When possible, residents completed the PTW immediately prior to an intensive care rotation. A flipped classroom model was used where residents received slides and videos to review before arrival, which detailed indications, contraindications, risks/benefits, procedure steps, troubleshooting tips, and hospital-specific workflow pearls. With a max 2:1 resident to instructor ratio, residents practiced performing paracenteses, LPs, and CVC placement on ultrasound compatible task trainers. Internal medicine attendings, chief residents, critical care fellows, and PGY-3 internal medicine residents served as instructors. Prior to each session, instructors were sent slides and checklists of key procedure steps for standardization. Sixteen sessions were conducted.

EVALUATION: Procedural knowledge and confidence were evaluated through multiple choice and survey questions administered immediately before and after participation. Number of bedside procedures attempted, success rate, and procedural complications in 2021 (year of implementation) were tracked and compared to 2020 (year prior to implementation).

DISCUSSION / REFLECTION / LESSONS LEARNED: Following implementation of the PTW, more residents reported feeling “well-prepared” to perform all three procedures after participation compared to before (69% from 12% for LP, 78% from 29% for paracentesis, 92% from 31% for CVC). Similarly, more residents felt they could perform these procedures without assistance after the workshop compared to prior (50% from 17% for LP, 64% from 26% for paracentesis, 54% from 29% for CVC).

While not the primary objective, improvement in resident confidence and familiarity with bedside procedure skills led to an increase in number of resident-performed procedures on general medicine wards with 79% more paracenteses and 65% more LPs and no rise in procedural complications.

The time out process was reviewed at every station. However, only 73% of residents felt they could do this independently after attending the PTW. Residents work at three different hospitals, and the time-out process varies at each site. To achieve 100% confidence, we suspect more attention is needed highlighting site-specific differences.

Key aspects in maintaining and improving the educational quality include ensuring low learner-to-instructor ratio, reviewing procedure checklists with instructors prior to sessions, providing institution-specific strategies, and recruiting adequate administrative support to assist with scheduling.

RASHES AND REFLECTION: A NOVEL CURRICULUM USING CLINICAL REASONING TO TEACH AMBULATORY DERMATOLOGY TO INTERNAL MEDICINE RESIDENTS

Anne A. Richardson¹; Katherine Gavinski²; Lauryn Falcone⁴; Alaina James⁴; Scott D. Rothenberger³; Tanya Nikiforova¹. ¹Internal Medicine, University Of Pittsburgh Medical Center, Pittsburgh, PA; ²General Internal Medicine, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; ³Medicine, University of Pittsburgh, Pittsburgh, PA; ⁴Dermatology, University of Pittsburgh, Pittsburgh, PA. (Control ID #4059675)

SETTING AND PARTICIPANTS: We developed, implemented, and evaluated a module-based dermatology curriculum that integrated clinical reasoning principles for internal medicine residents in the ambulatory setting.

DESCRIPTION: Despite frequently encountering skin diseases in primary care, most internists do not feel competent in diagnosing and treating common dermatologic conditions. Recently, there has been increasing focus on using clinical reasoning principles in graduate medical education to reduce diagnostic errors and improve diagnostic accuracy, but previously published dermatology curricula did not emphasize these skills. We developed a novel curriculum that uses clinical reasoning concepts to teach internal medicine residents how to describe common outpatient dermatologic lesions, develop differential diagnosis, and use deliberate reflection to improve diagnostic accuracy for four common dermatologic complaints. The curriculum includes five asynchronous, interactive 10-minute online modules and was administered to all 159 internal medicine residents at a large academic residency program in spring 2023.

EVALUATION: We developed a novel assessment tool that evaluated residents’ clinical reasoning skills in diagnosing dermatologic lesions. Residents completed this assessment before, immediately after, and four months after curriculum participation. At each timepoint, residents were presented with three randomized cases. For each, they were asked to describe the rash, provide a differential diagnosis, demonstrate deliberate reflection, name the final diagnosis, and select a treatment plan. The assessment tool and answer key were developed with input from dermatology and internal medicine faculty and literature review. The assessments were graded by two study authors who were blinded to the time point of the assessment. Agreement between raters was confirmed using the intraclass correlation coefficient. Next in our analysis, linear mixed effects regression models will be used to assess changes in assessment scores over time. Residents were also asked for narrative feedback; they reported using what they learned in their clinic practice, and noted they gained a deliberate approach to rashes in primary care.

DISCUSSION / REFLECTION / LESSONS LEARNED: Despite the increased focus on clinical reasoning in internal medicine, less has been studied about the benefits in specialties that rely on visual recognition, like dermatology. This makes our curriculum and its evaluation particularly novel. The development and implementation of this curriculum demonstrates feasibility of a clinical reasoning focused dermatology curriculum for internal medicine residents. The interactive modules invoke active learning without requiring additional faculty time, and make the curriculum easily transferrable to other institutions. Future investigations should explore longer term retention of the knowledge and reasoning skills gained.

SUPPORTED SPACES: DEVELOPING A PRIMARY CARE INTERNAL MEDICINE (PCIM) RESIDENT CURRICULUM TO CULTIVATE A COMMUNITY OF HEALERS

Sharada Narayan¹; Ryan Laponis²; Irina Kryzhanovskaya¹. ¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4062552)

SETTING AND PARTICIPANTS: 10 residents per class (2^nd [R2] and 3^rd year [R3]) in a PCIM residency program in a large, urban, academic medical center.

DESCRIPTION: Trainees becoming new physicians face the myriad complexities of modern medical practice including harm to patients from structural inequities which often engenders moral distress (1-3). Such distress can lead to less satisfaction in practice, lower empathy towards patients, and more burnout (1,4). Interventions to develop reflective capacity among trainees have been shown to mitigate this process (1-8). However, current approaches to reflection in graduate medical education (GME) often fall short, despite being identified as an ACGME competency (5,9,10). A focus group of PCIM R2s at our institution revealed lack of medical community, doubts about sustainability of a PC career, and desire to build skills in reflective practice. We aim to create and implement a PCIM R2 and R3 curriculum focused on identity formation, reflection, and community-building. The pedagogy draws from Schon’s concept of reflective capacity and the relationship-centered Healer’s Art model (8,11). Residents will participate in three 2-hour sessions a year with reflective exercises and facilitated discussion.

EVALUATION: Curricular evaluation will include assessment of impact and overall experience via pre-course and post-course surveys. Trainees will self-report impact on engaging with reflection, finding meaning in everyday practice, and feeling part of a community in medicine. We will conduct focus groups after the first year of the intervention for feedback to inform future iterations of the curriculum.

DISCUSSION / REFLECTION / LESSONS LEARNED: PCIM R2 class pre-course survey demonstrated widespread disengagement and isolation. 50% of respondents ‘sometimes’ or ‘rarely’ felt connected to their values during clinical work. 70% lacked an effective process to make meaning of experiences in training. 90% did not feel part of a community of practice that met their needs. We held a pilot session on the theme of ‘the shadow’ in November 2023. Residents engaged in a reflective exercise of depicting the experiences and emotions they carry in their metaphorical ‘bags’, then shared their stories in a discussion led by an experienced facilitator. According to informal post-session surveys, residents saw this intervention and its structure as an improvement on previous reflective offerings. By creating future supported spaces sessions for residents rooted in reflective practice, we hope to deepen relationships among trainees and to take the needed steps to authentically realize internal medicine as a healing profession.

ONLINE RESOURCE URL: References: https://docs.google.com/document/d/1BywnXTKhYsLReLyExT3__YJUDz6rOB966s_H9evWwXA/edit?usp=sharing

THE CLINICAL AUTOPSY SERIES

Fredrick Hetzel¹; Mateusz Tkacz²; Eleanor Belilos². ¹Hospital Medicine, Rush University Medical Center, Chicago, IL; ²Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4057506)

SETTING AND PARTICIPANTS: Internal Medicine residents within an academic medical center

DESCRIPTION: This new curriculum will aid residents in developing a set of treatment principles for common internal medicine inpatient issues founded in evidence-based medicine. A curriculum consisting of a series of case analyses will be conducted monthly via resident noon-conference, highlighting key principles in management based on current evidence-based guidelines. Residents will work together to retrospectively analyze a real clinical case and compare medical decisions made to current recommendations in management. This will provide an opportunity for residents to discuss how care could have been optimized in the presented case. This curriculum will highlight key treatment principles, gain exposure to current evidence-based medicine guidelines, and critically evaluate previous hospital cases to guide future patient care.

EVALUATION: Evaluation will be conducted through pre- and post-curriculum surveys focused on resident confidence in the identification and management of common internal medicine issues. The data will be analyzed to assess changes in resident knowledge and confidence presumed secondary to this curriculum. A narrative section will also be made available for residents to provide comments and feedback so that future iterations of the curriculum can be improved.

DISCUSSION / REFLECTION / LESSONS LEARNED: The aim of this project is to develop resident clinical reasoning and confidence supplemental to clinical training. Utilizing guidelines based in evidence-based medicine, this project envisions a curriculum that provides residents with the framework to develop a schema for management of common internal medicine issues that occur during an inpatient admission. The case series that is proposed works to compare clinical practice to what is recommended by current guidelines. The vision for this format will promote critical thinking and clinical reasoning during small group discussions so that residents optimize their future treatment plans through high value evidence-based care. The first session of this new curriculum will being in the Spring of 2024. Future versions of this curriculum could expand to include undergraduate medical education or faculty development.

UNLOCKING CARE: EXPLORING HEALTHCARE IN CORRECTIONAL SETTINGS

Laura J. Benjamins¹; Marissa Zhu²; Carmen McIntyre Leon⁴; Michelle Thomas⁵; LaShawnda Williams⁵; Phillip Zivku⁵; Latonya Riddle-Jones³. ¹Pediatrics, Wayne State University School of Medicine, Detroit, MI; ²Office of Learning and Teaching, Wayne State University School of Medicine, Detroit, MI; ³Internal Medicine and Pediatrics, Wayne State University School of Medicine, Detroit, MI; ⁴Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI; ⁵Wayne State University School of Medicine, Detroit, MI. (Control ID #4061756)

SETTING AND PARTICIPANTS: This course is designed for 300 second-year medical students at a large Mid-Western institution in their pre-clerkship phase.

DESCRIPTION: The curriculum includes two mandatory lectures and a panel discussion that takes place over two months. It is supported by three quizzes based on essential readings and podcasts, along with a self-reflection activity. Optional components include screenings of two documentaries and participation in a book club, enriching the learning experience.

EVALUATION: To assess the effectiveness of this module, students will complete a self-reflection exercise. We plan to conduct a thematic analysis of these reflections, employing Kirkpatrick's model of program evaluation. This model will enable us to systematically evaluate the program’s impact on students' learning and behavior. The four levels of Kirkpatrick's model—Reaction (how students perceive the learning experience), Learning (the resulting increase in knowledge or capability), Behavior (extent of behavior and capability improvement and application), and Results (the effects on the broader environment or society)—will guide our analysis. This comprehensive evaluation will help us understand the depth of students' engagement with the material and its practical application in their future medical practice.

DISCUSSION / REFLECTION / LESSONS LEARNED: Student feedback highlighted appreciation for the diverse learning opportunities provided in this module. The combination of lectures, panel discussions, readings, and interactive activities like quizzes and self-reflection offered a holistic view of the complex healthcare landscape in correctional settings. The course design emphasized the importance of ethical, sensitive, and comprehensive medical practice in these unique environments, preparing students for real-world challenges they may face in their medical careers.

V+Z: EVIDENCE-BASED CONTINUITY CLINIC REDESIGN, BEFORE AND AFTER RESIDENCY PROGRAM X + Y ADOPTION

Matthew Stevenson¹; Emmanuelle Yecies²; Sulaiman Somani³. ¹Internal Medicine, Stanford Hospital & Clinics, Menlo Park, CA; ²Women's Health, VA Palo Alto Health Care System, Palo Alto, CA; ³Internal Medicine, Stanford Medicine, Stanford, CA. (Control ID #4065155)

SETTING AND PARTICIPANTS: Participants include 40 internal medicine residents and 16 attendings at an academic VA primary care clinic in the California-Hawaii region.

DESCRIPTION: Resident satisfaction in primary care clinic is associated with patient care continuity; attending mentorship; high-functioning care teams; and lack of conflict between inpatient and ambulatory duties. At our institution, several residency- and clinic-specific factors undermined these educational principles. Residency factors included a non-X+Y rotation structure and a scheduling system that released clinic dates on short time horizons. Clinic factors included an “alternating half-day schedule” that divided residents’ learning time across multiple weekdays with multiple attendings and divided their clinic days into “inpatient” mornings and primary care afternoons.

Before academic year 2023-2024, our clinic implemented a comprehensive redesign including:

- A full-day schedule in which residents attend clinic on a single full day during every non-wards, non-ICU week

- a “full-year” clinic build in which clinic dates are released (and patients scheduled) on a 12-month horizon

- consolidation of resident clinics onto a single wing, with a common nursing pool and shared conference room

- a backup system in which jeopardy or sick leave does not trigger clinic cancellation, but coverage by a dedicated block resident

These innovations were intended to optimize:

- Continuity: by creating predictable schedules and reliable patient access

- Mentorship: by increasing the % of clinics supervised by a resident’s primary preceptor

- Team dynamics: by collocating residents and nurses on a teaching wing

- Harmony between self-care, primary care, and inpatient care by eliminating mid-day role transitions

EVALUATION: Pre-intervention, primary care clinics (including ours) were among the lowest rated outpatient learning activities in our residency program. 1-2 graduates/year pursued primary care jobs.

Post-intervention rotation evaluations—and graduating resident career choices--will be available at the time of presentation.

To assess improvements in care continuity, we will also assess the % of appointment slots filled by a resident’s primary panel patients

DISCUSSION / REFLECTION / LESSONS LEARNED: By redesigning our continuity clinic around evidence-based educational goals, we learned that we could bring about needed change even while awaiting larger reforms (i.e., X+Y scheduling) from our academic partner. Implementing these changes required consensus building within our clinic and partnership with residents and residency leadership. But by driving change forward, we prepared ourselves for an eventual transition to X+Y; possibly hastened that transition (next year!) by modeling proactive curricular reform; and modeled, for residents, the commitment and skillset necessary to effect process improvement in healthcare. In so doing, we demonstrated our commitment to the residents themselves, and to the importance of training--and retaining--the next generation of primary care leaders.

WEAVING DIVERSITY, EQUITY, AND INCLUSIVITY IN INTERNAL MEDICINE AMBULATORY EDUCATION

Laura K. Byerly¹; Emily R. Janetos^1,2. ¹Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR; ²Division of Hospital & Specialty Medicine, Portland VA Medical Center, Portland, OR. (Control ID #4054248)

SETTING AND PARTICIPANTS: In 2022-23, an academic medical center internal medicine (IM) residency implemented a longitudinal diversity, equity, and inclusivity (DEI) thread for all residents (PGY 1-3; n=105) within a structured ambulatory education series.

DESCRIPTION: ACGME requires residencies to promote trainees’ ability to care for diverse populations. As our IM residency worked to improve DEI exposure, we identified the lack of longitudinal exposure to DEI topics as a gap in our curriculum. We sought to incorporate an intentional longitudinal DEI series in Primary Care Ambulatory Topics (PCAT), our required 12-block, 28-session in-person ambulatory didactic series. In 2022, we asked all PCAT teachers to include a DEI topic. During planning meetings, faculty were guided by residents to identify applicable DEI topics that aligned with session content and met resident learning goals/gaps in training.

EVALUATION: Our evaluation of DEI topics focused on residents’ perception of utility and retention of the DEI point. We added two items to our post-session evaluation: a Likert-style question on the DEI point’s utility and clarity (1=not clear/useful, 5=extremely clear/useful) and an open-ended question asking residents to identify the DEI point they would incorporate in practice; the latter’s intention was to assist in understanding successful messaging of DEI content. We also reviewed session materials to identify the presence of a DEI point and if it was visually signposted. Twenty-four out of 28 sessions had an explicit DEI point but not all points were clearly signposted. We collected 1,777 evaluations over 1 year and reviewed both descriptive statistics and resident accuracy in identifying the DEI point. Overall average rating of clarity/utility of DEI topics was 4.1/5. Residents correctly recalled 64% of DEI points; % correct recall did not correlate with signposting.

DISCUSSION / REFLECTION / LESSONS LEARNED: Resident ratings of DEI points were comparable to overall session ratings. We presumed that signposting DEI points would increase recall but found this was not always the case. Signposted DEI points “stuck” with residents if the point was also found to be useful, while points with low utility ratings were less likely to be retained even when signposted. We were surprised to find that, even when there was no identifiable DEI point in session materials, the majority of residents still reported a DEI point. We hypothesized that these sessions incorporated an implicit focus on DEI which was seen as genuine and unforced. This bore out in the excellent DEI evaluations of sessions wholly focused on the care of marginalized populations (e.g. harm reduction), with resident feedback highlighting appreciation for passionate faculty. Residents were also more likely to retain topics related to their practice setting. Lessons learned from this pilot include the importance of resident input in coaching faculty to create DEI content and the utility of weaving DEI throughout curricula to provide authentic and unforced longitudinal exposure.

Innovation in Medical Education (IME) - Curriculum Development – UME

A CURRICULUM ON COMMUNICATING DIAGNOSTIC UNCERTAINTY FOR THIRD-YEAR MEDICAL STUDENTS

Neha B. Etherington¹; Amar Kohli³; Deborah DiNardo²; Casey N. McQuade³; Eliana Bonifacino⁴. ¹Medicine, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ³Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁴Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4064409)

SETTING AND PARTICIPANTS: Third-year medical students on the internal medicine (IM) clerkship at our academic institution

DESCRIPTION: Uncertainty is inherent to clinical medicine. Though students will inevitably face clinical uncertainty, they rarely receive formal education in uncertainty. Best practices in timing and educational strategies are not established. We developed a curriculum consisting of (1) pre-reading (2) facilitated discussion with reflection and communication drills and (3) a standardized patient (SP) session. Students reflected on their experiences with clinical uncertainty, wrote how they would communicate uncertainty in a clinical scenario and reviewed a modified Uncertainty Communication Checklist (UCC), a checklist designed for use in emergency medicine and adapted for use in IM. Students practiced key steps in communication drills and applied skills in SP encounters. Students were separated into control and intervention arms based on assigned rotation site.

EVALUATION: To assess attitudes regarding clinical uncertainty, students completed a subscale of the Physicians’ Reaction to Uncertainty Scale (PRUS), developed by Gerrity et. al to measure stress from uncertainty. To assess communication skills, students completed an Objective Structured Clinical Examination (OSCE), scored using the modified UCC. 54 students participated in the curriculum (30 intervention arm, 24 control arm). Mean student age was 26. 57% of students identified as female. 94% of students reported no prior training in uncertainty. PRUS increased in both intervention and control arms with no significant difference in change in PRUS between the intervention and control arms (mean change in PRUS for intervention arm = 2.7, for control arm = 3.6, p = 0.33). There was a significant difference in OSCE results with intervention arm students scoring 2.1 points higher than control arm students (mean OSCE for intervention arm = 14.3, for control arm = 12.2, p < 0.001). At the end of four weeks, 97.7% of students agreed that a curriculum on uncertainty should be included in their medical training.

DISCUSSION / REFLECTION / LESSONS LEARNED: This curricular innovation demonstrates that a curriculum on communication of uncertainty is a feasible and acceptable addition to an IM clerkship. The majority of students agreed that this should be included in their medical training. Students who participated in the curriculum demonstrated improved skills in communicating uncertainty during their OSCE. Interestingly, there was a significant increase in PRUS indicating decreased stress associated with uncertainty for all students. This may reflect high levels of baseline stress associated with starting a third-year clerkship, increased comfort because of maturation, repeated exposure to cases or role-modeling by members of the clinical team. The next step will be to categorize types of uncertainty and tailor the curriculum to include nuances by uncertainty type.

ADVANCING DIVERSITY IN THE PHYSICIAN WORKFORCE THROUGH MISSION-BASED PATHWAY PROGRAMS

Lisandra Franco¹; Melody Tran-Reina¹; Alicia Gonzalez-Flores¹; Melody Y. Hou²; Mark C. Henderson¹; Tonya L. Fancher¹; Eric J. Crossen³; Antoinette Martinez⁴. ¹General Internal Medicine, University of California Davis, Davis, CA; ²OB/GYN, University of California Davis, Davis, CA; ³Pediatrics, University of California Davis, Davis, CA; ⁴University of California Davis School of Medicine, Sacramento, CA. (Control ID #4054441)

SETTING AND PARTICIPANTS: Data on race and ethnicity of learners enrolled in UME pathways at one medical school in the California-Hawaii region.

DESCRIPTION: Despite a state ban on affirmative action, one medical school developed an innovative approach to support diversity, equity and inclusion and address a workforce shortage of culturally and linguistically competent physicians. Five community health scholar (CHS) pathway programs were established, each addressing the healthcare needs of vulnerable populations including rural, central valley, urban underserved, and tribal communities. These mission-based undergraduate medical education (UME) pathways focus on health equity, cultural humility, and the clinical care of underserved communities. The pathways provide individualized clinical experiences, mentorship, and leadership development for students. CHS enrolls predominantly first-generation (FG) college students, who reflect the rich racial and ethnic diversity of the state’s underserved populations, which will ultimately result in more equitable healthcare through enhanced access to care, racial and language concordance, and improved trust among disadvantaged patient groups.

EVALUATION: We retrospectively reviewed self-identified race/ethnicity and FG college status among current CHS students (n=125). We defined underrepresented in medicine (URiM) as American Indian/Alaskan Native (AI/AN), underrepresented Asian American (e.g. Filipino, Hmong, Vietnamese, Cambodian), Black/African American, Native Hawaiian/Pacific Islander, and Hispanic/Latino. Students who reported more than one race/ethnicity were categorized as Multi-Race/Ethnicity URiM if they belonged to at least one of the above URiM groups. Of 125 students, 98 (78%) self-identified as URiM, and 67 (54%) as FG. By URiM group: 5 students (4%) identified as AI/AN, 12 (10%) as underrepresented Asian American, 15 (12%) as Black/African American, 0 (0%) as Native Hawaiian/Pacific Islander, 45 (36%) as Hispanic/Latino, and 21 (17%) as Multi-Race/Ethnicity URiM. URiM students by program were: rural 17/30 (57%); central valley 29/32 (91%); urban underserved 29/35 (83%); tribal 8/8 (100%); and accelerated primary care 15/20 (75%). We also compared the race/ethnic distribution of CHS students to the state’s population and to practicing physicians.

DISCUSSION / REFLECTION / LESSONS LEARNED: Increasing the racial and ethnic diversity of the physician workforce is essential to meet the healthcare needs of our increasingly diverse nation. The race and ethnic distribution of CHS students is more similar to the state’s population than current practicing physicians, underscoring the need for pathway programs to improve health equity. Mission-based pathways focused on health equity, cultural humility, and underserved clinical care can be a model for diversity, equity, and inclusion in medical education. Additionally, these programs are highly sought after by applicants, aiding in recruitment and retention of a diverse student body.

CONVERTING SMALL GROUP SESSIONS TO STANDARDIZED PATIENT ENCOUNTERS DURING AN INTERNAL MEDICINE CLERKSHIP

Lisa C. Martinez, Jennifer Foster, Sarah Wiggill, Tilak Patel. Medicine, Florida Atlantic University, Boca Raton, FL. (Control ID #4064538)

SETTING AND PARTICIPANTS: Third year Internal Medicine Clerkship Academic Half Day

DESCRIPTION: Students at our institution have standardized patient or simulation encounters every other week during their first and second years. During the third-year clerkships, they have weekly Academic Half Days (AHD) that include one hour of lecture, followed by 2 hours of small group sessions, with no opportunities with simulation or standardized patients (SP). We converted one of our small group sessions to a session with 2 SP encounters. One was intended to focus on diagnosis and management, while the other was focused on history, physical exam and clinical reasoning, observed by a faculty member. This was followed by a 20-minute debrief covering the key components of the session. The objectives were based on the CDIM core medicine clerkship curriculum.

EVALUATION: Students completed an evaluation at the end of the clerkship using a 5-point likert scale. Components that were evaluated included structure to foster learning (4.7); use of SP to reinforce topics (4.7); improvement in history taking (4.7); improvement in physical exam (4.6); improvement in knowledge of the topic (4.7); improvement in clinical reasoning of the topic (4.7). Students were also asked to provide narrative comments on the strengths and weaknesses of the session. Themes that emerged included that it was more immersive than reading cases and provided great opportunity for observed H&P and clinical reasoning. Many students commented on this being the most effective session of the clerkship. Areas for improvement included making the cases a bit more challenging, and some students preferred not to be in pairs.

DISCUSSION / REFLECTION / LESSONS LEARNED: Simulation and standardized patient sessions are important parts of medical education and have been shown to be effective tools. In Internal Medicine clerkships, 84% of programs use simulation, however only 39% use it for the purposes of teaching. Specifically for standardized patients, 54% of programs use this modality in their clerkship, but in over 70% it was used for assessments rather than teaching. We found that incorporation of SP encounters as part of the learning process allowed students to apply knowledge in a simulated environment under the guidance and feedback of a faculty member. Students felt this was a highlight of the clerkship. We plan to continue to add additional sessions in the future covering topics such as “breaking bad news” that can be difficult to teach when not performing the activity.

DETERMINING PROFESSIONAL IDENTITY FORMATION IDEAS FOR CLERKSHIP YEAR CURRICULA: STUDENTS' AND DIRECTORS' VIEWPOINTS

Angela Kang-Giaimo¹; Donna Windish². ¹Medicine, Yale School of Medicine, New Haven, CT; ²Internal Medicine, Yale University, Cheshire, CT. (Control ID #4027785)

SETTING AND PARTICIPANTS: Clerkship directors and clerkship students separtely shared ideas in zoom consensus building groups.

DESCRIPTION: Teaching medical students how to become a physician is fundamental to their professional identity formation (PIF). Developing curricula around PIF is currently institution based, and most work has been done with only faculty input. At our New England medical school, educational objectives in PIF were established; however, how to teach these objectives needed to be explored. We targeted the clerkship years and sought to determine consensus between clerkship students and clerkship directors across disciplines on this topic. We used nominal group technique (NGT) in two separately recruited groups of clerkship students and clerkship directors to determine consensus around our research question: “What are the knowledge, skills values, experiences, and/or behaviors that you think should be incorporated in medical students’ clerkship years in order to form one’s professional identity (PI)?”. Groups independently generated ideas, and had time for discussion, voting, and ranking. Mean rank scores for each item were calculated and used to make final lists.

EVALUATION: The six members of the clerkship student group included third, fourth, and fifth-year students. The five members of the clerkship director group had representation from internal medicine, psychiatry, surgery, and primary care. In the student group, the top five ranked items included: practicing patient-centered care, empathetic communication, skills – active listening, having the experience of taking complete ownership of a patient, and adaptability. In the director group, the top five ranked items included: self-reflective capacity, growth mindset, recognizing distress in self and others, accountability, willing to speak up. Clerkship students focused on the patient-provider relationship. In contrast, clerkship directors focused on student values and self-regulating behaviors. Overlapping ideas were those of interpersonal skills and ethical values.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our study adds to the literature about PIF by uniquely including the opinions of clerkship students alongside opinions of clerkship directors from different specialties. We found that students’ ideas in particular may not be as well represented in the current literature. We focused on clerkships years, which positions our results to be specific to one of the key factors in development of one’s professional identity – community of practice. Communities of practice are most apparent on a student’s clinical rotations when the social nature of learning is emphasized. PIF is most important during this time, when relational role modeling and professional socialization are most pertinent. Students and clerkship directors have different views on what should be included in a curriculum that teaches PI, from ideas that are more patient-focused to ideas that are more self-focused. Both viewpoints should be considered in PIF curricula.

EMPOWERING FUTURE PHYSICIANS: A CURRICULUM FOR ENHANCING UNDERSTANDING OF LANGUAGE BARRIERS AND THE USE OF MEDICAL INTERPRETER SERVICES (MIS)

Taru Saigal²; Mark Troyer²; Joanne B. Vakil¹; Robert M. McCord^2,1; Sofia Baena^2,4; christopher Pierson³; Melissa M. Quinn^4,2. ¹Office of Curriculum and Scholarship, The Ohio State University, Columbus, OH; ²College of Medicine, The Ohio State University, Columbus, OH; ³Pathology, Nationwide Children's Hospital, Columbus, OH; ⁴Biomedical Education and Anatomy, The Ohio State University College of Medicine, Columbus, OH. (Control ID #4060982)

SETTING AND PARTICIPANTS: Pre-clinical students as participants. Physicians, staff of Office of Curriculum & Scholarship and MIS as course facilitators.

DESCRIPTION: In 2023, our large academic medical center served 15,449 limited English Proficiency (LEP) patients. The Liaison Committee on Medical Education expects medical schools to teach communication skills and cultural competence. However, many medical students lack the knowledge and skills to engage with MIS. We designed an IRB approved innovative study and curriculum to increase student's understanding of impact of language barriers on health and promote effective utilization of MIS. The course had two parts, an asynchronous 60-minute didactic session and a synchronous component consisting of 60-minute case-based discussions followed by a 20-minute workshop for each student where bilingual physicians took the roles of standard patients and provided feedback. Prior to implementing the course, a needs assessment survey was conducted followed by pre- and post-course surveys to identify knowledge gaps and improvements following the workshop.

EVALUATION: Of 409 medical students, 38 (9% response rate) responded to the needs assessment survey. A majority (92%) expected to interact with LEP patients during their training. Almost half (47%) disagreed, or strongly disagreed that the curriculum adequately addresses this issue. Of these 87% desired a course that enhances their understanding of language barriers as a social determinant of health (SoDH). Surprisingly, 19% admitted to being unfamiliar with accessing MIS, and 58% described themselves as somewhat aware or unaware of MIS use. Subsequently, 25 medical students participated in case-based learning and workshop with simulations, pre and post course survey. All students (100%) understood the influence of language barriers on individuals' health and access to high-quality healthcare. While, prior to the course, 8% viewed the use of family members and friends as interpreters as acceptable in non-emergency situations, and 4% believed there was no difference between professional interpreters and non-professionals; after the course, all students (100%) concurred that clinicians have both legal and ethical responsibilities to engage qualified interpreters in healthcare settings.

DISCUSSION / REFLECTION / LESSONS LEARNED: Notably, medical students acknowledged the importance of addressing this critical gap in medical education. The incorporation of workshops and didactic sessions effectively enhanced student’s knowledge and proficiency of MIS utilization. Limited student participation due to the course's optional nature, and absence of a post-course subjective assessment highlight areas for improvement. In summary, our study supports a mandatory medical school curriculum to enhance understanding of language barriers, and promote effective medical interpreter utilization.

HOW MEDICAL STUDENTS BENEFIT FROM PARTICIPATING IN A LONGITUDINAL RESOURCE STEWARDSHIP MEDICAL EDUCATION PROGRAM (STARS): AN INTERNATIONAL DESCRIPTIVE EVALUATION

William K. Silverstein^1,2; Sanne Vaassen³; Marlou Kerssens³; Christopher Moriates⁴; Brian Wong^1,2; Karen Born⁵. ¹Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; ²Medicine, University of Toronto, Toronto, ON, Canada; ³Universiteit Maastricht, Maastricht, Limburg, Netherlands; ⁴Medicine, University of California Los Angeles, Los Angeles, CA; ⁵Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada. (Control ID #4063827)

SETTING AND PARTICIPANTS: Since clinical training environments impact future practice patterns, influencing medical education to emphasize the importance of resource stewardship is a key pillar of Choosing Wisely campaigns’ strategies to reduce the ongoing delivery of inappropriate care. Thus, Choosing Wisely Canada designed and launched STARS (Students and Trainees Advocating for Resource Stewardship) in 2015 to promote integration of resource stewardship into medical education. This program has since spread to at least 7 countries. We conducted qualitative semi-structured interviews with a representative sample of STARS participants (n=26) from Canada, Japan, Italy, the Netherlands, New Zealand, Norway, and the US from May to December 2018.

DESCRIPTION: STARS empowers medical students to lead grassroots efforts that advance integration of stewardship principles into medical education at their local institution. This student-led approach was purposefully designed to facilitate bottom-up, grassroots cultural shifts in medical schools, as well as support formal curricular change. While STARS programs globally differ in terms of structures and approach, they share common features: participation of students from several medical schools, attending centralized leadership summits, and support from both national and local faculty mentors. Students are tasked with taking lessons learned from STARS programming to implement changes that advance resource stewardship initiatives at their own schools.

EVALUATION: We undertook a qualitative interpretive interview study design and an inductive analysis approach to understand how participation in this medical student advocacy and leadership program affects the knowledge and skills that student leaders gained or its impact on career trajectory. Students finished the program with better knowledge of topics related to resource stewardship, enhanced skills needed to influence change (including leadership, advocacy, and collaboration), and a commitment to incorporate resource stewardship into future practice. Nearly all respondents stated that they hoped to continue to engage in leadership activities in medicine, but most were unclear as to whether they would continue with leadership related to resource stewardship.

DISCUSSION / REFLECTION / LESSONS LEARNED: This international evaluation of the impact of STARS programs’ dissemination was delayed by the COVID-19 pandemic. We found that medical student participants gained knowledge as it relates to resource stewardship, change management skills, and catalyzed a commitment to incorporate high-value care into future practice. Future studies should evaluate the long-term impact that participating in STARS has on alumni. Organizations interested in eliminating low-value care should continue to leverage medical education initiatives as a key strategic approach to build capacity.

ONLINE RESOURCE URL: https://choosingwiselycanada.org/stars/; https://costsofcare.org/stars2024/

IMPACTS OF CLIMATE CHANGE ON HEALTH: A PEER EDUCATION INITIATIVE

Jennifer Caputo-Seidler, Dawn M. Schocken, Vinita Kiluk. University of South Florida Morsani College of Medicine, Tampa, FL. (Control ID #4063651)

SETTING AND PARTICIPANTS: A stand-alone climate change curriculum that occurs at the end of the fourth year of medical school. It incorporates an introductory lecture, small group activities, and in-person presentations. 175 fourth-year medical students participated in the climate change curriculum in the 2021-2022 academic year.

DESCRIPTION: Medical students have been at the forefront of advocating for the incorporation of climate change in the standard medical school curriculum. A 2022 survey by the Association of American Medical Colleges (AAMC) found that 55% of schools currently include climate change in their required curriculum. Our institution implemented this climate change innovation in 2021. The innovation consisted of a high-level introductory lecture on the effects of climate change on human health by an expert in the field. Following this introduction, students were assigned to small groups and each was given a climate change topic. Groups were subdivided into subgroups A and B. Subgroup A was tasked with describing the current health impacts of various aspects of climate change. Subgroup B was tasked with offering possible solutions to those impacts. Each group created a 15-20 minute PowerPoint presentation of their findings to educate their peers. The presentations were delivered in a two-day in-person event taking place during the week of graduation.

EVALUATION: Following the climate change presentations, a post-session survey was sent to all participants. 153 of the 175 participants completed the post-session survey. Free text responses indicated that students believed they were more aware of the effects of climate change on health after the presentations and had enjoyed learning solutions they could implement as they transitioned to residency. Sample responses are below:

“Gave me a much broader view as to how far reaching the climate impacts our health and well-being.”

“I enjoyed my peers presenting methods by which physicians can work to combat climate change-even changing anesthetic gases to avoid air pollution.”

DISCUSSION / REFLECTION / LESSONS LEARNED: The impact of climate change on health is undeniable and it is critically important that we equip our medical students with the knowledge and skills needed to recognize the relationship between climate change and health, diagnose climate-related illness, and advocate for climate change policies that will positively impact their patient’s health and healthcare. Similar to other institutions, we faced constraints of time and space within the core curriculum for this addition, thus leading to the stand-alone course at the end of the fourth year. This created its own challenge with buy-in from the participating students given the proximity to graduation. In addition, while the survey identified positive perceptions of improved knowledge after participating in this curriculum, we do not know if there was any impact on behavior as these students transitioned into residency.

NEAR-PEER MENTORSHIP: AN OPPORTUNITY FOR LEADERSHIP DEVELOPMENT AMONG MEDICAL STUDENTS

Anne Frank²; Frances Vernon³; Ann Mackey²; Jennifer Adams¹. ¹General Internal Medicine, University of Colorado, Denver, CO; ²Medicine, University of Colorado Denver School of Medicine, Denver, CO; ³University of California San Francisco, San Francisco, CA. (Control ID #4064070)

SETTING AND PARTICIPANTS: Fourth-year medical student graduates of longitudinal integrated clerkships (LICs) at a single medical school are selected through a competitive process to participate in a longitudinal elective peer-mentorship and leadership course. Ambassadors interface with junior students, faculty mentors, and curriculum staff.

DESCRIPTION: Peer mentorship is increasingly recognized throughout the continuum of medical education as a mechanism to support career and personal development. The LIC Ambassador (peer mentor) course runs through the 4^th year and serves as a formalized peer mentorship program. Secondary aims are to enhance student leadership skills and complete a mentored project. Projects are aimed at enhancement of the clerkship and clinical learning environment. Half of the LIC programs were assigned LIC Ambassadors creating an opportunity to pilot this curriculum and compare outcomes.

EVALUATION: A comprehensive evaluation was undertaken to assess the impact of the Ambassador program. At the end of the pilot year, the Ambassadors (n=10) were surveyed: 90% agreed/strongly agreed to the course increasing their likelihood to pursue leadership roles in the future, 90% felt prepared to address peer concerns, and 90% were satisfied/highly satisfied with their ambassador experience. LIC Directors (n=5) were surveyed: 100% agreed/strongly agreed that the LIC ambassadors were useful, helped to bridge communication, and added value to the program. LIC directors were split in opinion about whether the ambassador program saved or cost time, but 100% agreed the benefit outweighed the cost. Current LIC students (mentees) who had exposure to Ambassadors (n=88 ) and those who did not were surveyed (n=92). On a 6-point Likert scale, students with Ambassadors had a significantly higher mean response to the question: “how frequently did you feel supported by peer-mentors (students a year or two ahead of you)?” (3.47 vs. 2.98, p<0.05).

DISCUSSION / REFLECTION / LESSONS LEARNED: Near-peer mentorship meets an important need for clerkship students and provides an opportunity for leadership for senior medical students through the nurturing of collaboration and relationships. A longitudinal course model creates structure for curriculum delivery, oversight of project work, and meaningful student contributions to the medical school curriculum. All participants, including the mentor and mentee students, faculty, and staff, found value in this co-produced model of curriculum delivery. In recognizing the importance of relationship-based education, fostering models of mentorship beyond faculty/trainee has the potential to enhance educational experiences for all participants and improve educational outcomes.

REFRESHING “SOAP” TO ENHANCE TEAMWORK – A PRIMER ON “SBAP”

Nancy Chang, Suraj S. Shah, Mytra Haerizadeh. Internal Medicine, Columbia University Irving Medical Center, New York, NY. (Control ID #4064941)

SETTING AND PARTICIPANTS: Early career clinician educators for UME and/or GME

DESCRIPTION: A major focus of training is learning to gather, organize, process, and communicate clinical situations to teammates. Succinct, predictable, and informative synthesis in the form of oral case presentations allow colleagues and supervisors to quickly become helpful partners in the care of patients not yet seen. Trainees are taught to present patients using the typical “SOAP” (Subjective, Objective, Assessment, Plan) format for hospital admissions or clinic visits. This format, while great to succinctly represent single problem admissions or focused outpatient visits, is challenging to use when trying to capture multiple intersecting biopsychosocial domains and uncertainties in the illness experience. We present an update to the traditional SOAP model by merging it with SBAR. The new “SBAP” – Situation, Background, Assessment, and Problem identification – has the potential to standardize the communication paradigm, leading to more effective and efficient clinical and educational collaboration. The Situation and Background sections provide contextual information and history of present illness with relevant prior medical history to frame the subsequent Assessment and Problem identification. These latter two sections emphasize problem representation and showing one’s clinical reasoning through the identification of biopsychosocial problems to the highest level of uncertainty – thereby allowing a preceptor, consultant, or attending to be able to impart their expertise. With “P” now standing for Problem identification instead of Plan, we seek to affirm Lawrence Weed's original teaching – that problem identification paints a more complete road map toward patient centered care and better outcomes.

EVALUATION: Formal collection and interpretation of qualitative data is pending with a proposed plan of using surveys to collect assessments of SBAP after various styles of didactic interventions.

DISCUSSION / REFLECTION / LESSONS LEARNED: The SBAP model of patient presentation invites collaboration and communication amongst diverse teammates. Other presentation methods, like SOAP, SNAPPS, and SBAR, reviewed in prior observational studies lack the ability to halt and dissect the diagnostic momentum. The focus on problem identification in the SBAP model allows trainees to identify different biopsychosocial factors and construct a differential that acknowledges uncertainty, rather than immediately anchoring on a diagnosis and plan. The efficacy of implementing this model has yet to be assessed and can hopefully work best in early trainees who are developing their diagnostic and clinical reasoning – from UME to GME.

SOCIAL ISSUES IN MEDICINE: QUALITATIVE EXPLORATION OF AN INNOVATIVE, SERVICE LEARNING COURSE FOR MEDICAL STUDENTS.

James R. Martindale²; rebecca leatherwood²; andrew s. Parsons¹; Mohan Nadkarni¹. ¹Internal Medicine , University of Virginia Health System, Charlottesville, VA; ²Medical Education, University of Virginia, Charlottesville, VA. (Control ID #4063661)

SETTING AND PARTICIPANTS: Innovative Year- Long Required Community Service Learning Course at an Academic School of Medicine involving 1,490 First Year Medical Students and their 2976 reflective essays over 11 consecutive years.

DESCRIPTION: The Social Issues in Medicine ( SIM) course is an innovative, community based service learning course at a Southern school of medicine required for all first year medical students..SIM consists of 16 lectures, community service learning placements with local nonprofits ,(25 hour per student) ,class discussions and student narrative reflections with the following 4 goals

1) Identify social,cultural, economic and political issues( SDOH) that characterize the context in which medicine is practiced today.

2)Describe the qualities associated with the humanistic and professional practice of medicine.

3) Practice the skill of self-reflection and identify strengths, preferences and limitations that may influence their practice of medicine.

4) Describe what it means to practice an ethic of service.

EVALUATION: We conducted a thematic analysis of the narrative reflections to assess achievement of course goals.

2976 Student reflective essays written by 1490 students during the SIM course between 2012 and 2023 were included for analysis.

Narratives were analyzed using Speak Ai software.{ Speak Ai Inc. (2023). Speak [Large language model]. https://speakai.com} which was prompted to identify positive and negative themes discussed by students to describe their experiences from SIM..

Top positive themes reported:

1. Self-discovery and personal development through volunteering and service.

2. Importance of good communication skills and non-judgmental attitude in healthcare.

3. Awareness and understanding of social issues and their impact on patients.

4. Recognition of the unique narratives and backgrounds of individuals.

5. Advocacy for marginalized and vulnerable communities.

6. Importance of listening to and prioritizing each patient's voice and needs.

7. Education and awareness about addiction and its effects.

Top negative themes reported

1. Negative emotions and traits reflected in interactions with others.

2. Negative experiences and stories related to HIV diagnosis and healthcare communication.

3. Challenges and barriers faced by marginalized and vulnerable populations.

4. Impact of poor housing, substance use, mental health, and discrimination on health.

5. Lack of education and awareness about addiction and its consequences.

6. Systemic racism and inequalities in healthcare.

7. Difficulties in addressing social determinants of health and health policy issues.

DISCUSSION / REFLECTION / LESSONS LEARNED: Qualitative analysis of 11 years of narative refelctions derived from the SIM course indicate this service learning course is successful in teaching medical students the importance of SDOH in the practice of medicine, the need for adovcacy for vulnerable populations and in inculcating an ethic of service as part of professional medical practice.

ONLINE RESOURCE URL: https://learn.med.virginia.edu/course/social-issues-in-medicine/6513/mission-and-goals/351

USING TECHNOLOGY TO ENGAGE CLERKSHIP STUDENTS DURING ACADEMIC SMALL GROUPS

Lisa C. Martinez, Jennifer Foster, Sarah Wiggill, Celine Vartany. Medicine, Florida Atlantic University, Boca Raton, FL. (Control ID #4064497)

SETTING AND PARTICIPANTS: Third year Internal Medicine Clerkship Academic Half Day

DESCRIPTION: Our current third year curriculum utilizes an Academic Half Day each week to bring students back to learn core concepts in each clerkship. These AHD sessions are a combination of a one-hour lecture, and 2 hours of small groups. Students have become accustomed to and expect integration of technology into teaching. Further, with student body expansion, faculty time is more limited. We created an online gamified approach to teaching endocrine topics that can be completely student driven. Using an online slide platform (Google Slides) two escape rooms were created- one for thyroid and another for adrenals. Then, using an online survey software (Qualtrics), a skip logic case-based activity focusing on thyroid cases was developed. These two activities were merged into one Academic Half Day experience that replaced the need for a faculty member to facilitate a two-hour session. The objectives of this session were based on the CDIM core medicine clerkship clinical curriculum.

EVALUATION: Students were provided with an evaluation at the end of the clerkship specifically asking about their experience with the session, and these were scored using a 1-5 Likert scale. The areas assessed included structure of the session (4.5); effectiveness of session without faculty (4.5); case-based portion was organized and reinforced topics (4.6); escape room portion was organized and reinforced topics (4.2); session improved knowledge on topic (4.3); session improved clinical reasoning on the topic (4.4). The students were also offered an open-ended section to comment on strengths and weaknesses. Themes included students enjoyment of the creative and new way to approach a case and reinforce topics. Areas for improvement were regarding communication of how to actually complete the session, and in the case of the group that completed the activity virtually instead of in person, it was felt that it was difficult to collaborate on the games virtually.

DISCUSSION / REFLECTION / LESSONS LEARNED: The literature supports the use of technological games in general and medical education, although the evidence is limited. This activity introduced a fresh and novel way to engage students, which also resulted in subjectively improved knowledge and clinical reasoning. It also freed up a faculty member to deliver a hands-on simulation activity for another group of students. In response to the feedback regarding the organization and instructions, we have adjusted for the second half of the semester. We feel this is an applicable form of education that other Internal Medicine clerkships can utilize to both engage learners as well as more efficiently use faculty time. We will be expanding this format to additional clerkships as well.

ONLINE RESOURCE URL: https://docs.google.com/presentation/d/1CPmCUP9rh89OWxpqsbP_IsioYyGOpWwErfdHqPNUIvA/preview?usp=sharing

USING VERBAL PROCEDURES TO DEVELOP SKILLS IN IMPLICIT BIAS RECOGNITION AND MANAGEMENT FOR FIRST YEAR MEDICAL STUDENTS

Jessica Dennehy¹; Ryan Wilkerson³; Walter Parrish³; Richard E. Greene²; Renee Williams^1,2; Cristina M. Gonzalez¹. ¹Institute for Excellence in Health Equity, NYU Langone Health, New York, NY; ²Medicine, NYU Grossman School of Medicine, New York, NY; ³Office of Diversity Affairs, NYU Langone Health, New York, NY. (Control ID #4060302)

SETTING AND PARTICIPANTS: We describe an innovation on addressing implicit bias delivered to first-year medical students at two urban academic medical centers.

DESCRIPTION: Each cohort received an introduction to implicit bias and healthcare disparities; this session occurred ~8 weeks later. We highlighted the framework of Implicit Bias Recognition and Management, the influence of patients’ lived experiences (such as experiencing frequent discrimination, which may cause patients to perceive bias from their clinician on statements typically considered routine), and provided clinical examples. Session goals were to develop “verbal procedures” (verbatim statements) to restore rapport when: 1) Bias had been perceived by a patient on a routine statement; and 2) The clinician made a statement rooted in implicit bias. Cohort 1 worked in pairs. Guided by worksheets, students role-played (RP) the physician or patient, gave feedback, and revised their verbal procedures. Cohort 2 worked individually, submitting their answers through an audience response system (ARS).

EVALUATION: We received IRB approval to qualitatively analyze verbal procedures. In Scenario 1, a physician sees a 19-year-old Black man with an elbow injury and asks the patient if he smokes (perceived bias on a routine question). In Scenario 2, the physician sees a 22-year-old female for endometriosis. The physician responds to the patient with a statement rooted in implicit bias when wrongly assuming the patient’s sexual orientation. We received N=97/103 (Cohort 1) and N=22/166 (Cohort 2) complete responses. Two coders independently and in duplicate generated and applied codes to the verbal procedures. They assigned a point value to each code based on being unhelpful (-1) and helpful (+1) for restoring rapport with patients once bias was perceived. Scores ranged from 1 to 5. For example, “I am very sorry for making an assumption about your sexuality. I should have asked you why you were taking oral contraceptives before assuming. What can I do to help restore our relationship so I can help you get the care you need in a safe place for you.” (Score = 3). “I’m sorry if I offended you with that question. It’s not my intention to make you uncomfortable or imply anything about you. This is a question I ask all my patients in order to get a complete picture of their medical and social history.” (Score = 1) Cohort 1 attained higher scores on their verbal procedures than Cohort 2 (Scenario 1: 2.44 vs 2.12 p=n.s.; Scenario 2: 2.6 vs 2.3 p=n.s.).

DISCUSSION / REFLECTION / LESSONS LEARNED: Verbal procedures suggested achievement of the session goal. Verbal procedures had more helpful components for students who developed them in RP (cohort 1), but this was not statistically significant, possibly due to our small sample size. Findings suggest important lessons: 1) RP engage learners more effectively and may produce higher quality verbal procedures; and 2) ARS may allow for development and articulation of verbal procedures, be more efficient, and potentially not inferior to using RP.

VALUE-BASED CARE CASE REFLECTIONS BY MEDICAL STUDENTS DURING THE INTERNAL MEDICINE CORE CLERKSHIP

Felix D. Rozenberg¹; Isabel McFarlane². ¹College of Medicine, SUNY Downstate Health Sciences University College of Medicine, New York, NY; ²SUNY Downstate Health Sciences University Department of Medicine, New York, NY. (Control ID #4064935)

SETTING AND PARTICIPANTS: This initiative aimed to evaluate an entire class of third-year medical students as they progress through their core Internal Medicine (IM) clerkship at a medical school in the Mid-Atlantic region while concurrently completing value-based care (VBC) modules. Currently, 111 third-year medical students have completed pre-clerkship evaluation, followed by completing VBC modules. 77 students have completed value-based care case reflections with their attending preceptor.

DESCRIPTION: The integration of health systems science education into undergraduate medical education is vital for training physicians to navigate the evolving healthcare landscape. A key aspect of this integration is incorporating VBC concepts into medical school curricula. VBC aims to enhance health outcomes cost-effectively by prioritizing management strategies for long-term well-being. The shift to a VBC framework represents a paradigm change in healthcare delivery, necessitating the preparation of medical students with the knowledge and skills to excel in this evolving landscape and promote better health outcomes for patients.

This study introduced VBC concepts to third-year medical students through modules created by the Institute for Healthcare Improvement and American College of Physicians during their IM clerkship. Students met regularly with an attending preceptor to discuss cases seen during their rotation. The students were required to reflect on the themes of VBC as they applied to one case with each preceptor.

EVALUATION: Changes to students' perspectives and attitudes towards VBC and its applications were evaluated through pre and post-clerkship surveys and written reflections where students discussed how the experience of the IM clerkship and VBC modules had impacted their clinical decision-making approach.

Following VBC modules and the IM clerkship, 94.81% of students reported being "more likely" to “discuss the risks and benefits of tests” with their attending. Additionally, 93.51% were "more likely" to “discuss how test results would affect management” and “potential risks to the patient.” Moreover, 58.44% reported that the VBC curriculum strengthened their understanding of using information for clinical decisions. Mean ranked priorities after the clerkship remained largely unchanged. Finally, 46.34% strongly agreed, and 41.46% somewhat agreed that discussions with attending physicians about value-based care bolstered their medical knowledge.

DISCUSSION / REFLECTION / LESSONS LEARNED: The integration of the VBC curriculum during the IM clerkship effectively acquainted medical students with essential concepts VBC. Beyond merely introducing them to VBC principles, this curriculum served as a robust framework that not only broadened their perspectives but also played a pivotal role in enhancing their medical knowledge, particularly in the realm of evidence-based medicine.

“IT’S IN OUR LANE:” TEACHING MEDICAL STUDENTS CLINICAL AND PUBLIC ADVOCACY SKILLS FOR FIREARM INJURY PREVENTION IN A 90-MINUTE CLINICAL SKILLS LAB

Katherine Iossi^1,2; Patricia A. Carney⁵; Kelsi Manley⁶; Ryan Kane⁴; Rebecca Teichman²; Joel Burnett³. ¹General Internal Medicine, Portland VA Medical Center, Portland, OR; ²Oregon Health & Science University, Portland, OR; ³Medicine, Oregon Health & Science University, Portland, OR; ⁴General Internal Medicine, Duke Medicine, Durham, NC; ⁵Family Medicine, Oregon Health & Science University, Portland, OR; ⁶Internal Medicine, Oregon Health & Science University, Portland, OR. (Control ID #4062091)

SETTING AND PARTICIPANTS: Required Clinical Skills Lab for all 2^nd year medical students (n=147) at one academic medical center in the Northwest

DESCRIPTION: Firearms caused 48,830 deaths in the US in 2021 and have surpassed motor vehicle accidents as the leading cause of death for children, teens, and young adults. Although evidence-based solutions exist, national discourse on the issue is charged. Physicians remain a credible source of information on health and have an opportunity to bridge social and cultural divisions. Leading U.S. medical organizations call for clinical and policy advocacy by physicians on firearm injury prevention, though skills are not widely taught. We implemented a required course on these skills for 2^nd year medical students at one academic medical center. The course included 30 minutes of asynchronous prework and 90 minutes of synchronous active learning in small groups. Prework included a voice-over Powerpoint and short videos on epidemiology, evidence-based interventions (secure storage, lethal means counseling, violence prevention programs, and “red flag” laws), and frameworks for conversations with patients and policymakers. Small groups, consisting of 9-10 students, were led by pairs of clinicians and public health officials or researchers on firearm injury prevention. Active learning activities included role-play scenarios on conversations between physicians and patients as well as physicians and policy makers.

EVALUATION: We used a de-identified assessment with a retrospective pre- post design to assess changes in students' perceived knowledge and intent for advocacy using a five-point scale (1=Strongly Disagree to 5=Strongly Agree). We also assessed self-reported firearm injury and use. Paired t-tests were used to assess for statistical significance. All tests were two-tailed with alpha set at 0.05 to determine statistical significance.

DISCUSSION / REFLECTION / LESSONS LEARNED: One hundred and five students completed the assessment (71.4% response rate). All nine measures of knowledge and intention to integrate advocacy increased significantly (p<0.001) with Cohen’s d >0.80, indicating educationally meaningful effect sizes for all findings. Greatest increases in knowledge were for: understanding evidence-based public health approaches (mean pre-program: 1.97; mean post program: 4.01; p<0.001) and confidence in ability to discuss firearm safety with patients (mean pre-program: 2.53; mean post program: 3.74; p<0.001). Over 13% of respondents (13.3%) reported they or those close to them had been injured by firearms, and 40% have used firearms. Qualitative results identified variability in preferences for learning content and areas for improvement to overcome strong cultural differences. Students appeared to embrace the role of physician as patient and policy advocate. They understand and can apply what they learned in patient care toward addressing firearm safety.

Innovation in Medical Education (IME) - DEI, Health Equity, and Social Determinants of Health

A NATIONAL VIRTUAL CURRICULUM FOR PHYSICIAN-ADVOCACY: Nicole Damari. Internal Medicine, University of Cincinnati, Cincinnati, OH. (Control ID #4064723)

SETTING AND PARTICIPANTS: This virtual curriculum was available nationally, ultimately reaching 82 participants across 6 webinars, 34 of whom responded to the post-attendance survey. Of those surveyed, 52.9% were residents, 38.2% were medical students, with the remainder consisting of fellows and attendings. Surveyed participants represented 24 states and territories in the United States. Prior to participating, on a Likert scale for 1-5 (strongly disagree to strongly agree), 85.3% of surveyed participants strongly agreed that advocacy was an important part of a physician’s role and 82.4% strongly agreed that they wanted to incorporated advocacy into their career as a physician.

DESCRIPTION: The curriculum consisted of hour-long webinars timed from 8-9 pm Eastern on six advocacy topics: LGBTQ Health, Intimate Partner Violence, Disability Rights, Anti-Racism, Immigrant and Refugee Health, and Health of Incarcerated and Formerly Incarcerated Populations. Each session included 1-4 invited expert panelists who each spent 5-10 minutes presenting their work, highlighting the advocacy tactics and strategies used to meet their specific advocacy goals. The remainder of the session was used for participant questions and discussion.

EVALUATION: After each webinar, participants received a survey with 5 questions on a Likert scale from 1-5 (strongly disagree to strongly agree), as well as an opportunity for free response. 91.1% of participants agreed or strongly agreed that the session was relevant to their career as a physician. While 26.4% of participants agreed or strongly agreed that they felt knowledgeable about the presented advocacy topics prior to attending, 91.2% did after attending. Similarly, while 22.5% of participants agreed or strongly agreed that they felt comfortable applying the skills discussed to their own advocacy projects, 82.4% did after attending. 18 participants used the free response section to discuss specific initiatives that they hoped to launch or grow using the skills.

DISCUSSION / REFLECTION / LESSONS LEARNED: With the growing role of advocacy in medicine and medical education, there is a need to continue to develop accessible curricula that demonstrate how advocacy can be incorporated into a physician’s career and empower trainees with tools to develop and execute their own advocacy initiatives. This virtual curriculum allowed trainees to learn from nd dialogue with physician-advocates from across the United States. The virtual curriculum was logistically and financially low cost and could be easily replicated, included with advocacy topics not addressed in this series. The use of brief presentations from the expert panelists with a sizeable portion of the time left open for questions and discussion led to high engagement sessions that left participants feeling more knowledgeable about the advocacy area and more comfortable executing their own advocacy projects. Creating this forum for learning and discussion met the dual goal of helping trainees identify key advocacy issues and empowering them with tools to address them.

A RESIDENT-LED LONGITUDINAL ADVOCACY PROJECT

Abhishek Dhar, Nabil Abou Baker. Internal Medicine/Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #4062593)

SETTING AND PARTICIPANTS: There has been significant interest recently in teaching trainees to be physician advocates. However, thus far, that work has focused largely on didactic education about skills required in advocacy and has lacked the development of those skills through practical application. In this project we enlisted all residents in the internal medicine/ pediatrics program at an academic institution in the Midwest to initiate, manage, and complete a year-long project to develop and apply those skills while making a real-life impact.

DESCRIPTION: At the beginning of the year, residents brainstorm and vote on an advocacy topic with the potential for practical impact that they will then undertake for the rest of the year. As they rotate through 2-week ambulatory rotations throughout the course of the year, they have 4 hours per week set aside to take the lead on and advance the project. The first phase involves direct outreach (volunteer work) to perform a needs assessment. The second phase involves advocating to appropriate parties (through op-eds, meetings with government officials, etc) to address the identified needs. The capstone is a grand rounds presentation by the residents on their impact. This process is overseen and guided by faculty members experienced in advocacy work. At the beginning of the following year, they choose whether to continue the project or choose to undertake a project in a different area of interest.

EVALUATION: The evaluation includes pre - and post- project surveys completed by residents measuring their attitudes towards, comfort with the skills required in, and future plans for physician advocacy. We expect residents to feel more passionate about advocacy after seeing the human impact firsthand, feel more comfortable using advocacy skills after practical experience, and be more likely to incorporate advocacy into long-term career plans after being involved in the project.

DISCUSSION / REFLECTION / LESSONS LEARNED: A longitudinal advocacy project gives residents practical experience performing advocacy work, as well as allows them to use, develop, and hone the skills required to be a physician advocate. Such a project can be undertaken by a wide range of training programs and tailored towards individual specialties. Unfortunately, this project does require regular time set aside from clinical duties for residents to be able to commit to and make significant progress on a topic in addition to their normal residency responsibilities. In addition, as there was one topic chosen for all residents in the program, there may be different levels of buy-in and efforts from individual residents based on their varying levels of interest in and passion for the topic. Larger programs may have to divide residents by similar interests to facilitate buy-in and coordination.

BE THE CHANGE: INFUSING EQUITY AND ANTI-OPPRESSION IN LEARNER-DRIVEN CLINICAL DIDACTICS

Christopher Sha^1,2; Denise L. Davis^1,2; Nadine Pardee^1,2. ¹Medicine, University of California San Francisco, San Francisco, CA; ²General Internal Medicine, San Francisco VA Health Care System, San Francisco, CA. (Control ID #4059216)

SETTING AND PARTICIPANTS: Outpatient VA clinic in California-Hawaii region MD residents, NP students & residents, MD & NP attendings

DESCRIPTION: Education with a focus on equity has seen significant growth in recent years, with foundational sessions such as implicit bias and anti-racism becoming more ubiquitous in medical education. While these central elements provide a common language to start conversations around diversity, equity and inclusion, there is more work to be done to bring equity to the forefront of our learning environment and clinical care. We sought to compliment this foundational teaching by integrating equity-based education into our existing post-clinic conference on core primary care topics taught by interdisciplinary trainees at our academic VA clinic (78 sessions annually).

Only 1 of 21 available presentations from AY 2022-23 discussed an issue of equity. At the beginning of AY 2023-2024, we presented “Building an Equitable Post-Clinic Conference,” instructing trainees to approach their presentations with an equity lens, and to teach their colleagues about how equity – or inequity – comes to bear on a given clinical topic. The aim was to incorporate one anti-oppressive (AO) teaching point or perspective in each conference and to demonstrate the impact of incorporating AO pedagogy in creating culture. During the session, learners reflected on effective AO approaches and we provided 10 concrete strategies with salient examples, such as representation in research and medical education, structural causes of health disparities, and shared decision-making. We provided a range of different ways to engage with AO concepts, with latitude for the teacher to include what they felt was most meaningful or relevant.

EVALUATION: To date we have collected 14 slide decks from AY 2023-24, 10 of which contain at least one AO teaching point - an increase from 4.8% to 71.4% after our intervention. Learners readily incorporated important equity and AO concepts into their talks, such as lack of research on PSA screening in transwomen, higher breast cancer mortality in black women despite lower incidence, and race, gender and income disparities in colon cancer screening.

DISCUSSION / REFLECTION / LESSONS LEARNED: These types of teaching points are critical in several ways. Attention to equity impacts quality of care for patients in marginalized groups. It also encourages us to consider the impact of disparities on our interpretation of trial data, guidelines and doctor-patient relationships. It establishes that AO teaching is as important as clinical teaching in diagnosis and treatment, and creates a learning environment where more voices are represented. Finally, it highlights areas where more or better research is needed to care for diverse populations. With a relatively small intervention, we achieved a demonstrable increase in learner-driven exploration of equity. Infusing every element of our curriculum with these concepts is essential to build a more equitable medical culture in future generations – to be the change we want to see.

BRIDGING THE GAP: UNITING PROVIDER EDUCATION AND COMMUNITY RESOURCES TO ADVANCE HEALTH EQUITY

Nicole Thomason, Christine Santiago. Internal Medicine, Stanford Medicine, Stanford, CA. (Control ID #4064368)

SETTING AND PARTICIPANTS: Academic medical center in the California-Hawaii Region

DESCRIPTION: Despite the importance of education on health disparities, medical residents often receive limited and inconsistent training in this area. Because of this, valuable research on health disparities published in esteemed journals often goes unnoticed and undiscussed. Moreover, we recognize that health equity education should not be solely informative but should empower providers to take action and collaborate with their communities to address disparities. This project aims to advance health disparities education and also connect it with action by linking curated health disparities research with targeted resources in the local hospital community.

We will implement a comprehensive quarterly newsletter which covers new social determinants of health research; the newsletter will be paired with a reference document containing curated resources available at our academic center and the surrounding community for caring for vulnerable patient populations. Resources provided will be designed to address topics such as, but not limited to, food insecurity, overcoming language barriers for limited english proficient patients, LGBTQ+ health and housing assistance. By linking education with actionable steps, our project both addresses the knowledge gap surrounding healthcare inequalities and equips healthcare providers to effectively address these issues.

EVALUATION: We will quantitatively measure the impact of our newsletter and resource initiative with a Likert scale to assess effectiveness in meeting the outlined learning objectives. Participants will be asked to rate the degree to which healthcare providers integrate ongoing health disparities research into their patient care practices and evaluate their ability to incorporate additional resources into daily clinical decision-making to address social determinants of health. The first edition of our newsletter will be released in January of 2024 and will have data by February 2024 which will be analyzed prior to presenting at SGIM.

DISCUSSION / REFLECTION / LESSONS LEARNED: By searching for new and ongoing health equity research, this project has illuminated the depth of social determinants of health research that often goes undiscussed within medical training, revealing a critical gap in awareness. Furthermore, uncovering the hosptial and community-based resources revealed their potential impact on addressing social determinants of health, yet the lack of clear connections poses a challenge for healthcare providers unaware of their existence. As we move forward, the lessons learned from navigating these complexities will guide our ongoing efforts to bridge gaps, foster collaboration, and enhance the accessibility of resources, ultimately contributing to more effective and widespread initiatives in addressing health disparities.

ONLINE RESOURCE URL: https://docs.google.com/presentation/d/1uDuOeIpNpc63TzgwMuOvIL6jxG1_G8eaSfgWomFx2mk/edit?usp=sharing

CO-PRODUCING AN INCLUSIVE LEARNING ENVIRONMENT: RESIDENTS AND FACULTY DESIGN OSCES TO ADDRESS BIAS BY PATIENTS

Christian Torres, David Morales, Amber Whitley, Renee Heller, Margaret Horlick, Barbara Porter, Richard E. Greene, Sondra R. Zabar. Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4064964)

SETTING AND PARTICIPANTS: Internal medicine (IM) residents and faculty at an academic medical center.

DESCRIPTION: Discrimination toward trainees is a pervasive problem, with surveys showing it is often perpetrated by patients. For several years, residents and faculty in our IM program have participated in a workshop offering a framework for responding to discriminatory behavior by patients. As part of a larger effort to reinforce this teaching and promote an inclusive environment, we pursued a multi-pronged simulation curriculum across multiple learner levels. First, we conducted resident and faculty focus groups to better understand their experiences. Qualitative data was collected including best and worst practices for responding to discrimination, characteristics of the most common experiences, and trainees’ own ideas for worthwhile simulation scenarios. We then brought together residents and faculty in a collaborative process to co-develop simulation cases. Our first two cases targeted two high-yield learner groups identified in focus groups: chief residents and hospital medicine faculty. The former participated in a team-based simulation curriculum with a case in which they counseled a standardized resident struggling after multiple episodes of discrimination. Our hospital medicine faculty participated in a combination workshop and simulation experience where they practiced responding to a standardized patient who made biased comments toward a standardized intern. Both groups debriefed the simulations and were given frameworks and feedback. Participants then completed a retrospective pre/post evaluation survey.

EVALUATION: 25 chief residents participated in the simulation and 16 completed the survey. Half reported that prior to the session they were uncomfortable engaging in a conversation with a resident struggling with discrimination, and 7 of 16 were uncomfortable with counseling and explicit acknowledgment of discrimination. This significantly improved following the case, with 15 chiefs reporting comfort with these activities.

13 hospital medicine faculty participated in the workshop and 11 completed the survey. About half (6) reported being uncomfortable responding to discriminatory behavior by a patient toward a trainee prior to the session, but 10 of 11 reported comfort afterward.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our first two simulation cases in this comprehensive project highlighted the importance of promoting an inclusive environment at all learner levels in academic medicine. By integrating a collaborative process among residents and faculty, we were able to develop cases that recognized their respective roles and truly reflected the experiences of our community. We plan to continue collaborative case development to create a repository of cases involving discrimination against trainees, in order to continue offering repeated and varied practice to maintain these important skills. We also plan to implement these workshops and simulations across the medical center for house staff and faculty of different specialties.

CREATING A STANDARDIZED PROTOCOL TO PERFORM AN IN-DEPTH STUDENT-LED REVIEW OF AN UNDERGRADUATE MEDICAL CURRICULUM TO ADDRESS TOPICS OF RACISM IN MEDICINE, INCLUSIVITY, DIVERSITY, AND EQUITY.

Ashley C. Kramer, Elizabeth Choi, Abrielle Fretz, Emily K. Smith, Maximillian Wehner, Latonya Riddle-Jones. Medical Education, Wayne State University School of Medicine, Detroit, MI. (Control ID #4064366)

SETTING AND PARTICIPANTS: All medical students in years 1-4 of the undergraduate medical curriculum were sent a standardized application recruiting students to assist with curriculum reform through a lens of racism in medicine, inclusivity, diversity, and equity (RIDE). Thirty student reviewers were split into six groups. Curricular review was performed remotely via individual review and virtual group meetings. Review findings were then presented to a faculty-led Social Justice in Medical Education Subcommittee (SJMES) of the Curriculum Management Committee (CMC).

DESCRIPTION: In 2020, the Institutional Justice and Inclusion External Committee of the medical school Student Senate conducted a Community Needs and Assets Assessment (CNAA) to determine how students are affected by issues relating to RIDE. This assessment revealed a lack of focus on RIDE within the undergraduate medical education curriculum. To address this gap, students and faculty formed the SJMES to lead comprehensive curricular reform. Student leaders developed a protocol to perform standardized curricular content review for incorrect/outdated information, image inclusivity, and context additions. The ultimate objective of this work is to produce a contextualized medical education that promotes deeper understanding of health disparities and barriers to care in the next generation of healthcare providers.

EVALUATION: Multiple student evaluations served as baseline data, including student evaluations through New Innovations, the LCME Independent Student Analysis, and the 2020 CNAA. These surveys, along with an additional survey about this project, will serve as initial data regarding student impressions of RIDE in the curriculum. Review findings were quantified by category - i.e. recommended text change, image inclusivity, or social determinants of health context addition - and then presented to faculty lecturers to implement changes. Following review completion, student evaluations of the curriculum will be performed again, and the data will be compared.

DISCUSSION / REFLECTION / LESSONS LEARNED: Throughout this project, the student curricular review team has continued to refine and develop our protocol as we encounter challenges and identify areas for increased efficiency. In the first block of curricular review, we reviewed 94 lectures, identifying 62 suggested changes. The most common RIDE category in need of intervention was race/ethnicity, comprising 58% of findings, followed by disabilty and LGBTQ+ categories. Following review completion, our next focus will be finding experts in the RIDE space that can provide new “context addition” material for a longitudinal social justice and accountability curriculum integrated into the 4-year undergraduate medical curriculum.

CREATING CHAMPIONS FOR RACIAL EQUITY IN MEDICINE THROUGH A SCHOOL OF MEDICINE ELECTIVE

Tamara F. Godfrey¹; Carmen Gutierrez². ¹Internal Medicine, University of North Carolina System, Chapel Hill, NC; ²Public Policy, The University of North Carolina at Chapel Hill, Chapel Hill, NC. (Control ID #4024003)

SETTING AND PARTICIPANTS: The Racial Equity in Medicine (REME) elective is available for second year medical students at the University of North Carolina Chapel Hill (UNC). During the fall semester there are 8-10 ninety minute sessions that take place on Monday afternoons. During the first two years of the pandemic the sessions took place virtually, and subsequently it has been a mix of virtual and in person. Faculty guest lecturers are recruited by the course directors each year.

DESCRIPTION: The elective was created in 2017 with the goal of providing medical students at UNC an opportunity to learn about structural racism and its manifestation in the U.S. health care system and medical education. Throughout the semester the course provides students with an understanding of racism in all forms through guest lecturers who present on a variety of topics. These have included, but are not limited to, Men's Health in the U.S. Carceral System, Disparities in Cardiovascular and Kidney Health, The Diversity Pipeline, Maternal and Neonatal Disparities, Inequities in the COVID-19 pandemic, and Disparities in Cancer Treatment. Students devise independent or group projects aimed at addressing racism and dismantling systems of oppression within the medical school or the larger American healthcare system, and these are presented during the last class session. Examples of projects over the years include, but are not limited to, One Minute Preceptor for Health Equity, Language Justice for Refugees, Responding to Racial and Political Trauma, Addressing Race in the Curriculum, and Faculty Training on Responding to Discrimination.

EVALUATION: Course evaluations are requested from the students at the end of the course using the One45 software system. Evaluations were available for review from 54 students over a five year period. On a 1-10 scale, the effectiveness of the teaching by faculty average rating was 9.67/10. On a 1-10 scale, the average overall rating of the course was 9.33/10.

DISCUSSION / REFLECTION / LESSONS LEARNED: Through this course medical students have gained a significant foundation of knowledge on typically under taught topics in the School of Medicine (SOM) curriculum such as the different forms of racism, social and institutional determinants of health, and how both of these contribute to health inequities. Over the years the SOM has implemented several initiatives that are the direct result of REME student projects including improving how race is discussed throughout the pre-clinical curriculum and consideration of how to counteract racial/ethnic biases in clerkship grading. Most of the lecture topics remain the same year to year, with some variability based on student feedback, course director discretion, and lecturer availability. In the future we aspire to have the UNC SOM change this course to be required for all students, include more non SOM-affiliated guest lecturers, expand our lecture material to include more social science and anti-capitalist frameworks, and to offer the elective to students from other UNC professional schools.

DEVELOPING A NOVEL HEALTH EQUITY CURRICULUM FOR INTERNAL MEDICINE RESIDENTS

Caroline Olt¹; Nayan Agarwal²; Richard Wardrop¹. ¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²internal medicine, Cleveland Clinic, Beachwood, OH. (Control ID #4065047)

SETTING AND PARTICIPANTS: Ten 1-hour lecture series over the course of 6 months delivered to PGY1 residents

DESCRIPTION: We developed a new standardized educational curriculum that incorporates health equity into internal medicine residency training. Our internal medicine residency program has a robust 3-year clinical didactic curriculum and a weekly intern half day educational session. We have a diverse group of residents with varying degrees of previous educational exposure to health equity, social determinants of health, and US healthcare policy. We have developed a 10 session lecture series with a variety of lecture formats and activities for interns that introduces all PGY1 internal medicine residents to a variety of health equity topics, including social determinants of health, trauma informed care, advocacy, and healthcare policy. Lecture activities include case-based discussion, simulation, and small group discussions. This curriculum ensures that PGY1s have a framework for evaluating and addressing social determinants of health and further provides them with resources and skills to provide better patient care by incorporating principles of health equity into their clinical practice.

EVALUATION: Evaluation of the course will be completed at the end of the lecture series through survey completion and a brief knowledge assessment. We plan to ask residents to rate the lecture series on a variety of metrics, including relevance to their practice, usefulness of topics, content, lecture delivery, and whether they would recommend the lecture series to their peers.

DISCUSSION / REFLECTION / LESSONS LEARNED: Designing informative and interactive sessions on social determinants of health and health equity can be challenging but is well worth the effort. Informal feedback from residents has been positive, with several residents sharing examples of how they’ve incorporated knowledge gained from these lectures into their clinical practice. Continuing to refine the curriculum based on final feedback will be a crucial next step.

DISMANTLING STRUCTURAL RACISM IN MEDICAL EDUCATION: A CASE REVIEW PROCESS

Kristin Furfari¹; Rita Lee². ¹Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ²Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4027139)

SETTING AND PARTICIPANTS: An academic medical center in the mountain west developed a case review process to proactively address lack of representation of race, ethnicity, gender, determinants of health, and other dimensions of diversity in undergraduate medical education (UME) teaching materials. All paper cases longer than one paragraph are included in this process. Cases are used across the four years of UME.

DESCRIPTION: Medical education has a unique opportunity to develop future physicians poised to address health inequities. However, much of the teaching material centers whiteness—most cases or photographs are of white skinned individuals. The lack of representation in curricular materials fails to teach learners how to address medical conditions in people of color or misattribute differences in outcomes to biologic risk rather than the determinants of health or structural racism. This perpetuates implicit biases, fails to recognize the structural factors impacting health, and propagates a cycle of oppression for minoritized learners and patients. We proactively addressed these structural issues by creating a process to review curricular patient cases.

The case review process involved three areas of focus: creation of a case-writing template, individual case review, and a broader curriculum level demographic distribution review. All cases over one paragraph long were reviewed by at least two individuals who provided feedback on stereotype/bias and language. Demographics across cases were tracked and authors asked to adjust patient identities for broad representation and inclusion across the curriculum.

EVALUATION: A total of 133 unique cases were submitted for review--40 were accepted with no revisions, 86 required minor revisions, and 7 required major revisions. The majority of originally submitted case demographics as provided by the case-writer did not specify race/ethnicity or sexual orientation and were cisgender. More than a quarter of the cases included stereotypes and/or bias. Revisions to language fell under the following categories—portraying the patient as antagonist, patient blaming, gendered language, failure to use person-first language, outdated terminology, and stigmatizing language.

DISCUSSION / REFLECTION / LESSONS LEARNED: Implementing a case review process is a feasible strategy to decrease structural racism in medical education. Our case review process revised multiple cases resulting in removal of stereotypes and problematic language, which improved representation of marginalized identities. Despite requiring explicit statement of race/ethnicity in the case template, authors often did not follow directions and frequently made assumptions about patient characteristics based on dominant culture, which raises the concern that learners may do this as well. Additional faculty development and case writing workshops will be needed to decrease bias, stereotyping and stigmatizing language.

DIVERSITY DIALOGUES: A MULTIDISCIPLINARY, COLLABORATIVE APPROACH TO ANTI-BIAS TRAINING AT A RESIDENCY PROGRAM

Mari Kai, Irina Gelman, Mary Anne J. Nidiry, Qian L. Leng. Providence Portland Medical Center Internal Medicine, Providence Health and Services, Renton, WA. (Control ID #4053145)

SETTING AND PARTICIPANTS: A community hospital-based IM residency program and primary care clinic. Participants include IM residents, core IM faculty, allied health professions, and clinic staff.

DESCRIPTION: An anti-racism task force was created to identify and address racism within us as individuals, as structures of healthcare education and clinical work, and as a community. Initiatives were multi-modal: created listening sessions, curated materials for self-study, a microaggression tracking form. A cornerstone of the curriculum has been “Diversity Dialogues” (DD), a series of DEI workshops running longitudinally throughout the academic year, repeating to allow all to participate. Each session has 20-25 attendees, a mix of residents, faculty, and clinic staff, supporting diverse perspectives and rich conversations. Each session lasts 80 minutes with protected time to attend. A planning team chooses themes and develops the year-long curriculum. Themes have included identifying implicit bias, microaggressions, and macroaggressions. Each interactive session combines time for education, dialogue, and experiential learning.

EVALUATION: An initial survey of our target audiences sought learner goals, especially from our BIPOC community to help develop the most relevant curriculum. Each subsequent DD session solicited participant feedback to inform future topics. 88 feedback evaluations received in the first year asked: 1 )How much did you learn? 2) Can you recognize a microaggression? 3) Do you understand the definition of implicit bias? 4) Future anti-bias learning goals? 5) Feedback for facilitators? A majority, 62, responded learning “A great deal or a lot,” 19 responded learning “A little”, 1 reported learning “Nothing.” All respondents reported an ability to recognize a microaggression, and all but one reported an understanding of the definition of implicit bias. Suggested topics for future learning included 1) More training and practice on responding to microaggressions, 2) Guidance on inclusive mentoring and 3) Further training on healthcare disparities for individual patients and systems. Most gave positive feedback for facilitators; creation of a safe space, maintaining a neutral stance, and allowing participant sharing were all mentioned as positives.

DISCUSSION / REFLECTION / LESSONS LEARNED: This anti-racism work continues to evolve into its 3rd year and remains a valued part of the residency. The DD sessions allow opportunities for self-reflection and help to develop tools to address microaggressions and respond to difficult situations. A key factor has been the diverse pool of participants. The safe space for open dialogue has allowed sharing of unique perspectives. A volunteer facilitator group allows for diverse participation of residents, faculty, and clinic staff. Despite competing time commitments, 4 faculty currently contribute approximately 8 hours monthly to build content and facilitate sessions. The ability to change content and evolve from feedback is key to content and session relevancy in a rapidly changing environment.

DO YOU SEE WHAT I SEE? RESIDENT KNOWLEDGE AND PERSPECTIVE IN AN INTRODUCTORY COMMUNITY ENGAGEMENT CURRICULUM

Xi K. Chu^1,2; Agustin Castaneda^1,3; Tony Li-Geng^1,2; Daniel Sartori^2,1; Cristina M. Gonzalez^3,1; Rachael Hayes^1,2. ¹Medicine, NYU Langone Health, New York, NY; ²Internal Medicine, New York University, New York, NY; ³Medicine and Population Health, New York University Grossman School of Medicine, New York, NY. (Control ID #4060711)

SETTING AND PARTICIPANTS: Community academic medical center in a large urban setting. N = 22, first-year residents. 55% categorical internal medicine, 45% primary care program.

DESCRIPTION: The AAMC has declared a call to action to address health inequity through community-engaged health care (CEHC). While some descriptive literature exists on community engagement curricula in graduate medical education, few report objective knowledge or the resident perspective. We implemented a curriculum which included traditional reading and/or didactics, then paired with relevant interaction between community members and residents. Session topics included: 1) Community Health in Profile, paired with a structured neighborhood exploration; 2) the History of Federally Qualified Health Centers and their Governance, paired with a Q&A session with a community board member; 3) Neighborhood Food Insecurity, paired with client service at our local food pantry; 4) Preventative Health Education, paired with small-group dialogues with community members at our local senior center.

EVALUATION: Our preliminary evaluation consists of 1) an objective knowledge assessment and 2) focus groups. Residents wrote a reflection on their management plan of a patient experiencing a barrier to achieving a health goal; these reflections were assessed for identification of a social determinant of health (SDOH), and a specific community resource. Of the 22 residents, all 22 identified at least one SDOH and 19 identified a specific resource. Of those that identified a resource, 3 specifically described clinical faculty helping them to identify the resource. Focus groups were then conducted to explore the resident perspective; transcripts were coded through thematic analysis. Three themes emerged: 1) Direct community interaction affects how residents’ view their relationship with the community: “Personally, I feel more connected to the community...you feel more invested in the community”; 2) Residents value direct experience with the community resources to which they refer their patients: “I remember the patient was anxious about being referred and I as a physician couldn't explain to her what to expect, because I myself didn't know”; 3) Residents want more concrete teaching on connecting patients with community resources; “We just need a lot more education and training - the services themselves, but then how to get the services for the patients.”

DISCUSSION / REFLECTION / LESSONS LEARNED: 1) Future iterations of this curriculum could include further skills-based teaching, as residents value community relationships and can identify SDOH and resources but feel unsure about how to navigate connecting patients with some resources. 2) Narrative knowledge assessments may be particularly useful as a curricular evaluation tool, allowing objective evaluation as well as providing contextual insight; here, faculty development may be an area to explore given residents citing the role of faculty guidance in identifying resources.

ONLINE RESOURCE URL: http://bit.ly/communityengagementmaterials

EFFECT OF A NEIGHBORHOOD RESOURCE WALK ON INTERNAL MEDICINE RESIDENT KNOWLEDGE OF SOCIAL DETERMINANTS OF HEALTH AND INTEREST IN COMMUNITY ENGAGEMENT.

Anita Leon-Jhong¹; Anusha Amaravathi¹; Anna K. Donovan². ¹General Internal Medicine, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4064986)

SETTING AND PARTICIPANTS: This urban, resident-run primary care clinic serves a historically African American neighborhood. Residents have traditionally had limited interaction with the community outside the clinical setting, which may affect their ability to address patients’ social needs. This project sought to expose residents to the area surrounding the clinic via a neighborhood walk to increase understanding of social determinants of health (SDH) and interest in community engagement. Participants were internal medicine residents, near the end of their PGY1 year.

DESCRIPTION: The 1-hour, attending-led “Neighborhood Resource Walk” leaves from the clinic and covers 2 miles of surrounding neighborhood. During the walk, residents in groups of 2-3 identify community resources including a future grocery store, syringe exchange, women’s shelter, and health department clinic. Participants discuss the history of the neighborhood, displacement and systemic racism, food access, housing, transportation, community trust and collective trauma. Half of the PGY1 class completed the walk and post-curricular survey, while the other half served as controls. The survey focused on three areas: (1) Knowledge of SDH, (2) Confidence in addressing SDH, and (3) Interest in engaging with the community/serving patients with high social needs. A six-month follow-up survey was conducted and a second cohort of PGY1s participated in the study the following year.

EVALUATION: For the first cohort, 21 PGY1 residents (100%) completed the baseline survey. 11 PGY1s participated in the walk and all completed the post-walk survey. 10 PGY1s served as controls. Comparing baseline with post-walk surveys, residents completing the walk showed increased familiarity with the history of the community (2.6 vs 8.1 on 10-point Likert scale, p <0.01) and with resources available to help meet patients' needs (4.6 vs 7.1, p 0.01). The survey also reflected an increase in residents' interest in getting involved with the local community after the walk (4.7 vs 6.3, p <0.01). Residents reported benefits of the walk as "being able to list resources nearby to those that need it" and a commitment to "asking about access to food" during clinic appointments. The second cohort and six-month follow-up data is pending and will be available for presentation.

DISCUSSION / REFLECTION / LESSONS LEARNED: The Neighborhood Resource Walk was feasible and well-received by residents. Those who completed the walk reported increased knowledge of neighborhood history, understanding of the role of social determinants on health, confidence with resources and desire for community involvement. Further analysis of the 6 month follow-up survey will help to determine whether the curriculum has a lasting impact.

EMPOWERING ALL; TARGETS, WITNESSES AND PERPETRATORS TO RESPOND TO MICRO-AGGRESSIONS.

Herrick Fisher³; Huma Farid⁴; Cancan Zhang²; Catherine DesRoches²; Daniele Olveczky¹. ¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ³Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; ⁴OB-GYN, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4064191)

SETTING AND PARTICIPANTS: The intervention took place at an academic medical center in the northeast which has approximately 2000 faculty physicians, 673 licensed beds, including 493 medical/surgical beds, 77 critical care beds, & 62 OB/GYN beds. 700 fellows and residents train there annually in 13 core residency programs and 85 fellowship programs. All faculty and trainees were invited to participate.

DESCRIPTION: Background

Many studies have demonstrated the harmful effect of microaggressions on the target but evidence about curricula that foster change in those responsible for microaggressions is lacking. Building upon the curricula created by Sandoval et al. to teach medical students how to address microaggressions in the learning environment and the curriculum by Fisher et al. which taught this to internal medicine residents, a 90-minute curriculum was offered to all attendings and trainees at an urban teaching hospital over the course of two years from 2020 to 2022. The sessions were held remotely on Zoom during the COVID-19 pandemic.

Using a microaggression response toolkit, participants engaged in role-playing exercises during the sessions. Pre and post-surveys were designed and administered to assess the effect of the workshop.

EVALUATION: Three hundred and forty two trainees and faculty attended the workshop and completed pre and post workshop surveys. Demographic analysis revealed a diverse sample consistent with the institution's overall composition, with 30% self-identified as non-white and 54.7% as female. 62% were attendings. 31 % of participants were from the Department of Medicine. Responses were analyzed using Wilcoxon signed rank sum test on individual imputed datasets and test statistics were pooled in accordance with Rubin's rule. The significance level is set at 0.05.

DISCUSSION / REFLECTION / LESSONS LEARNED: Compared to before the workshop, participants thought that they were better able to respond to microaggressions when they were a target of a microaggression (p< 0.001). Similarly, participants reported an improved ability to respond to microaggressions when they witnessed them (P< 0.001). More importantly, they also reported an improved ability to respond to microaggressions when they perpetrated the microaggression (P< 0.001).

Our study is one of the few studies that documents the increased self-efficacy of participants to respond to their own microaggressions after an intervention. Given the hierarchy that exists in medicine and the importance of faculty in creating safe educational spaces, future work will focus on ways in which attendings improve their ability to recognize and respond to their own microaggressions.

ENHANCING CLINICIAN TRAINING TO COMMUNICATE ABOUT SOCIAL NEEDS WITH PATIENTS THROUGH THE DEVELOPMENT AND VALIDATION OF A PERFORMANCE-BASED ASSESSMENT CHECKLIST

Iman Hassan¹; Rachel Berman²; Victoria Gorski²; Elizabeth Spurrell-Huss²; Zoon Naqvi²; Joe Grochowalski³; Felise Milan²; Shadi Nahvi². ¹Internal Medicine, Montefiore Health System, Bronx, NY; ²Montefiore Health System, Bronx, NY; ³College Board, New York, NY. (Control ID #4024122)

SETTING AND PARTICIPANTS: An interdisciplinary team of internal medicine, pediatric, family medicine, and population health faculty conducted a literature review and met over an extended period to draft an initial communications checklist for social needs conversations with patients.

DESCRIPTION: Unmet social needs impact morbidity, mortality and healthcare engagement and utilization. Screening patients for social needs and referring to services that can address those needs improves patient-level outcomes and are part of 2023 Centers for Medicare and Medicaid Services and Joint Commission requirements. Clinicians report a key barrier to addressing social needs is discomfort having conversations with patients and concern about negative impacts on patient relationships. Conversations are susceptible to bias and microaggressions and can result in patient and provider frustration. Currently, no performance level assessment tools exist for communication skills around social needs.

We aim to develop a stakeholder-informed, multi-disciplinary communications checklist for social needs conversations with patients, and assess its reliability and validity in resident physicians using standardized patients and workplace-based assessment.

EVALUATION: Using principles of relationship-centered communication, we drafted an initial version of a communications skills checklist for use by faculty and standardized patients to assess conversations around social needs. To guide checklist items, we utilized principles of trauma-informed care and strengths-based approach. Components of the checklist include explaining social needs screening, asking permission, delving into social needs, exhibiting empathy, exploring patients’ perspectives, and partnering to develop a plan.

Ongoing work will incorporate stakeholder perspectives on social needs communication skills through national surveys, and patient and clinician focus groups.

DISCUSSION / REFLECTION / LESSONS LEARNED: This project will fill a critical gap in performance-based assessment in the clinical setting. It will offer an innovative and transferable stakeholder-informed social needs communication assessment checklist with reliability and validity evidence.

HEALTH EQUITY REPORT: GETTING COMFORTABLE WITH DISCOMFORT

Sheba Ebhote¹; Karthik W. Rohatgi²; Aba Black³. ¹Internal Medicine - Primary Care, Yale New Haven Hospital, New Haven, CT; ²Internal Medicine, Yale New Haven Hospital, New Haven, CT; ³Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4064854)

SETTING AND PARTICIPANTS: This innovation was based at an academic medical center in New England. Participants were Internal Medicine residents, faculty, and medical students.

DESCRIPTION: The ACGME has identified residency as a critical opportunity for education on health inequities and social determinants of health, as residency is often the time in which new physicians develop professional identity frameworks that they will rely on for the rest of their career. Health Equity Report is an interdisciplinary case conference in which aspects of a patient’s identity and/or lived experience(s) results in suboptimal patient experience and adverse care outcomes. Each report begins with a summary of the clinical course and honest reflections from the primary team (including residents, clinical consultants, and other health professions) surrounding decision-making, inequities faced, and overall outcome. We then facilitate a series of small group discussion questions asking residents to reflect on their impressions of the care, identify the inequities faced, and discuss how they would act to promote health equity at either the direct care or systems level. Lastly, we expand the dialogue to include physician experts on the topic as well as other relevant stakeholders. After each report, attendees are asked to complete a survey.

EVALUATION: At the end of data collection, on average 17 residents attended each session. Most attendees strongly agreed that each aspect of the presentation was useful, including primary team reflections, small group discussions, and expert/stakeholder-mediated conversations. Of attendees surveyed, 92% of participants reported an expected change in clinical practice and/or attitudes towards the discussed marginalized population after participating in the session. For example, after the discussion of a patient who was incarcerated, residents reported they would “be more aware of provider’s rights, patients rights, and Hospital policies regarding shackles”, “feel more empowered to make the decision of removing shackles when appropriate instead of deferring to officers” and “[have] a better idea on how to handle conflicting issues when taking care of an incarcerated patient”.

DISCUSSION / REFLECTION / LESSONS LEARNED: Survey responses demonstrate that residents find Health Equity Reports to be valuable, with the majority of attendees identifying tangible changes they can make in their clinical practice. By implementing Health Equity Report into the curriculum as a recurring case conference, our goal is to shape the lens by which residents view patients and barriers to care. This educational tool will further allow residents to feel empowered to advocate for historically marginalized patients.

INCORPORATING AN INTERSECTIONAL FRAMEWORK IN TRAUMA INFORMED CARE FOR LGBTQ+ PATIENTS

Usama Irshad, Shwetha Iyer, Mary Gover, Viraj V. Patel. Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4063026)

SETTING AND PARTICIPANTS: A resident physician-led interactive session about expanding the trauma informed care (TIC) model for LGBTQ+ patient care to make it intersectional. Participants included 26, second-year residents in primary care residency programs at an academic medical center in the Northeast.

DESCRIPTION: Since its coining in 1989, intersectionality has been used to describe various systems of oppression and trauma across diverse disciplines. Current medical education around TIC for LGBTQ+ patients has not been intersectional which may result in vulnerable individuals falling through the cracks in our healthcare system, leading to healthcare disparities. We hypothesized that these healthcare inequities can be prevented by training our residents to be able to understand and use an intersectional framework.

We thus designed and delivered a 90-minute session 3 times to residents as part of their residency didactics and during our department’s quarterly health equity rounds over three years. This interactive session included 1) asking residents about their existing knowledge about the concept of intersectionality 2) introduction to the concept and how to use it as a frame when providing trauma informed care (TIC) to LGBTQ+ patients and 3) three small group discussions about residents' experiences and reflections facilitated by us. We used clinical vignettes to provide learners with examples to help them better understand and apply the concept in their clinical practice. We also recapitulated the main principles of trauma informed care (TIC) with an emphasis on how to approach it through an intersectional lens.

EVALUATION: Information about participants' existing knowledge, skills and behaviors was collected using a pre-survey designed by the authors. 26 participants completed the survey. Only 22% of participants reported having received any teaching around intersectionality during their medical training. In comparison, 89% of our participants had received some form of teaching about TIC as part of their training. 59% of participants agreed that presently healthcare providers were not adequately equipped to use intersectionality as a tool to inform dialogue with their patients, while only 7% believed that healthcare providers are adequately using intersectionality as a framework in healthcare settings.

DISCUSSION / REFLECTION / LESSONS LEARNED: Intersectionality can help better understand and address trauma and social injustice. Medical trainees currently receive inadequate education about intersectionality. It is feasible to incorporate it into our existing curricula for LGBTQ+ healthcare using less than two extra hours of didactic time; is in keeping with most institutional diversity, equity and inclusion efforts and will be an important step towards equitable healthcare. Future evaluation will assess whether an understanding of intersectionality helps residents provide better TIC to LGBTQ+ patients.

INCORPORATING EMPATHY TRAINING INTO RESEARCH COORDINATOR TRAINING: RECOGNIZING AND RESPONDING TO IMPLICIT BIAS TO ENHANCE RECRUITMENT AND RETENTION

Jennifer Adams²; Maura Minsky²; Suchismita Datta³; Joseph Ravenell³; Cristina M. Gonzalez^3,2; Colleen Gillespie¹. ¹PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; ²Institute for Innovations in Medical Education, New York University Grossman School of Medicine, New York, NY; ³NYU Langone Health, New York, NY. (Control ID #4064501)

SETTING AND PARTICIPANTS: Research Coordinators working within an academic medical center’s Clinical Research Centers

DESCRIPTION: Recruiting and retaining research participants often requires overcoming structural and historical barriers related to trust as well as understanding the influence of individuals’ lived experiences on interest in or ability to participate in research. We report on a pilot workshop designed to educate research coordinators in using the skills of empathy to recognize and mitigate bias in interactions with research participants. The workshop used an innovative curriculum built around a high-quality animated film (The Elephant in the Waiting Room) designed for clinical settings. We report on translating this approach for research education. The film was developed with input from patients and national experts in implicit bias and empathy. It 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 in healthcare yield multiple opportunities to use empathy to restore the encounter after the patient perceives bias. The training guide identifies key discussion points throughout to reinforce the interplay between empathy and implicit bias recognition/management. For our preliminary evaluation, participants completed a brief, anonymous survey about their experience and its impact on their self-efficacy related to empathy and implicit bias, with focus on translating this workshop to their recruitment/retention training needs.

EVALUATION: The 19 participants completed an anonymous post-workshop survey. 94% agreed (somewhat or strongly) with the following: the workshop hleped them more effectively practice perspective taking, recognize implicit bias during research recruitment, recognize opportunities for empathy, and develop strategies for being more empathic and mitigating bias in recruitment /enrollment. Using a retrospective pre/post design, participants reported their confidence in being able to perform core clinical research skills before and then after the workshop. For all 12 tasks (e.g., I can recognize my own implicit bias while I am recruiting participants; I can encourage someone with reservations about research to share those concerns in detail; I’m able to create a safe space for potential research participants to ask questions), participants were significantly more confident after the workshop than before (paired t-tests; effect sizes ranged from .45 to 1.25).

DISCUSSION / REFLECTION / LESSONS LEARNED: The workshop, designed to be used with clinical professionals, proved to be effective for research staff. Participants suggested that next steps should include more skills-building opportunities directly relevant to research recruitment and retention and data collection. This intervention can be further adapted and combined with experiential learning to meet the needs of the translational research work force and enhance equity in research.

ONLINE RESOURCE URL: https://www.empathyproject.com/

INSTITUTIONALIZING COMMITMENT TO ANTI-RACIST PEDAGOGY THROUGH THE DEVELOPMENT AND IMPLEMENTATION OF A MEDICAL SCHOOL-WIDE CURRICULUM OBJECTIVE

Manasa S. Ayyala, Michelle DallaPiazza, Maria Soto-Greene. Rutgers New Jersey Medical School, Newark, NJ. (Control ID #4059015)

SETTING AND PARTICIPANTS: All medical students at a US medical school in the Northeast

DESCRIPTION: Academic medical centers must answer the call to teach about the effects of structural racism on health outcomes. Codifying a commitment to anti-racist pedagogy into required medical education curricular competencies may help prioritize curricular and systemic efforts focused on addressing structural racism in medicine. With efforts already underway to further education focused on structural racism in our longitudinal Health Equity thread, we drew inspiration from calls for educators to formalize mastering the health effects of structural racism as a professional medical competency. The six overarching goals of the medical education program at our institution include “Goal #4: Commitment to the Health of the Community and Appreciation of Social and Cultural Diversity,” under which we aimed to incorporate a well-defined objective addressing structural racism. Through an iterative process involving key educational stakeholders and using a modified Delphi method for group consensus, a curriculum objective was approved in May 2021: “To demonstrate the ability to identify and address the health effects of structural racism.” This starts with definitions in Phase 1 (pre-clerkship years) and ends in the formulation of potential solutions with physician advocacy in Phase 3 (4th year).

EVALUATION: Pre-clerkship and clerkship curricula were audited for content meeting the objective. Curriculum leads meet with pre-clerkship and clerkship directors on an annual basis to discuss outcomes evaluation from the previous year and how curricula can be further developed, implemented, and evaluated to achieve the medical school-wide objective.

DISCUSSION / REFLECTION / LESSONS LEARNED: Faculty champions and senior leadership prioritized a longitudinal curriculum on structural racism by codifying it into the most formal of spaces – the curriculum-wide goals and objectives upon which competencies are structured. This demonstrates an institutional commitment at the highest level and keeps the institution accountable to continue the work around ongoing review of curricular content and expected outcomes. The language defining the objective & process for continuous curriculum development & implementation can be effectively adopted by other institutions. Since implementation in academic year 2021-2022, the curriculum continues to evolve, with clerkship directors tailoring their specialty-specific content to focus on advocacy and systemic solutions. However, we have found that faculty development can lag behind the innovation in the curriculum. Continued attention to professional development, evolving concepts, and political climate remains essential to achieving the objectives of the structural racism curriculum.

ONLINE RESOURCE URL: https://njms.rutgers.edu/education/office_education/documents/NJMSGoalsandObjectives.pdf

INTERRUPTING MICROAGGRESSIONS: USING CASE-BASED VIDEOS TO BECOME AN “UPSTANDER”

Manasa S. Ayyala¹; Michelle DallaPiazza¹; Zoya Munsar¹; Prachi P. Trivedi²; Stephanie Shiau²; Maria Soto-Greene¹. ¹Rutgers New Jersey Medical School, Newark, NJ; ²Rutgers School of Public Health, Piscataway, NJ. (Control ID #4064775)

SETTING AND PARTICIPANTS: All 3^rd year medical students at a medical school in the Northeast

DESCRIPTION: In the context of clinical training, microaggressions can lead to a range of negative learner outcomes, from diminished confidence and disengagement to anxiety and depression. Because microaggressions can be commonplace in clinical environments, instruction on tools to address them must be prioritized if we want to achieve greater learner wellness, improved patient care outcomes, and an enhanced sense of connection and belonging for both care teams and patients. Currently, there is limited evidence on the best strategies to respond to microaggressions in the clinical learning environment. Responding to the need for formal training, we created case-based videos to increase awareness and empower those who experience or witness microaggressions to act using the INTERRUPT language-based toolkit. These videos were piloted in an interactive workshop session for all 3^rd year students at our medical school in October 2023.

EVALUATION: Participants completed linked anonymous pre- and post-surveys to evaluate the effectiveness of teaching. Confidence in achieving the stated learning objectives and satisfaction with the didactic components and case-based videos were measured using a 5-point Likert scale. The post-survey also provided space for narrative feedback. Variables were descriptively summarized using frequencies and proportions, and pre- and post-surveys were compared using paired t-tests (continuous variables) and chi-square or Fisher’s exact tests (categorical variables). All analyses were performed using SAS version 9.4.

DISCUSSION / REFLECTION / LESSONS LEARNED: 166 students participated in the workshop and anonymous identifier-matched pre- and post-survey were submitted by 127/166 (76.5%) of students. There were significant increases (p<0.05) in confidence levels across all learning objectives including “describe how microaggressions can affect the clinical learning environment and physician-patient relationship” and “utilize the INTERRUPT toolkit to address microaggressions that surface in the clinical learning environment.” Student attitudes on the statement, “Learning about how to interrupt microaggression in the clinical learning environment is important to me as a future physician”, also showed improvement (Mean Difference = -0.95, 95% CI [-1.17, -0.74], p < 0.0001). Most participants (96.6%) felt that the case-based videos were helpful in demonstrating how to utilize the INTERRUPT language-based toolkit. In narrative feedback, participants were satisfied with the delivery and feasibility of the case-based videos, and provided feedback on how they could be more effective and more widely implemented. Next steps include using these materials for continued trainee and faculty development incorporating feedback from our session about the power imbalances between learner, faculty, and patients and concerns for real or perceived retaliation with potential impact on relationships and reputation.

LEVERAGING THE VOICE OF LATINX COMMUNITY MEMBERS TO IDENTIFY GAPS IN HEALTH EQUITY CURRICULUM IN AN INTERNAL MEDICINE RESIDENCY

Julie Knoeckel¹; Neelam Mistry²; Silvia Gutierrez Raghunath³; Sarah A. Stella¹; Ellen Sarcone¹. ¹Hospital Medicine, Denver Health, Denver, CO; ²Department of Medicine, University of Colorado, Denver, CO; ³Denver Health Main Campus, Denver, CO. (Control ID #4064582)

SETTING AND PARTICIPANTS: The curricular pathway dedicated to health equity at a large, midwestern Internal Medicine Residency Program has engaged in iterative evaluation and process improvement since it began in 2016. With increasing resident competence of fundamental SDOH (Social Determinants of Health) principles over time with the expansion of undergraduate medical SDOH curricula, the health equity curricular pathway has increasingly aimed to increase knowledge and skills pertinent to local health disparities. Pathway leadership sought to decrease the risk of bias in selecting this curricular content by leveraging the voice of local community members at risk for healthcare disparities, better understanding their experience with healthcare provider knowledge, skills, and values as it pertained to the minoritized identity. As such, three focus groups with a total of fifteen community members who self-identified as first-generation Latinx were performed between 2020-2021 to guide further curricular content.

DESCRIPTION: The first-generation Latinx community was selected for this pilot curricular gap analysis based on community demographics; Latinx patients are the most commonly encountered minoritized patient group for this training site, and are underrepresented in medicine. A focus group interview guide was developed with input from local content experts and a qualitative methodology consultant. The focus groups were conducted in Spanish by a native-Spanish-speaking research assistant over a virtual platform. The recordings were professionally transcribed and translated into English. Participants were compensated for their time with gift cards. Transcripts were inductively coded. Findings were utilized to guide curriculum development.

EVALUATION: Perceived gaps in equity-oriented education of local healthcare providers included the importance of appropriate interpretation and assessment of health literacy, and inadequate knowledge of healthcare costs, and the ability to incorporate cost into discussions and planning. Community members also spoke to the importance of avoiding over-generalizing or stereotyping based on ethnicity and the value of empathetic communication in developing trust with healthcare providers. Since these focus groups were completed, the health equity curricular pathway has included content on cost of care, cultural humility, and health literacy specifically to address the identified gaps.

DISCUSSION / REFLECTION / LESSONS LEARNED: This approach to a curricular gap analysis offers a roadmap for medical educators who are striving for ways to tailor SDOH education to the specific experiences of their community members. This gap analysis was feasible to complete through a virtual platform and community members were easily recruited through existing community engagement programs. Funding for community member compensation at a minimum is necessary for this approach. A limitation is the inability to include all or intersecting groups at risk for health disparities due to limited time and funding.

MEDICAL STUDENT PROFESSIONAL IDENTITY AND BEHAVIOR: EVALUATING THE IMPACT OF A NOVEL FIRST-YEAR HEALTH EQUITY CURRICULUM

Marcus Hines¹; Katherine O. Chebly³; Tiffany E. Cook⁴; Richard E. Greene². ¹Internal Medicine, NYU Langone Health, New York, NY; ²Medicine, NYU Grossman School of Medicine, New York, NY; ³Medicine, NYU Langone Health, New York, NY; ⁴Diversity and Inclusion, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4064421)

SETTING AND PARTICIPANTS: Health equity content is an essential component of undergraduate medical education (UME), but its impacts on learners’ outcomes are under-studied, and when evaluated, not studied longitudinally. In this innovation, we longitudinally evaluate the impact of a first-year health equity curriculum at an urban academic medical center on the participants’ sense of professional identity and behaviors.

Participants include 104 students who completed an inaugural health equity course in 2020 as MS1s. They were surveyed twice over time, in 2020 as MS1s and in 2023 as MS3s after completion of clinical clerkships, to evaluate their self-perceptions of the course’s impact on their professional identity and behavior.

DESCRIPTION: Results of the initial survey (2020) showed 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 more action-oriented objectives such as “formulating strategies for anti-racism in healthcare practice” (59%) and “identifying strategies clinicians can use to address SDOH” (52%).

An updated survey was disseminated in 2023, and included questions to measure student self-perceptions of mastery of recent AAMC Diversity, Equity, and Inclusion Competencies. A control group of students from a class who did not participate in the health equity curriculum were also surveyed. Semi-structured focus groups with curriculum participants have also been held to gain a deeper understanding of core themes in the curriculum’s impact on individual behaviors. Qualitative data is being coded for themes using a grounded theory approach.

EVALUATION: Data from the 2023 survey and focus groups are currently under analysis and will be finalized by the time of the conference. Preliminary analysis shows trends when comparing students who took the course and those that didn’t. One is higher comparative feelings of preparedness by students who took the course in understanding the impacts of systems of oppression and public policy on health outcomes. Another is higher comparative feelings of preparedness by students who did not take the course in practicing cultural humility and moral courage during clinical encounters.

DISCUSSION / REFLECTION / LESSONS LEARNED: This longitudinal approach to evaluating UME health equity curriculum compares student perspectives before and after they experienced clinical clerkships and had opportunities to put their knowledge into action. Preliminary findings interestingly show that those who technically have more training in certain action-oriented concepts like demonstrating cultural humility may rate themselves as less prepared, perhaps because they better understand how challenging these activities can be (and control groups “not knowing what they don’t know”). Future research to measure the impact of the curriculum on patient care should involve testing modalities such as direct observation or standardized simulations.

NAVIGATING POWER DYNAMICS WHEN ADDRESSING BIAS: STUDENT RESPONSES TO CLINICAL MICROAGGRESSIONS

Jade A. Connor^1,4; Tatheer Adnan²; Avik Chatterjee^3,4; Daniele Olveczky^5,4. ¹Internal Medicine, Massachusetts General Hospital, Boston, MA; ²Harvard University, Cambridge, MA; ³Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ⁴Harvard Medical School, Boston, MA; ⁵Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4059253)

SETTING AND PARTICIPANTS: First-year medical and dental students at a New England academic medical school participated in a microaggression workshop prior to the start of clinical rotations.

DESCRIPTION: The workshop consisting of two parts: large group didactics and small group practicum. The didactic portion of the workshop was a primer on microaggressions and their impacts, and session leaders presented frameworks for addressing microaggressions. The second portion of the workshop presented cases in small groups, in which students practiced applying the frameworks. The cases were based on experiences of students at the institution, integrating themes of racism, sexism, model minority myth, minority tax, and internalized bias. A detailed description of the workshop can be found on MedEdPORTAL (Sandoval et al. 2020).

EVALUATION: Online surveys were collected from 3 cohorts of students from 2018-2020 at the conclusion of the microaggression training. Survey respondents were presented with a written clinical vignette in which a microaggression was directed towards a patient. They were asked questions about the impacts of the microaggression and how they would respond to the incident. Responses were analyzed using thematic content analysis. Across 3 years, 218 students completed the survey. Forty-five percent of students identified as female or non-binary individuals, and 29.4% of students identified as underrepresented in medicine. Students reported 3 main themes regarding the impact of the clinical microaggression: (1) Microaggressions are detrimental to patients’ healthcare experience, (2) Microaggressions can cause patients psychological distress, and (3) Microaggressions impair care team dynamics and functioning. The most common responses to the microaggression were: (1) ask for clarification, (2) alert leadership or report the act, and (3) interrupt and redirect.

DISCUSSION / REFLECTION / LESSONS LEARNED: Though the microaggressions workshop taught students many strategies to address incidents including directly challenging the microaggression and educating the offender, students commonly relied on indirect methods of addressing the microaggression. Students may favor deploying indirect methods of addressing microaggressions to maintain social cohesion within the care team and mitigate the risk of retaliation. This highlights the limitation of trainings for students alone given their role in medical teams; multilevel interventions including leadership involvement must be implemented to combat microaggressions in clinical settings.

ONLINE RESOURCE URL: https://doi.org/10.15766/mep_2374-8265.10893

STRIVING FOR INCLUSIVE EXCELLENCE AND CREATING SUSTAINABLE CHANGE

Ria Roberts¹; Carrie Tibbles^2,1; Emmanuel Mensah¹; Pablo Quintero¹; Daniele Olveczky¹. ¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Emergency Medicine , Beth Israel Deaconess Medical Center, Lexington , MA. (Control ID #4064176)

SETTING AND PARTICIPANTS: The intervention took place at an academic medical center in the northeast which has approximately 2000 faculty physicians, 673 licensed beds, including 493 medical/surgical beds, 77 critical care beds, & 62 OB/GYN beds. 700 fellows and residents train there annually in 13 core residency programs and 85 fellowship programs.

DESCRIPTION: The benefits of recruiting health care professionals with lived experiences which reflect the patients they serve are well known. Ethnic and racial concordance between physicians and patients has been shown to improve care for marginalized patients as well as decrease the implicit biases of their fellow colleagues. Systemic racism's impact on physician representation necessitates intentional efforts in the recruitment of diverse physicians for equitable healthcare.

We employed the McKinsey 7-S change model, which consists of 'hard elements' (structure, strategy, system) and 'soft elements' (shared values, style, staff, skills) to increase Under Represented In Medicine (URIM) trainee numbers, despite overall low URIM faculty representation at the institution. Leveraging a librarian-mediated search, tracking previous years’ URIM applicants’ metrics, analyzing patient demographics, and reviewing institutional history formed our approach. Structuring recruitment efforts involved standardizing procedures across departments. Program leaders reviewed metrics from previous years, implemented holistic reviews, updated websites with DEI efforts, and engaged with URIM students at national conferences and HBCU medical schools. Educating interviewers to mitigate unconscious bias and foster comfortable discussions about the institution's DEI efforts during interviews was also critical. Zoom sessions which hosted hundreds of applicants and post-match reviews were also held.

EVALUATION: These synergistic interventions resulted in a 247% increase in URIM trainees over three years, consistently matching 23% URIM residents annually.

DISCUSSION / REFLECTION / LESSONS LEARNED: Utilizing the McKinsey 7-S model, our multifaceted approach significantly and sustainably increased URIM trainee recruitment in an academic medical center with low URIM faculty representation. Next, piloting this approach in URIM faculty recruitment aims to further institutionalize diversity and inclusion efforts.

Lesson learned:

Explicit leadership commitment, an authentic institutional tactical narrative, in tandem with the implementation of the McKinsey 7S model of change resulted in a sustained increase in the recruitment of URIM trainees at an academic medical center in the northeast despite initial low numbers of URIM faculty.

THE CHALLENGE OF CHOOSING CHIEFS: OPERATIONALIZING AN EQUITABLE AND TRANSPARENT CHIEF RESIDENT SELECTION PROCESS

Ryan Abe¹; Theresa King²; Ahmed Salahudeen². ¹Department of Medicine, University of Washington Department of Medicine, Seattle, WA; ²Washington State University, Everett, WA. (Control ID #4065248)

SETTING AND PARTICIPANTS: Residents eligible to apply for a chief resident (CR) position at an academic medical center in the Northwest were surveyed after the inaugural CR class was selected.

DESCRIPTION: Residency programs utilize a range of styles and methods to select chief residents, often involving subjective opinion, resident and faculty nominations, resident popularity, and perceived medical knowledge. In designing a selection process, we aimed to create a process that was transparent, fair, equitable, and effective in identifying strong candidates who demonstrate the qualities we value in this role. Johnson et al recently published a standardized process for the equitable recruitment and selection of more diverse chiefs in JGIM (1). We implemented some of these key recommendations, including open applications, standardized interviews, and a diverse selection committee.

EVALUATION: To assess the new chief selection process, we conducted a survey of the PGY-3 resident class to understand their perspective on the process. Some of the survey questions were adapted from the AAMC Diversity Engagement Survey (2). The survey asked residents to rate statements about the process on a scale from 1, “Strongly Disagree” to 5, “Strongly Agree”. Examples of questions include “The culture of my program is to accept chief residents who bring different ideas to the table” and “From my perspective, I feel that my program chooses chief residents fairly compared to other IM residency programs I’ve heard of.”

The survey had a participation rate of 75% (n = 9). In this first year of implementation of the selection process, 89% of residents (n = 8) “Agreed” or “Strongly Agreed” that application process to become a chief resident was advertised fairly to all residents and 78% of residents (n = 7) agreed that it was easy to figure out how to apply to become chief resident. However, only 22% of residents (n = 2) agreed that the job described clearly communicate the expectations and ideal qualities for the role.

DISCUSSION / REFLECTION / LESSONS LEARNED: Based on resident surveys, the program’s approach to CR position announcement and detailing of the application process ranked favorably in terms of clarity and being advertised fairly and we will replicate this process will be replicated in the coming CR selection process. However, two changes we will make from the results include clearer communication about the role in addition to having CRs model ideal qualities and exemplify the job’s expectations. Additionally, surveyed residents inconsistently felt applicants with diverse ideas were valued, and over half the surveyed residents did not agree the ultimate CR selection was fair. Changes to the interview questions and increased transparency in the selection committee and process will be implemented to make positive change in these areas. Finally, a similar survey will be sent to faculty involved in the program and selection process to assess more perspectives and ideas to improve the sense of fairness and transparency.

THE DEVELOPMENT OF A RACIAL EQUITY READING GROUP TO FOSTER DEI CONVERSATIONS AMONG FACULTY

Meghan C. Geary¹; Vidya Gopinath²; Kyla Dewar³. ¹General Internal Medicine, Brown University, Providence, RI; ²General Internal Medicine, University of Utah Health, Salt Lake City, UT; ³Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI. (Control ID #4062081)

SETTING AND PARTICIPANTS: The participants of this group were all general internal medicine faculty in a single academic division in New England

DESCRIPTION: During the summer of 2020, faculty members in the Division of General Internal Medicine were having many informal conversations about race, police violence, minorities in medicine and racial differences in medical outcomes. Outside of the hospital, there were protests in the wake of the murder of George Floyd, How to be An Anti Racist was on the NYT best seller list and racial differences in maternal mortality continued to make newspaper headlines. In the hospital, residents circulated and discussed the Journal of the American Heart Association (JAHA) white paper arguing against affirmative action and we confronted the enormous disparities in the morbidity and mortality of COVID-19 infections. Among faculty, there was a wide range in background knowledge on the topic and experience with leading and having these conversations about race with residents and patients.

We created this racial equity reading group to offer a space and time for faculty to discuss these topics. It was a forum for us to gain knowledge of important historical context and numerous topics indirectly related to health. We discussed intersectionality and the necessity of having nuanced perspectives on these complex social issues to better serve our patients and learners. It improved our experience and comfort in leading these conversations in our role as physicians. These regular gatherings kept DEI an active topic of conversation as we meet approximately every 3 months for 3 years. The number of participants varied from five to twelve per gathering.

EVALUATION: A survey was sent to all faculty at the end of year 3 (summer 2023) after having discussed ten books ranging from Kendi’s How to be an Antiracist, to a history of the local indigenous community and the troubled history of Thanksgiving to Ross and Solinger’s Reproductive Justice: An Introduction. We wanted to assess perceived benefit and any logistical changes that might enhance participation. Nine faculty responded and the greatest number attended the reading group on Caste: The Origins of Our Discontents by Wilkerson. Elements cited as most appreciated by attendings were the book selection and the facilitation of discussion. Suggestions for improvement included sending out question prompts prior to the discussion so individuals could think about them while reading the book and sending out a take-home point or action item to DGIM listserv or at meetings. Timing and logistical barriers were other responses given patient care responsibilities and conflicting meetings.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our objectives for the group were humble goals of increasing our baseline knowledge, improving comfort leading these conversations and maintaining the importance of this topic among our faculty. I think we succeeded in these goals. We would like this to remain a part of many DEI initiatives and activities in the department.

WALKING A MILE IN OUR PATIENT'S SHOES- EXPERIENTIAL LEARNING OF BARRIERS TO CARE

Hayley Specht¹; Naomi Newman¹; Jayne Peterson²; Alvin G. Wong^1,3. ¹Internal Medicine, The University of Arizona College of Medicine Phoenix, Phoenix, AZ; ²Medicine, The University of Arizona College of Medicine Phoenix, Phoenix, AZ; ³Phoenix Veterans Affairs Healthcare System, Phoenix, AZ. (Control ID #4064197)

SETTING AND PARTICIPANTS: First and second year Internal Medicine residents on their ambulatory care rotations are tasked to visit community resources near their continuity clinic.

DESCRIPTION: The ACGME requires internal medicine programs to ensure that residents understand the social determinants of health affecting their patient populations and learn how to address these needs. Despite this requirement, the ACGME’s 2022 Clinical Learning Environment (CLE) Review found that most CLE’s did not have strategies in place to reduce healthcare disparities in their populations.

We created an innovative experiential curriculum for residents to learn about how social determinants of health affect patients’ access to community resources. Faculty, social workers, and case managers collaborated to create a case scenario in which a patient faces several challenges commonly experienced by patients in our continuity clinics. Residents are given the case scenario and spend the day tracing the footsteps of their patients in a “community resource scavenger hunt,” using only a provided public transportation day pass.

EVALUATION: Residents submit written reflections around the quality and accessibility of available resources, their impressions throughout the day, and how this experience will impact their approach to patient care. A total of 13 responses were collected and analyzed using Thematic Analysis. Common themes identified in these reflections included:

Long waits- lines, time spent at bus stops, and hold times on helplines

Food options- food boxes often lacked fresh foods and fiber, many donated foods required a kitchen to prepare, limiting access for unhoused patients

Reliance on cellphones to navigate bus routes, locate resources, or call helplines

Residents identified several areas of growth:

Including social determinants of health screening/referrals at every appointment

Utilizing telehealth for patients who rely on public transportation

Lowering their threshold to involve social workers in patient care

DISCUSSION / REFLECTION / LESSONS LEARNED: The Community Health Exploration Day gave residents an opportunity to gain first-hand knowledge of some of the barriers to care faced by their patients. In their written reflections, residents correctly identified how social determinant of health deter their patients from obtaining community resources. The residents identified opportunities for growth in their clinical practices managing patients with significant barriers to care. This low-cost experience could easily be incorporated into other residency programs.

Innovation in Medical Education (IME) - Geriatrics and Palliative Care

AGITATION IN THE MEDICINE WARDS: A MULTI-DISCIPLINARY WORKSHOP ON NON-PHARMACOLOGIC STRATEGIES TO MANAGE CHALLENGING BEHAVIORS IN HOSPITALIZED OLDER ADULTS WITH DELIRIUM AND DEMENTIA

Shivani Bhatnagar¹; Hannah Ward²; Shaista U. Ahmed². ¹Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD; ²Geriatrics, Johns Hopkins University, Baltimore, MD. (Control ID #4061305)

SETTING AND PARTICIPANTS: Internal medicine residents often care for hospitalized older adults experiencing agitation associated with delirium and dementia, the management of which can be challenging. Non-pharmacological interventions are first line in management, although medications (such as antipsychotics) with potential for harm and limited benefit are often prescribed instead. Internal medicine residents at our academic medical center in the Mid-Atlantic region attended a 45-minute workshop on non-pharmacological interventions developed and led by a multi-disciplinary team.

DESCRIPTION: Informed by prior needs assessment surveys of both patient safety attendants (PSAs) and residents at our institution, we designed a workshop to address the challenge of managing agitation in the inpatient medicine ward. This 45-minute interactive workshop is co-led by a geriatrician, occupational therapist, and recreational therapist with geriatric expertise. It includes a presentation about pharmacologic and non-pharmacologic management of agitation in delirium and dementia, as well as roles of various team members including PSAs in implementing non-pharmacologic interventions. The majority of the workshop is case-based discussion to reinforce learning.

EVALUATION: An initial needs assessment was completed by electronic surveys that were sent to resident participants. This needs assessment had a response rate of 43% (23 out of 54 possible respondents). The majority of respondents (87%) reported caring for a patient experiencing agitation often or very often (nearly every day or more than half of the days) during a typical rotation on the internal medicine ward. The respondents felt equally confident in their ability to use pharmacologic vs non-pharmacologic interventions for management, and only 13% felt that pharmacologic options are superior to non-pharmacologic options. Although 64% of respondents strongly agreed that PSAs have an important role in caring for this patient population, 47% felt that PSAs are not adequately trained for these situations. Evaluation is ongoing, with a survey planned after completion of the workshop that will assess satisfaction with the sessions, as well as confidence in using non-pharmacologic interventions and working with multi-disciplinary team to manage agitation. We will utilize a post-then-pre survey design to assess these changes, to mitigate response shift bias.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our needs assessments emphasized the importance of resident exposure to multi-disciplinary collaboration to best care for hospitalized older adults experiencing agitation due to delirium or dementia. The practice of prioritizing pharmacologic interventions has greater momentum through resident training, especially when residents are limited to physician-led sessions. Recreational, physical, and occupational therapists with expertise in geriatrics can provide valuable perspective and content in non-pharmacological interventions, which are not formally provided to residents at other stages of their training.

AN AGE-FRIENDLY CHART REVIEW SELF-ASSESSMENT TOOL: INTEGRATING GERIATRICS EDUCATION AND QUALITY IMPROVEMENT (QI) FOR INTERNAL MEDICINE RESIDENTS IN PRIMARY CARE CLINICS

Ethan Samet^4,2; Shoshana Streiter^1,2; Christine Beltran³; Andrea W. Schwartz^5,2; Julia Loewenthal^1,2. ¹Division of Aging, Brigham and Women's Hospital, Boston, MA; ²Harvard Medical School, Boston, MA; ³Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University Grossman School of Medicine, New York, NY; ⁴Brigham and Women's Hospital Department of Medicine, Boston, MA; ⁵New England Geriatric Research Education and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, MA. (Control ID #4019660)

SETTING AND PARTICIPANTS: Second-year Internal Medicine residents at an urban academic medical center participating in a required Geriatrics rotation completed a quality measures chart review activity for two of their older primary care patients from November 2021 to May 2023. Data includes responses from 30 residents at 13 primary care clinic sites.

DESCRIPTION: Insufficient time for both clinical care and Geriatrics education are barriers to high quality primary care delivery by residents. Medical educators rarely assess clinical performance on care measures specific to Geriatrics, leading to a dearth of data to inform educational and QI initiatives. To address these needs, we developed a structured chart review tool for resident self-assessment of quality of care within geriatric domains.

The chart review structure and domains were adapted from the American Board of Internal Medicine’s 2005 Care of the Vulnerable Elderly Practice Improvement Model using the Age Friendly Health System initiative’s “4Ms” framework: Mobility, Mentation, Medications, and What Matters. Residents were asked whether elements of these domains had been documented in the Electronic Health Record (EHR) and to identify clinical goals for future visits.

EVALUATION: To ensure residents used the self-assessment tool correctly, two members of the research team independently audited 20% of charts, comparing accuracy with the EHR. Audits found 89% agreement between resident self-review and EHR documentation.

The open-ended resident responses included in the chart review tool were coded by themes describing the type of follow-up action recommended.

DISCUSSION / REFLECTION / LESSONS LEARNED: The domain most likely to be documented was medications, included in 95% of charts. Sensory assessment was least likely to be documented (52%), followed by function (53%) and cognition (63%). Qualitative analysis of resident comments demonstrated patient goals and values as the care domain most likely to be identified as a high priority while cognition was most likely to be identified as low priority. Optimization of polypharmacy was identified most often as a clinical challenge.

Integrating education and quality is an efficient way of teaching Geriatrics principles while improving the quality of care. The resident self-assessment chart review tool was designed to serve as an educational activity incorporated into a Geriatrics rotation, allowing residents and educators to identify knowledge and practice gaps in a time- and resource-efficient manner. Patterns of under-documented domains may reflect a lower emphasis on Geriatrics training, institutional priorities, or division of care between practice team members.

DEMENTIA CARE AWARE: A CALIFORNIA STATEWIDE EFFORT TO EDUCATE PRIMARY CARE PROVIDERS IN THE DETECTION OF DEMENTIA

Anna H. Chodos²; Wagahta Semere¹; Josette Rivera². ¹Division of General Internal Medicine, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ²Division of Geriatrics, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA. (Control ID #4062257)

SETTING AND PARTICIPANTS: Primary care providers (PCPs) practicing in the state of California.

DESCRIPTION: Alzheimer’s disease and related dementias are underdiagnosed in primary care, in large part due to provider and health system barriers. PCPs report lack of confidence and training to diagnose and manage dementia in their practice settings. Further, PCPs face health system barriers such as visit time constraints and limited access to specialists and resources to support dementia care. In response to these challenges, the California Department of Health Care Services launched Dementia Care Aware (DCA), a state-wide initiative led by a multidisciplinary group of expert stakeholders in dementia and primary care from academic medical centers as well as community organizations. Launched in March 2022, DCA aims to introduce a cognitive screening approach and new Medi-Cal only benefit for annual dementia screening among individuals age 65 and older. The DCA has outlined three key objectives to reach this goal: (1) Development: create the Cognitive Health Assessment (CHA), an efficient dementia screening approach with validated tools, and an associated training required for provider medical billing; (2) Education: disseminate provider trainings on dementia screening, assessment and care, with a focus on underserved patients; (3) Implementation: support primary care to implement screening and improve dementia care. The DCA program includes a comprehensive online training (approved for continuing medical education units), reviewing the CHA and accompanying modules addressing key topics in dementia care such as advanced care planning and assessing care partners. Regular webinars, podcasts, and interactive case conferences provide additional learning opportunities. Additionally, the DCA provides practice support resources, including a warmline staffed by dementia specialists and one-on-one coaching for clinician support in dementia screening and care.

EVALUATION: From July 2022 to November 2023, 2,264 participants from 45 of 58 California counties completed the core CHA training. Participants who completed a continuing education survey for the online training (n=333) rated the overall average quality 4.5/5 (1=Poor; 5=Outstanding). Among these participants, 89% were “somewhat” or “very” confident in their ability to make practice changes; 65% intended to “increase frequency of conducting, scoring, and interpreting a cognitive screening tool (e.g. Mini-Cog or GP Cog)” and 57% intended to “start a brain health plan with their patients after conducting a cognitive health assessment.”

DISCUSSION / REFLECTION / LESSONS LEARNED: The DCA is an innovative and comprehensive strategy that aims to better support dementia screening and management in primary care settings. Initial data evaluating the DCA curricula are promising with regards to training quality and provider engagement. Moving forward, the DCA team is developing an implementation toolkit to further disseminate trainings and provide practice-based support.

ONLINE RESOURCE URL: dementiacareaware.org

HOSPITALTALK: DELIVERING GOAL-CONCORDANT CARE AND BRIDGING INEQUITY AT THE END-OF-LIFE

Param Sampat²; Art Evans¹; Sonal S. Mehta¹; Kimberly Bloom-Feshbach¹. ¹Medicine, Weill Cornell Medicine, New York, NY; ²Cedar Falls High School, Cedar Falls, IA. (Control ID #4063991)

SETTING AND PARTICIPANTS: We adapted and implemented a Powered by VitalTalk-based curriculum, HospitalTalk, for interprofessional inpatient clinicians on goals of care (GOC) communication skills at two hospital sites affiliated with a large urban academic medical center. 56 clinicians participated in HospitalTalk across 6 sessions, including hospitalist, critical care, and emergency department physicians and PAs, palliative care NPs, social workers, and chaplains. Due to Covid-19, 4 sessions were conducted virtually.

DESCRIPTION: The 4 hour workshop combined a didactic presentation and interactive role play with trained actors. A framework for delivering serious news included response to emotion and value-concordant recommendations. Groups reviewed disparities in end-of-life (EOL) care, and communication tools for bridging inequity and addressing racism. Faculty discussed how to perform GOC discussions via telemedicine. To practice skills and receive feedback, learners interacted with actors portraying an adult child of a patient with advanced dementia and acute illness, and a woman of color with end-stage cancer addressing discrimination in care in facilitated encounters.

EVALUATION: Anonymous pre- and post-surveys assessed self-efficacy, with participants self-rating on communication metrics. Qualitative query included value of the session content, facilitator evaluation, and suggestions for improvement. Quantitative data was analyzed utilizing a matched-pair t-test and a 95% CI for difference in means in STATA. Qualitative data was coded by two researchers and thematically analyzed. Post-survey data indicated statistically significant improvements in all metrics, including serious news delivery, GOC conversation initiation, values elicitation from patient and surrogate, EOL care recommendation, building trust, addressing racism, and using telemedicine (p-value < 0.001). Participants described intentions to recommend the workshop to colleagues and apply skills in clinical care.

DISCUSSION / REFLECTION / LESSONS LEARNED: HospitalTalk sought to address a key issue nationally: a discordance between patients’ expressed EOL care preferences and the care they receive in the hospital when time is short. Skills-based education on GOC communication for frontline clinicians is one tool to bridge this gap. However, many curricula do not incorporate strategies to bridge inequity and address racism in EOL care. In addition, primary palliative care post-pandemic demands familiarity with telemedicine. HospitalTalk demonstrated that training can integrate cross-cultural skills with GOC frameworks, with improvement in skills and values endorsement by interprofessional frontline clinicians.

Innovation in Medical Education (IME) - Healthcare Delivery and Redesign

ENRICHING CLINICAL COMPETENCY AND CONFIDENCE VIA EXPERIENTIAL LEARNING: A STUDENT-RUN INPATIENT CONSULT SERVICE FOR THE UNHOUSED

Adrienne-Denise V. Bilbao¹; Kathy Z. Lu¹; Karis Tutuska¹; Abhijay Kumar¹; Richard Bryce^1,2. ¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Family Medicine, Henry Ford Health System, Detroit, MI. (Control ID #4064761)

SETTING AND PARTICIPANTS: This presentation highlights the workflow and benefits of a medical student-led consult service based in an urban academic non-profit hospital in the Midwest region.

DESCRIPTION: The Street Medicine consult service is tailored towards providing compassionate, systems-based care and long-term follow-up to individuals experiencing housing insecurity. While working as consult leaders, students hone their patient care skills while also learning to facilitate healthcare accessibility for unhoused individuals.

The workflow involves three phases: completing the inpatient consult, forming a treatment and follow-up plan, and facilitating post-discharge follow-up. Consults are placed by the patient’s primary team, at which point a medical student consultant sees the patient and completes a standardized note. The student then consults with our supervising attending to create a plan to address the patient’s short and long-term medical and social needs. Afterward, the student consultant contacts a member of our Street Leader team to discuss the patient’s needs and find an appropriate time to follow up with them post-discharge. The Street Leader team then finds the patient during their street or shelter run and provides them with resources such as harm reduction, housing information, or case management.

EVALUATION: Within the past 9 months, the team has completed 76 consults. During clinical encounters, all 9 medical student consultants endorsed often or always practicing skills including note writing, patient interviewing, obtaining alcohol/drug use history, inter-team communication, and creating an actionable plan alongside an attending physician. 8 of 9 consultants endorsed often or always participating in chart review and completing hand-offs, and 5 of 9 consultants endorsed often or always obtaining sexual history and performing immunization counseling. Seven months after joining the team, students were surveyed on the benefits of consult system participation in their confidence in carrying out various clinical skills. 100% of respondents endorsed agreement or strong agreement that participation as a consultant has increased their confidence in independently seeing patients, utilizing community resources, and obtaining alcohol/drug use history. 67% of students endorsed agreement or strong agreement that the consult system has made them more comfortable obtaining sexual histories, addressing immune hesitancy, and navigating and writing notes in the EMR. 100% of consultants believed that their experiences as consultants have positively influenced their performance and team contributions during clerkships and increased their preparedness for residency.

DISCUSSION / REFLECTION / LESSONS LEARNED: The Street Medicine consult service provides medical students with the opportunity to work independently within the hospital setting, increasing students’ confidence and competency in clinical skills required for residency while also providing members of the unhoused community with more comprehensive and longitudinal healthcare.

Innovation in Medical Education (IME) - Health Policy

CLINICIAN-FACILITATED CASE-BASED DISCUSSIONS TO ILLUSTRATE HEALTHCARE SYSTEM BARRIERS AUGMENTED HEALTH POLICY EDUCATION FOR PRE-CLINICAL MEDICAL STUDENTS

Nihar Rama¹; Prachi Shah¹; Gregory Ruhnke²; Venkatesan R. Krishnamoorthi². ¹Pritzker School of Medicine, The University of Chicago, Chicago, IL; ²Medicine, The University of Chicago, Chicago, IL. (Control ID #4064675)

SETTING AND PARTICIPANTS: First-year medical students at a Mid-West medical school in a required health policy course.

DESCRIPTION: The majority of medical students indicate that they receive insufficient health policy and health systems education, even though they will face systems-level barriers to practicing high quality care. In addition, there is little uniformity or evaluation of pedagogical approaches to health policy in undergraduate medical education. Case-based learning and small group learning have been effective for medical students’ learning about clinical medicine but have not been evaluated for health systems education. This project piloted the use of clinical faculty to facilitate case-based discussions with pre-clinical students in a health policy course in order to illustrate health policy topics and systems barriers to high quality care.

In our introductory first-year course on health policy and the US healthcare system, we provided lectures and readings on a variety of topics such as the history of public and private health insurance, provider reimbursement, quality and value, drug prices. In addition, students are divided into small groups facilitated by 4th-year students who served as Peer Educators (PEs). In Fall 2023, for three of six scheduled small groups, clinicians with no specific expertise in health policy were invited to present cases with structured discussion points to illustrate health policy topics including high-value care, provider reimbursement, and prescription drug prices. Cases were realistic examples involving barriers to care commonly faced by general internists.

EVALUATION: Voluntary surveys were administered to students after the completion of small group sessions. We compared students’ learning experiences through case-based learning and clinician-facilitated sessions to the learning from readings, didactic lectures, and PE-facilitated sessions.

Of 91 students, 89 responded to a survey after sessions on high-value care and physician payment, and 69 responded to a survey after a session on prescription drug prices. For these sessions, 84%, 78%, and 77% of students agreed or strongly agreed that invited clinicians were valuable to their learning. Overall, respondents indicated that clinical faculty (83%) and the use of clinical cases (85%) made their small group experience slightly or significantly better. When asked about overall learning about health policy and system topics, 82% of students indicated that their learning was strong or strongest from faculty-led small group discussions and clinical cases compared to 60% from didactic lectures and 25% from readings.

DISCUSSION / REFLECTION / LESSONS LEARNED: Clinician-facilitated case discussions were rated higher than discussions at which clinicians were not present and over other modalities of learning for several specific health policy topics and for overall learning. This pilot suggests a valuable role for case-based learning in health policy education for medical students led by clinicians without formal expertise in these fields.

TEACHING HEALTH POLICY AND ADVOCACY ACROSS SUBSPECIALTIES: THE FELLOWS’ ADVOCACY CURRICULUM

Caroline Sloan^1,2; Lisa Criscione-Schreiber¹; Daniella A. Zipkin¹. ¹Department of Medicine, Duke University School of Medicine, Durham, NC; ²Duke Margolis Center for Health Policy, Durham, NC. (Control ID #4059102)

SETTING AND PARTICIPANTS: An increasing number of US Internal Medicine residency programs have advocacy curricula that teach physicians to be active and effective advocates for their workforce and their patients. But many internists develop an interest in advocacy while pursuing subspecialty fellowship training. We established the Fellows’ Advocacy Curriculum (FAC), an 8-month elective track for fellows in any of 11 Department of Medicine subspecialties. Our goals were to help fellows 1) develop the skills to carry out a group advocacy project; 2) strengthen interdisciplinary networks across subspecialties; and 3) develop a plan for incorporating advocacy into their future careers. Six fellows were accepted into FAC’s inaugural year, with representation from 4 subspecialties.

DESCRIPTION: FAC comprises a didactic curriculum and a practical curriculum. In didactics, fellows learn about the US healthcare system, the current health policy landscape, and the impact of government policies on the physician workforce and the patients they treat. Invited speakers teach about the many ways to “do” advocacy, including writing op-eds, working with professional societies, and engaging in legislative advocacy. In the practical curriculum, fellows develop a cross-subspecialty legislative advocacy platform, develop a pitch, and create a “leave-behind.” The program is highly interactive, with guidance and frequent feedback from the course director, the health system’s government relations office, an assigned local physician mentor, and each other. FAC culminates in a two-day trip to Washington, DC where fellows meet with legislative staffers and present their advocacy platform.

EVALUATION: We developed a pre-curriculum survey based on prior literature on residency-based advocacy curricula. We administered the survey in August 2023, prior to the first FAC session. The survey evaluated fellows’ prior training in health policy (e.g., in medical school or residency), experience with various types of advocacy (e.g., professional society advocacy days), comfort with the aforementioned types of advocacy, knowledge of current health policy topics (e.g., roles of legislative committees), and attitudes toward physician advocacy and advocacy training. Finally, we asked fellows to comment on their future advocacy plans beyond FAC. The same survey will be distributed in May 2024 to evaluate for any response changes after completion of the curriculum. We plan to formally evaluate outcomes after 3 years or after at least 20 fellows have gone through the program, whichever is sooner.

DISCUSSION / REFLECTION / LESSONS LEARNED: FAC is an innovative curriculum aimed at providing Internal Medicine subspecialty fellows with the knowledge and experience necessary to become effective physician advocates. Strengths of the program are that it fosters relationships and understanding across subspecialties and opens fellows’ eyes to the many ways that physicians can “do” advocacy throughout their careers. Future work is needed to evaluate the long-term impacts of the curriculum.

Innovation in Medical Education (IME) - Inter-Professional Education

AN INTERPROFESSIONAL, STUDENT-FACILITATED TELEHEALTH HOME CARE PROGRAM FOR HOMEBOUND OLDER ADULTS AND PEOPLE WITH DISABILITIES

Beau Blass²; Allison Chu²; Nicole Schindler²; Dana Rubenstein²; Julia Graham³; Anne Derouin^3,1; Mary Affronti³; Pedro Gomez Altamirano¹; Ashley Price¹; Truls Ostbye¹; Howard Eisenson^2,4. ¹Family Medicine and Community Health, Duke University School of Medicine, Durham, NC; ²Duke University School of Medicine, Durham, NC; ³Duke University School of Nursing, Durham, NC; ⁴Lincoln Community Health Center, Durham, NC. (Control ID #4056427)

SETTING AND PARTICIPANTS: Student teams consisting of a third-year medical student and graduate nursing student facilitate regular home visits with the same 2 patients for a program cycle (about 8 months). Home visits accompanying the licensed primary care provider alternate every other month with enhanced video telehealth encounters supervised by the provider and facilitated by the in-home student team. Patients are underserved older adults and disabled people who face significant barriers to accessing primary care in the traditional office setting. We have 5 student teams serving 10 patients.

DESCRIPTION: In-home care can improve health outcomes and equity for underserved older adults and people with disabilities. However, health professional students receive limited, if any, in-home and telehealth training. Our student-led initiative developed an enhanced telehealth component of a home-based primary care program to address this gap, focusing on interprofessional education and firsthand exposure to social factors impacting health.

Our project is a collaboration of a local, federally qualified health center and an academic center’s division of community health. In our model, an office-based primary care provider guides onsite students (in the patient’s home) in real time to gather history, collect vital signs and basic physical exam findings, assess adherence to treatment regimens, and provide education and coaching to the patient and any caregivers. Students are poised to assess the home environment, including resource needs, social drivers of health, and accessibility concerns which may not be apparent in the clinic setting.

Student teams come together for monthly debriefing sessions and are encouraged to share challenges and insights related to home visits. They also receive a longitudinal curriculum, which includes relevant topics of home safety, goals of care, physical activity and nutritional assessment, wound care, and proper use of medical devices.

EVALUATION: Students are evaluated through mixed methods surveys completed pre- and post-program. Our assessment centers on four domains of learning: in-home care, social drivers of health, interprofessional education, and primary care perspectives.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our innovative program presents a unique opportunity for interprofessional collaboration between medical and graduate nursing students. These trainees are increasingly finding themselves in healthcare delivery systems where their complementary skills and care coordination are highly valued for chronic care management, as well as safe and effective transitions of care between the home, outpatient, and inpatient environments. Most importantly, the program reflects a patient-centered and cost-effective response to the needs of a vulnerable segment of our community. Students and patients are very satisfied with our program and initial results highlight the program’s value for meeting patients where they are, addressing social drivers of health, and building longitudinal relationships with patients.

ASSESSING CLERKSHIP STUDENT COMPETENCIES USING AN “INTERPROFESSIONAL ATTRIBUTES TOOL”: DEVELOPMENT, IMPLEMENTATION, AND LESSONS LEARNED

Dawn Cooper, Skye McKennon, Dawn E. DeWitt. Elson S. Floyd College of Medicine, Washington State University, Spokane Campus, Spokane, WA. (Control ID #4063653)

SETTING AND PARTICIPANTS: Medical students and their non-physician team members from a community-based medical school.

DESCRIPTION: Interprofessional (IP) skills are core components of Competency-Based Education (CBE) frameworks. Despite collaborative practice being a core competency, medical students typically do not receive formal feedback from IP team members. Because CBE places significant emphasis on workplace learning, assessment should utilize individuals best positioned to provide authentic judgements about trainee development. Few published workplace-based IP assessment tools exist for medical students in clinical settings. To facilitate authentic IP assessment, we designed an “Inter-Professional Attributes Tool” (IPAT) to capture workplace teamwork, communication, and professionalism skills. Here we present the feasibility, acceptability, and lessons learned from incorporating the IPAT tool into the longitudinal integrated clerkship (LIC) and year 4 rotations at our medical school. We identified observable, competency-related attributes important to team-based care. Clerkship and IP education leaders reviewed initial drafts to ensure that IPAT questions were framed appropriately and captured relevant, directly observable skills. The final instrument incorporated attributes (defined skills) that students could demonstrate, and that IP team members could observe, during clinical experiences.

EVALUATION: Two cohorts of 80 students collected IPATs during Year 3 LIC and Year 4 (AYs 2022-2023). LIC students collected an average of 6 IPATs and Year 4 students collected 1-2 IPATs per rotation. Nurses, physician assistants, medical assistants, radiology technicians, pharmacists, and physical/occupational therapists completed IPATs. Data shows that students are meeting IP expectations for dependability and teamwork in clinical settings. Preceptors and IP team members rated students similarly for dependability, self-awareness, and integrity. A utility and quality review indicated that IPATs support coaching and student learning. Importantly, IPATs captured narrative comments about current performance, but feedback focused on future skills development was absent.

DISCUSSION / REFLECTION / LESSONS LEARNED: Incorporating formal feedback from IP team members signals the importance of teamwork and the value of feedback from IP colleagues, and facilitates student understanding of, and respect for, IP team-members’ roles. We anticipated resistance to tool completion, but IP team members appreciated the opportunity to provide feedback. IPAT feedback is integrated into our assessment and coaching programs and has been identified as useful by coaches and faculty. Recognizing that students will be learning from IP team members, formally capturing their feedback is key to facilitating student development of skills and competencies for successful team-based care. Identifying ways to facilitate form completion and to increase specific improvement-oriented suggestions are important next steps in sustaining this effort and increasing feedback effectiveness.

COMPARING THE EFFECTIVENESS OF TEAM-BASED LEARNING (TBL) VS COMBINED TBL-SIMULATION PEDAGOGY IN TEACHING INTERPROFESSIONAL COLLABORATION IN THE OUTPATIENT CARE SETTING

Elaine Cruz^1,2; John S. Sweetko³; Mamta K. Singh⁴. ¹Education, VA Northeast Ohio Healthcare System, Cleveland, OH; ²Case Western Reserve University, Cleveland, OH; ³Interprrofessional Improvement Research and Education Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, OH; ⁴Internal Medicine, Case Western Reserve University, Cleveland, OH. (Control ID #4062055)

SETTING AND PARTICIPANTS: This pilot study was conducted at a Midwest VA medical center in 2023 as part of primary care curriculum. Participants included internal medicine, nurse practitioner, pharmacy, psychology and social work residents participating in a longitudinal interprofessional primary care residency program (N=40).

DESCRIPTION: The purpose of this pilot study was to compare the effectiveness of using a combined team-based leaning-Simulation pedagogy with team-based learning (TBL) alone for interprofessional learners to actively learn the Interprofessional Education Collaborative (IPEC) core competencies. A quasi-experimental study with two learner groups and data collection at two time points was conducted. Group one (n=19) received TBL training only, while group two (n=21) received combined TBL-Sim training. The content of the 4-hour pilot session was focused on outpatient management of post-stroke patients. The TBL portion consisted of one session that provided the foundational knowledge needed to care for post-stroke patients and facilitated learners to establish teamwork skills. In the simulation session the trainees completed one of four simulation cases where they were required to practice interprofessional collaborative skills.

EVALUATION: The Interprofessional Collaborative Competency Attainment Survey (ICCAS) was administered to each group at the end of the outpatient block as a retrospective pre/post-test to evaluate learners’ perceptions of IPC competency attainment. Participants also received a survey upon completing activities to evaluate satisfaction with, and acceptability of, the training. The TBL and combined TBL-Sim were both effective at improving perceived competency attainment as measured by the ICCAS (Z=3.85, p<.001). A closer look at the descriptive statistics revealed that the combined TBL-Sim group had a greater improvement across each of the 20-items of the ICCAS. Learners felt they needed the training and found that both formats were acceptable and beneficial. The combined TBL-Sim group found the combination of pedagogies synergistic. Learners in the TBL-Sim group highlighted the ability to see the mental models of other disciplines in real time as a major benefit of the training.

DISCUSSION / REFLECTION / LESSONS LEARNED: Both TBL and combined TBL-Sim groups saw significant increase in self-evaluated IPC competency. The TBL-Sim group had greater improvement according to the ICCAS, but further study with larger groups in different contexts is needed to determine if this a significant and meaningful difference. In addition, further evaluation is needed to identify the behavioral implications of this training in practice.

FACTORS THAT CONTRIBUTE TO HIGH LEARNER RATINGS OF AN INTERPROFESSIONAL EDUCATION WORKSHOP FOR QUALITY IMPROVEMENT AND PATIENT SAFETY

Vaishnavi Sankar¹; Emily Wang¹; Yuanyuan Zhou²; Lindsey J. Gay⁷; Andrew Caruso⁷; Phuong Huynh¹; Rebecca Aulbach⁸; Catherine L. Hatfield³; Diane Nguyen⁴; Sarah-Ann Keyes⁵; Anne C. Gill⁶; Doris Lin⁷. ¹Baylor College of Medicine, Houston, TX; ²Education, Innovation, and Technology, Baylor College of Medicine, Houston, TX; ³College of Pharmacy, University of Houston, Houston, TX; ⁴Pediatrics, Baylor College of Medicine, Houston, TX; ⁵Physician Assistant Program, Baylor College of Medicine, Houston, TX; ⁶Pediatrics - Academic General, Baylor College of Medicine, Houston, TX; ⁷Internal Medicine, Baylor College of Medicine Margaret M and Albert B Alkek Department of Medicine, Houston, TX; ⁸Texas Woman's University - College of Nursing, Denton, TX. (Control ID #4029676)

SETTING AND PARTICIPANTS: We developed an interprofessional quality improvement/patient safety (QI/PS) workshop that included students from the schools of medicine, nursing, physician assistant, and pharmacy. Workshops were conducted at an academic medical institution in the Southern region.

DESCRIPTION: We implemented a monthly 2-hour IPE virtual workshop to review QI/PS concepts and practices including process maps, fishbone diagrams, and root cause analysis. Prior to participating in the workshop, all students completed the Institute for Healthcare Improvement module, QI 102: How to Improve with the Model for Improvement. The workshop took place on Zoom and was designed to be interactive, with a mix of didactic PowerPoint slides and breakouts into smaller groups consisting of students from the four disciplines. Each group also had a faculty facilitator who monitored the discussion, answered questions, and moved the case forward. At the end of the workshop, students completed an online questionnaire to rate the activity and comment on strengths and areas for improvement.

EVALUATION: From January 2021 to April 2023, 217 medical, 138 nursing, 60 PA, and 30 pharmacy students participated in the workshop. Data showed that 93% of the nursing students and 80% of pharmacy students rated the overall quality of the workshop as very good or excellent while medical students and PA students had the lower ratings at 68% and 63% respectively. Students generally exhibited a good understanding of each discipline's roles, responsibilities, and perspectives concerning the evaluation of patient safety events (88.2% to 94.9% agreement) and quality improvement (89.6% to 94.9% agreement). Students tended to have a better grasp of their own discipline's role compared to others, and nursing and pharmacy students consistently rated their own disciplines more favorably than others. Overall, students held positive opinions about the effectiveness of the facilitators and the workshop's quality. Notably, ratings varied across disciplines, with nursing students giving the highest ratings (4.75 for facilitators and 4.60 for overall quality). Comment analysis demonstrated that medical and PA students enjoyed working with other disciplines, nursing students appreciated the small group activities and interactivity, and pharmacy students liked the clinical teaching methodology.

DISCUSSION / REFLECTION / LESSONS LEARNED: We implemented an interactive IPE workshop to educate students on important QI/PS concepts that they can utilize throughout their careers as practicing healthcare professionals. Nursing and pharmacy students rated the QI/PS workshop more highly than medical and PA students, with learners from each discipline valuing different aspects of the session. Further investigation into these differences will allow for continuous improvement of the workshop.

LOVE IT AND LEARN IT: INTERPROFESSIONAL COMPETENCY DEVELOPMENT IN VIRTUAL LONGITUDINAL TEAM-BASED STANDARDIZED PATIENT SIMULATIONS

Dawn E. DeWitt²; Ross J. Bindler³; Skye McKennon²; Connie M. Remsberg¹; Jennifer C. Miller¹. ¹Washington State University College of Pharmacy and Pharmaceutical Sciences, Spokane, WA; ²Washington State University Elson S Floyd College of Medicine, Spokane, WA; ³Washington State University College of Nursing, Spokane, WA. (Control ID #4063671)

SETTING AND PARTICIPANTS: Health professions students from multiple statewide programs and universities in 2023.

DESCRIPTION: During two virtual longitudinal, interprofessional simulation education activities (Sim-IPE), teams of 4-6 students collaborate to interview a standardized patient and create a holistic treatment plan. In the initial Sim-IPE activity, interprofessional student teams assess a patient with acute musculoskeletal pain who is transitioning to a chronic pain diagnosis with escalating use of prescription opioids and alcohol. During the second activity student teams reassess the same patient who has progressed to a likely substance use disorder (SUD). After each IPE activity, students were invited to complete the Interprofessional Collaborative Competency Attainment Scale (ICCAS Revised). The ICCAS is a validated tool that uses a retrospective pre-post design.

EVALUATION: The first activity was attended by 550 students; 218 completed an ICCAS (39.6% response rate). The follow-up activity was attended by 242 students with 135 submitting an ICCAS (55.8% response rate). Following participation in the initial Sim-IPE activity, average ICCAS scores increased significantly from 3.52 (SD: 0.82) to 4.14 (SD: 0.69, p<0.001) with a large effect size (Cohen’s d: 0.945). After the second activity, average ICCAS scores again increased significantly from 4.01 (SD: 0.82) to 4.19 (SD: 0.75, p<0.001) but with a smaller effect size (Cohen’s d: 0.406) than after the initial activity. Significantly higher ‘before’ activity scores were seen when comparing the first Sim-IPE activity to the follow-up activity (p<0.001). However, no statistical differences were seen in the ‘after’ activity scores between the first and follow-up activities. There were no significant differences between individual professions’ average ICCAS item or domain scores before or after each activity. Most participants (76%) rated the activities as good or excellent and student comments highlighted the benefit of authentic team interactions.

DISCUSSION / REFLECTION / LESSONS LEARNED: Separate but linked virtual longitudinal Sim-IPE incorporating IP student teams and standardized patients is feasible and can lead to improvements in reported interprofessional core competencies (roles & responsibilities, collaborative patient family-centered care, communication, interpersonal) as measured through the ICCAS instrument . Learners maintained competencies in the second session, while gains plateaued as expected with the Likert scale ceiling. Improvements were more pronounced with the initial activity and were significant for all professions combined and individually.

ONLINE RESOURCE URL: https://opioideducation.wsu.edu/

PREPARING RESIDENTS FOR COLLABORATIVE CARE FROM DAY ONE: LEARNING TO NAVIGATE INTERPROFESSIONAL TEAMWORK USING A CASE-BASED ORIENTATION PROGRAM

Nissa Mazzola^1,2; Daniel J. Coletti¹; Leslie Rosenberg¹; Melanie Ritter¹; Anna Andrews¹; Jennifer Verbsky¹. ¹Division of General Internal Medicine, Northwell Health, New Hyde Park, NY; ²College of Pharmacy and Health Sciences, St. John's University, Queens, NY. (Control ID #4064452)

SETTING AND PARTICIPANTS: Ambulatory orientation for new interns is critical and at times an underutilized opportunity to engage residents in applying key outpatient care skills. An added challenge to mastering required diagnostic and treatment skills is learning roles and collaborative protocols for engaging members of an interprofessional team. As a Patient Centered Medical Home (PCMH), our practice site utilizes a large interprofessional team to offer high quality, cost effective care. Residents in our training program follow a 4+1 model, where once every five weeks they have their ambulatory care experience. At the beginning of the academic year all residents participate in a half-day orientation to understand the practice workflows and roles of each member of the interprofessional team. Historically, this was done lecture style.

We decided to modify the traditional format to include all members of our IP team and to engage residents in case-based interactive learning to identify roles and protocols for IP team engagement.

DESCRIPTION: Each week, the firm of residents was split into smaller groups of three to four. The groups were given scenarios starting at various points in the patient care cycle. Stations consisted of meeting with a medical social worker, a member of the behavioral health team, a substance use -health coach, and a clinical pharmacist. The residents were expected to ask/answer questions to learn the role of each interprofessional team member, and the team members provided additional information to bridge the knowledge gaps in real time. The residents were then prompted to navigate to the next station. At the completion of the scenario, there was an online game to quiz the residents on team member roles and identities. To evaluate the new format, residents were given an anonymous paper survey to obtain their perceptions with the new format.

EVALUATION: Of the 59 surveys completed, 96% indicated they agreed or strongly agreed that the activities increased their understanding of each interprofessional team members’ roles. Of the second and third year residents who completed the traditional format of orientation, 94.8% indicated they preferred the flipped classroom format.

DISCUSSION / REFLECTION / LESSONS LEARNED: Active learning has been shown to increase the quality of instruction and help learners retain and understand the information. Using an interactive, scenario based approach to orienting new medical residents to interprofessional team members was overwhelmingly favored compared to the traditional lecture based format. Further interactive experiences are planned to continue to improve resident experiences.

Innovation in Medical Education (IME) - Medical Education and Scholarship

A COMPARATIVE ANALYSIS OF NUTRITION EDUCATION IN LATINX COMMUNITIES: A PRE-POST INTERVENTION STUDY IN STUDENT-LED FREE CLINIC ACROSS RURAL AND URBAN SETTINGS

David Lee¹; Stephanie C. Marín¹; Iris Marquez²; Ricardo R. Flores¹; Kimberly Del Toro¹; Henry Duran¹; Ann Cheney¹. ¹School of Medicine, University of California Riverside, Riverside, CA; ²California State University Long Beach, Long Beach, CA. (Control ID #4055043)

SETTING AND PARTICIPANTS: Participants (n=14), exclusively 40 to 59 and self-identify as Hispanic, engaged in either a rural group setting facilitated by a promotoras de salud or an urban one-on-one setting that received one-on-one sessions led by medical students.

DESCRIPTION: The rising prevalence of diet-related health issues underscores the urgent need for effective nutrition education, particularly in underserved communities (1,2). This study evaluates the impact of nutrition education delivered in a rural group setting by community health workers known as promotoras de salud (PDS) or one-on-one lessons by medical students in urban settings. The objective is to assess whether these approaches enhance knowledge about general nutrition principles, a crucial factor that empowers individuals to make informed dietary choices, promotes healthy lifestyle habits, and prevents various chronic conditions (1).

EVALUATION: By conducting a pre-post test design using the validated General Nutrition Knowledge Questionnaire-Revised3, the study evaluates the influence of tailored nutrition education aligned with the U.S. Department of Agriculture's MyPlate dietary guidelines. In this study, participants (n=14) exclusively comprised individuals aged 40 to 59, self-identified as of Hispanic ancestry, and were born in Latin America. Results from the paired t-test demonstrated statistically significant differences in both urban (p<0.001) and rural settings (p=0.014) when comparing the pre- and post-test results independently. However, assessing the disparities between the two free clinics via independent t-test, revealed no statistical significance (p=0.409).

DISCUSSION / REFLECTION / LESSONS LEARNED: The findings shed light on the comparative effectiveness of nutrition education led by PDS and medical students in underrepresented communities. The findings suggest that both methods-group sessions from PDS and individual sessions with medical students-effectively enhance nutrition knowledge. However, a notable limitation is the small sample size, therefore, further research is needed to assess the generalizability of the results. In conclusion, this study underscores the significance of culturally tailored educational strategies in enhancing the understanding of the critical relationship between diet and chronic diseases.

AN INNOVATIVE LONGITUDINAL OUTPATIENT MEDICAL SUBSPECIALTY EXPERIENCE DURING AMBULATORY BLOCKS: PERSPECTIVES AND IMPACTS

Brett Chen²; Zainab Mabizari²; Afek Kodesh²; Jay Chudow¹; Darlene LeFrancois². ¹Cardiology, Montefiore Einstein Center for Heart and Vascular Care, Bronx, NY; ²Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4063309)

SETTING AND PARTICIPANTS: A longitudinal subspecialty clinic (LSC) experience offered to all 39 PGY-2 Internal Medicine categorical residents during ambulatory blocks at a large urban academic medical center utilizing a traditional 6+2 block schedule.

DESCRIPTION: Internal Medicine residency training ideally exposes residents to both general practice and subspecialties. Traditionally, subspecialty experience is facilitated through inpatient rotations lasting two to four weeks involving consult and primary services, and frequently precludes exposure to outpatient care integral to many subspecialty practices. The brief duration of inpatient subspecialty electives and the cycling of attending physicians within them reduces continuity in teaching and hinders the development of mentoring relationships and career planning.

The LSC program was initiated in part by resident feedback requesting increased outpatient subspecialty experience. Most subspecialties within the Department of Medicine participated. PGY-2 residents dedicate a half day per week during their two-week outpatient clinic blocks for six months before switching to another subspecialty clinic for the remainder of the year. Each resident submits a prioritized rank list of subspecialties for clinic assignments, though assignment to their top-ranked clinic is not guaranteed. Residents can also decline participation in an LSC and remain at their primary clinic site or create their own subspecialty experience with a pre-existing mentor.

EVALUATION: In the first six months of implementation of the LSC program, 97% of PGY-2 residents participated. Seventy-two percent of residents were placed in their first-ranked LSC, and 15% were placed in their second choice. A survey featuring both narrative and Likert scale questions will assess resident perspectives on the impacts of the LSCs, specifically focusing on clinical knowledge, various aspects of career planning, and satisfaction. The effects of assignment to a first-ranked LSC versus one with a lower ranking will also be assessed. A separate subspecialty preceptor survey will assess residents’ longitudinal participation, clinical performance, as well as career and research mentorship. A comparison with PGY-3 residents who did not participate in an LSC due to initiation of the program after their PGY-2 year will measure the impact of the LSC program on residency training.

DISCUSSION / REFLECTION / LESSONS LEARNED: Implementation of the LSC program thus far has garnered widespread support from residents as evidenced by near universal participation. The LSC program exposes residents to subspecialty ambulatory care which may enhance mentorship and career exploration and refine clinical knowledge. Through individualization of the ambulatory educational experience, satisfaction in ambulatory medicine may improve. Evaluations will assess the extent of the impact of the LSC intervention on knowledge, mentorship relationships, and career planning.

A QUALITATIVE ANALYSIS OF A GAMIFIED, INTERACTIVE ECG TEACHING APPLICATION FOR INTERNAL MEDICINE CLERKSHIP STUDENTS

Bhavya Ancha¹; Yoav Karpenshif². ¹University of Pennsylvania, Philadelphia, PA; ²Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4062878)

SETTING AND PARTICIPANTS: This project is a qualitative research study using semi-structured interviews around 30min in length with a script focused on the study questions and constructed with the validated technology acceptance frameworks PICRAT (passive, interactive, creative, replacement, amplification, and/or transformation) and TAM (technology acceptance model) in mind. Students on their internal medicine rotation who have been given access to The Daily Rhythm, the ECG learning application, were invited to participate.

DESCRIPTION: Electrocardiogram (ECG) reading is an essential skill for graduating medical student, though previous work shows that students report difficulty understanding, remembering, and applying ECG skills (Ohn 2020). In order to improve ECG education, we introduced The Daily Rhythm, a gamified ECG learning platform, into the internal medicine clerkship curriculum. The Daily Rhythm’s principles of interactive learning, foundation building, and gamification make this platform a new approach to ECG teaching. This study gauges students’ perception of their ECG education with The Daily Rhythm to better understand in their self-reported comfort with the platform compared to traditional learning, barriers to using The Daily Rhythm for their ECG learning, and how applicable this gamified model would be to other areas of medical education.

1. Ohn MH, Souza UD, Ohn KM. A qualitative study on negative attitude toward electrocardiogram learning among undergraduate medical students. Tzu Chi Med J. 2020;32(4):392-397. doi:10.4103/tcmj.tcmj_91_19

EVALUATION: Interviews were transcribed and coded with both inductive from open coding and deductive codes generated from technology acceptance models. Replicability of codes will be validated by another investigator. The coded data will then be analyzed for themes.

This project is still currently undergoing analysis. Early thematic analysis shows emerging themes of competing obligations, lack of overall time to devote to learning, pressure to favor the most condensed approach to learning, and difficulty to maintain previous proficiency due to significant time gap between ECG learning in the pre-clinical setting and application of knowledge during clerkships.

DISCUSSION / REFLECTION / LESSONS LEARNED: Gamified applications and curricula like the Daily Rhythm strive to make ECG learning interactive, approachable, and fun, though there are challenges in incorporating this learning approach in a medical clerkship. These findings elucidate the unique challenges of the contemporary medical student and the nuances that come with the introduction of a novel medical education tool. Through this study, future directions include potentially introducing the Daily Rhythm to pre-clinical students as well as including different learners such as residents.

ONLINE RESOURCE URL: www.dailyrhythm.io

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A QUALITY IMPROVEMENT CURRICULUM FOR MEDICAL RESIDENTS: MULTI-LEVEL INTERVENTIONS TO IMPROVE COLORECTAL CANCER SCREENING IN AN URBAN SAFETY-NET SYSTEM

Brittany T. Abel³; Ghezal Saffi¹; Raphaela Lipinsky DeGette¹; Blake Gregory²; Anne Rosenthal¹. ¹General Internal Medicine, University of California San Francisco, San Francisco, CA; ²San Francisco Department of Public Health, San Francisco, CA; ³University of California San Francisco School of Medicine, San Francisco, CA. (Control ID #4061508)

SETTING AND PARTICIPANTS: Setting: Large primary care clinic at an urban academic medical center

Participants: 2nd and 3rd year primary care internal medicine residents

DESCRIPTION: Course faculty designed a two-year curriculum using principles of A3 Thinking and Human Centered Design to teach residents a framework for quality improvement work in clinical settings. Residents completed an A3 and designed and implemented an equity-focused QI project. The group chose CRC screening because CRC screening rates at our clinic and across our primary care network declined substantially as a result of an electronic health record (EHR) transition, the COVID-19 pandemic, and an expansion of screening to include patients ages 45-49. Residents also wanted to address significant disparities in screening rates for Black, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander patients as compared to other patients at our clinic.

Residents designed a 4-pronged intervention that relied on skills learned in 3 domains

Population health: “Panel Review” activity based on creating electronic reports and performing targeted outreach to patients from groups with the greatest disparities in CRC screening rates

Systems improvement: Submitted and gained approval to embed two changes in the EHR to support CRC screening across a network of 14 primary care clinics

1. Visual (diagrammatic) instructions for how to complete Fecal Immunochemical Test (FIT) testing that are included automatically in an After Visit Summary for all patients

2. A reduction in the interval after ordering for which an alert fires if a FIT has not been returned

Clinic-based QI: Developed an incentive program to raffle gift cards for clinic patients who complete their FIT testing

EVALUATION: Overall clinic CRC screening rates dropped markedly when our guidelines expanded to include patients age 45-49 yo. Rates have since returned to baseline (60%) while the gap between all patients and B/AA patients narrowed (10% to 8%). Two of the resident project interventions launched in April 2023: Panel Review and Visual FIT instructions. The improvement in screening rates correlated with this timeline.

The FIT raffle incentive will launch in January 2024, and the EHR build for reducing the alert interval for unreturned FITs is also expected in early 2024. We will continue to track clinic screening rates stratified by race and ethnicity.

Residents gained skills in designing quality and systems improvement interventions. Course evaluation was solicited using the Design Thinking framework “I like, I wish, I wonder”. Sample responses were

1. “I feel like I can take and run with a QI project”

2. “Every job has asked me about my QI experience, and then wanted tangible examples – this experience gave me the ability to do that”

DISCUSSION / REFLECTION / LESSONS LEARNED:

1. A multi-pronged intervention taught residents to effect systems change at multiple levels in the organization

2. In addition to project deliverables, this longitudinal resident-led project developed diverse QI skills that are desired by GIM jobs

ASSESSING THE IMPACT OF AN UNDERGRADUATE MEDICAL STUDENT VOLUNTEER HOSPITAL PROGRAM: ACTIVE MIND, ACTIVE BODY

Kareena Nanda¹; Jaslyn Rasmuson¹; Julian Lau¹; Pamela Mathura^1,2; Winnie Sia^1,2. ¹University of Alberta Faculty of Medicine & Dentistry, Edmonton, AB, Canada; ²Alberta Health Services, Edmonton, AB, Canada. (Control ID #4043468)

SETTING AND PARTICIPANTS: Active Mind, Active Body (AMAB) is based out of 1 acute care and 1 rehabilitation hospital in Edmonton, Alberta. Since the program’s start 2 years ago, 299 patients and 61 medical students have participated in the program. Patients on specific hospital units were identified through referral criteria.

DESCRIPTION: AMAB is a novel student-led initiative that was started in July 2021 during the COVID-19 pandemic. The program aims to address the mental and physical health effects of long-term hospitalization through patient-directed social activities and physical rehabilitation by medical students. AMAB also uniquely allows medical students in pre-clinical years to independently engage with patients and provides early exposure to internal medicine specialties. It also encourages students to consider patients' non-medical needs and develop a collaborative and interdisciplinary approach to integrate aspects, such as social determinants of health, mental health, and lifestyle choices, into patients’ health as a whole.

A quality improvement study was launched to improve AMAB’s impact on both patients in the hospital and the medical students participating in the program. Anonymized patient interaction records and feedback were analyzed to quantify the volume of patients seen and the type of interactions performed. In addition, a survey was sent to medical student volunteers inviting them to provide feedback on their experiences in the program, what prior clinical experiences they had, and what skills they felt they gained in the program.

EVALUATION: The results showed that 424 patient encounters with 220 patients were completed. 49% of interactions lasted longer than 30 minutes. 98% of visits included socialization, 27% focused on cognitive activities, and 22% of visits involved physical activity.

Based on the survey of volunteers with a response rate of 56%, 94% of medical students felt that AMAB was valuable for patients and 88% felt that AMAB was meaningful for them as a volunteer. 67% felt that AMAB exposed them to different medical specialties, and 74% felt that AMAB changed the way they would interact with patients in the future. Volunteers also reported that AMAB enhanced their communication skills, facilitated interprofessional collaboration, and provided an early introduction to building strong patient-physician relationships.

DISCUSSION / REFLECTION / LESSONS LEARNED: Based on feedback from patients and volunteers, opportunities for improving this initiative include the provision of more diverse activities that address patient-specific goals and improving the volunteer experience by implementing a structured peer-to-peer support system to enhance the learning of interpersonal skills.

This study highlights the importance of initiatives such as AMAB in improving both the experience of hospitalized patients and the early clinical teaching of medical students. These results showcase a model that can be applied and adapted to the benefit of other medical education programs.

ASSESSMENT OF A NOVEL PROGRAM HIGHLIGHTING STUDENT STORIES IN PRE-CLINICAL MEDICAL CURRICULUM AT AN ACADEMIC INSTITUTION

Elyse Olesinski¹; Seth Bergenholtz²; Yesh Datar¹; Ariel Hirsch^3,1. ¹Chobanian & Avedisian School of Medicine, Boston University, Boston, MA; ²Mount Sinai Health System, New York, NY; ³Radiation Oncology, Boston Medical Center, Boston, MA. (Control ID #4063942)

SETTING AND PARTICIPANTS: The program took place at an academic institution in New England for medical students in their second year of pre-clinical training between 2020 and 2023. The program consisted of 8-15 student presentations and Q&A follow-up lasting 30-60 minutes, which were held either in person or remotely. Session content varied by class year, and voluntary attendance ranged from 25 to 160 students.

DESCRIPTION: The Student Perspectives Initiative (SPI) is a novel student-led program that empowers medical students to share their personal experiences with medical conditions, thereby providing nuanced education of their illnesses based on evidence-based medicine while also highlighting the lived experience that lectures alone may struggle to capture. These presentations were integrated into the pre-clinical curriculum by scheduling sessions close to relevant lecture material. For example, one student presented their story of childhood leukemia after hematological cancers were discussed in the oncology module. Presentations were student-created and utilized visual media including text, personal pictures, and lab values or imaging.

EVALUATION: We evaluated the impact of the SPI program on educational enhancement, connections between peers, and student preparation for clinical rotations. We emailed an anonymous REDCap survey (IRB: H-41979) to all medical students who were in their second year of pre-clinical training when SPI presentations were conducted, with two reminders sent 1 and 2 weeks after the original email. Survey questions included yes/no, 5-point multiple choice scale (1-strongly disagree to 5-strongly agree), and free text. Respondents were individuals who shared a story, attended a session, or did not engage with the program. We also included targeted questions regarding the longitudinal impact of SPI on students’ experiences during rotations for those who had completed some or all of their third-year rotations. We analyzed the program by calculating the mean values for responses.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our preliminary data, including 44 individual responses so far, shows that the SPI program increased engagement with lecture material (4.42/5), improved understanding of patients with disabilities (4.22/5), and overall was an effective educational tool (4.08/5). Respondents felt that it was easier to cultivate connections with their peers (3.97/5) and that the program added value to building community (4.42/5). Those who underwent clinical training reported greater retention of clinical knowledge (3.72/5) and better skills for expressing empathy for their patients (3.67/5).

This innovative program was received positively by students and faculty and reinforces the importance of student-directed programs in pre-clinical narrative medicine training. We demonstrate for the first time to our knowledge that creating a structured space for students to share personal/family medical experiences with peers can serve as a powerful educational tool and cultivate a shared understanding of different diseases.

BACK TO BASICS: RAPID RESPONSE TRAINING FOR THE ACADEMIC HOSPITALIST

David Fruchter, Kimberly Christophe, Benjamin Felder, Jessica Goldberg, Dahlia Rizk, Patricia Dharapak. Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #4043523)

SETTING AND PARTICIPANTS: Division of hospital medicine faculty at an academic hospital in the Northeast

DESCRIPTION: The hospitalist role has traditionally been within the hospital setting. While hospitalist involvement in RRT/Codes can vary by institution, the academic hospitalist is infrequently the RRT/Code team leader. As our clinical scope expands to areas outside of the traditional hospital setting, forums for continued faculty development in critical event response are increasingly prudent.¹ In anticipation of our group providing RRT/BLS coverage at a new, off-site, inpatient behavioral health facility without trainee or critical care backup, we developed a targeted behavioral health RRT curriculum. We aimed to standardize best practices in RRT management and familiarize our faculty with the most common critical scenarios to expect.

The experience of our 30+ faculty hospitalist group ranged from 1-25 years. A pre-intervention survey revealed that 46% of respondents disagreed/strongly disagreed with feeling confident in leading an RRT while another 19% responded indifferently. Not surprisingly, respondents who were within five years of residency training reported feeling more confident.

Our first intervention was an educational conference to provide an overview of the indications and outcomes of past behavioral health RRTs at our institution and review the management of common RRT scenarios. Elective in-person simulation training was offered as a second intervention. The effectiveness of theses interventions on RRT confidence was assessed through anonymous pre- and post-surveys.

EVALUATION: Eight-one percent of respondents were in agreement/strong agreement that a faculty development conference was an effective means of building RRT confidence. All of the respondents who attended the in-person simulation training agreed/strongly agreed that the training improved their RRT confidence. We also observed that in-person simulation RRT training further augmented the positive effect of the faculty didactic on RRT confidence. Both learning modalities appeared effective at increasing faculty confidence in leading an RRT regardless of experience level.

DISCUSSION / REFLECTION / LESSONS LEARNED: Maintaining competence and confidence in RRT is increasingly essential for today’s hospitalist, whose clinical scope can easily extend beyond the traditional hospital setting. Multi-modal RRT training with didactics and in-person simulation can be effective and synergistic in building RRT confidence regardless of years of experience. Next steps include monitoring the durability of self-reported RRT confidence and analyzing the impact of our RRT curriculum on clinical outcomes.

ONLINE RESOURCE URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9195092/

BIDIRECTIONAL MULIT-PATIENT OBSERVATION IN RESIDENT PRIMARY CARE CLINIC AND ITS EFFECTS ON PERCEIVED QUALITY OF FEEDBACK

Sarah Beilke¹; Tyra Fainstad². ¹Medicine, University of Colorado System, Denver, CO; ²Internal Medicine, University of Colorado, Denver, CO. (Control ID #4064502)

SETTING AND PARTICIPANTS: Residents and attendings at two large academic teaching clinics within the same institution were offered surveys in June 2023. Resident surveys included dimensions of satisfaction with feedback and overall clinic experience as well as comfort with clinical competency and likelihood to choose a career in primary care. Attending surveys included dimensions of satisfaction with resident observations and material to provide feedback around. All residents and teaching attendings at one of the two clinics were included in an intervention for scheduled bidirectional multi-patient observation and feedback. Residents at the other clinic did not participate in the intervention and serve as a control. Post surveys mirroring the pre-survey will be offered to both groups in May, prior to the conference and preliminary data will be available for the conference.

DESCRIPTION: Each time a resident is in a primary care month (three times per year), they are matched with a mentor attending for one of the attending’s personal clinic sessions. The resident and attending are instructed to split the patients (the resident will see half (~4 patients) of the patients while their attending observes, and the attending will see the other half (~4) while the resident observes. The primary goal is to improve feedback quality by increasing bi-directional observation and feedback. The secondary goal is to improve resident attitudes towards primary

EVALUATION: Pre intervention surveys have been distributed in June of 2023 and post-surveys will be offered in May 2024 to all internal medicine residents and resident clinic attendings at the intervention and control clinics. These surveys assess residents’ perception of feedback in clinic including quantity and quality. We also assess attitudes towards primary care. The attending surveys assess their perception of their ability to provide feedback to residents based on their observations in clinic.

DISCUSSION / REFLECTION / LESSONS LEARNED: At this time the observation half-days have been implemented at one primary care clinic. Anecdotal qualitative feedback has been positive: residents have reported the time to be meaningful. They find it allows them to better understand what a career in primary care looks like. They have also picked up strategies to be more efficient. Our post-survey quantitative data will be used to see if there is a statistically significant difference in resident perception of feedback, careers in primary care or clinic efficiency.

BRIDGING THE GAP: TRANSFORMING HEALTHCARE THROUGH INTEGRATION OF SEX AND GENDER-BASED EDUCATIONAL CONTENT

Julia Lorence¹; Iris Dupanovic⁴; Amanda Maxfield⁵; Juliette A. Janiszewski⁶; Sneha M. Chaturvedi⁷; Janice L. Werbinski³; Deborah Kwolek². ¹College of Health Solutions, Arizona State University, Tempe, AZ; ²Medicine, Harvard Medical School, Boston, MA; ³Ob Gyn, Michigan State University, Portage, MI; ⁴Harvard Extension School, Cambridge, MA; ⁵Geisel School of Medicine at Dartmouth, Hanover, VT; ⁶Massachusetts General Hospital, Boston, MA; ⁷Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #4064114)

SETTING AND PARTICIPANTS: In 2018, the Sex and Gender Health Collaborative (SGHC), in partnership with the American Medical Women’s Association (AMWA), launched a student-led initiative to increase understanding and education of sex and gender-based medicine (SGBM). This effort was launched in response to a crucial gap in SGBM curricula in medical schools. It was reported that only 25% of medical lectures cover the relevance of SGBM (Thande et al. 2019) and 22% of primary care doctors feel prepared to assess women's heart disease risk (Bairey Merz et al. 2017). The initiative recruited over 200 AMWA medical and pre-medical students to collaborate with each other and physician mentors in creating 75 factsheets that outline sex and gender differences in common medical conditions.

DESCRIPTION: Each SGBM fact sheet focuses on the impact of sex and gender on risk factors, symptoms, diagnostics, and treatment of one medical condition. The topics include heart disease, mental health, and chronic illnesses. The physician mentorship and expert review process ensures the integrity and applicability of the content, aiming to equip medical students and physicians with vital information to improve health equity and patient care.

EVALUATION: Pre- and post-interventional surveys aimed to evaluate students’ self-reported knowledge about SGBM and assessed the amount of SGBM integration in their curricula. The pre-interventional survey illustrated that among 41.67% of medical students, SGBM was “mostly not” included in the curricula, while 50.73% considered that they possessed knowledge about sex and gender differences in medicine. In the post-survey, 63.21% of the students “strongly agreed” that participating in the fact-sheet development significantly increased their knowledge of SGBM. After creating the first 2 factsheets, 5 cognitive interviews were conducted with students unfamiliar with the project to provide insights on potential improvements of the factsheets. Phase 3 aims to include focus groups with physicians, residents, and medical students to further the initiative.

DISCUSSION / REFLECTION / LESSONS LEARNED: Integrating SGBM educational materials into medical curricula has the potential to positively impact patient care and offer medical trainees an increased ability to individualize medical recommendations based on sex and gender considerations. Overall, among our participants, the project has increased SGBM knowledge in measurable ways and was well received by contributing students, with 93% of them recommending the project to others. Lessons learned thus far include the need for more mentors, dedicated faculty, and resident physicians to advance the project while also adapting new forms of summarizing and disseminating sex and gender data.

ONLINE RESOURCE URL: https://www.amwa-doc.org/sghc/sghc-crunch-sheets-toolkits/

CHOGORIA ROUNDS: A NOVEL CLINICAL REASONING TEACHING TOOL FOR RESIDENTS

Banks Kooken¹; Charles Barrier¹; William M. Smith²; Michael Leonard³. ¹Internal Medicine, Atrium Health, Charlotte, NC; ²Internal Medicine, PCEA Chogoria Hospital, Chogoria, Kenya; ³Infectious Diseaes, Atrium Health, Charlotte, NC. (Control ID #4055067)

SETTING AND PARTICIPANTS: We present a novel educational tool for Internal Medicine (IM) residents involving a series of case presentations (Chogoria Rounds, CR) from a physician partner in Kenya to general IM and Infectious Disease attendings with experience and knowledge of international medicine, along with IM residents at different stages of training at a community medical center in the Southern Mid-Atlantic region.

DESCRIPTION: Over an 18-month period, 30 cases were presented virtually, de novo, allowing attendings to discuss their clinical assessment of these cases in real time with the residents in attendance. A survey with Likert scale response (1 strongly disagree, 5 strongly agree) was distributed to residents to assess CR as an effective clinical reasoning teaching tool.

EVALUATION: Of the 30 presented cases, 11 were related to tuberculosis (pulmonary, miliary, meningitis), 10 to other infections (severe malaria, leishmaniasis) and other interesting cases such as African night shade ingestion. Thirteen residents were surveyed with 10 respondents. All 10 strongly agreed or agreed that CR was a useful clinical reasoning teaching tool (50% strongly agreed, 50% agreed), and 90% felt it impacted patient care. 80% reported CR drove them to read more about a particular disease process that was discussed. 50% of residents did not feel CR impacted their practice regarding high value care, but 90% felt it generated meaningful discussion surrounding resource utilization. All residents expressed interest in participating in a global medicine experience in the future, and 90% became more interested in global medicine.

DISCUSSION / REFLECTION / LESSONS LEARNED: Chogoria Rounds showed to be an effective clinical teaching tool for IM residents by giving them insight into clinical reasoning from expert attendings as well as rapid fire case conferences to provide increased volume of exposure. Teaching clinical reasoning is limited by time, volume and ability to communicate thought process. By holding virtual case discussions, this overcomes time and volume of seeing patients in person. The virtual setting also allows attendings to explain their reasoning in real time as they learn about a case. This also provided clinical support to an early career internist in Kenya, lending expertise to cases for patients in a resource limited setting. This virtual case conference model can easily be replicated for the benefit of residents and other learners at the US-based institution while at the same time benefiting those at the partnering international institution. Presenting a few short cases per session can quickly increase resident volume of case exposure along with the opportunity to observe the clinical reasoning of the participating attendings.

CHRONIC KIDNEY DISEASE SCREENING, DIAGNOSIS, AND MANAGEMENT IN THE ERA OF RACE-FREE EGFR: A RESIDENT-LED AMBULATORY EDUCATION AND QUALITY IMPROVEMENT PROJECT

Rohan Khazanchi²; Raquel Selcer^1,2; Sanjna L. Surya^1,2; Jacob Cedarbaum⁴; Meybel Lopez-Flores¹; Ndang Azang-Njaah^2,1; Staci Eisenberg^2,1; Mallika L. Mendu³. ¹Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Departments of Internal Medicine and Pediatrics, Brigham and Women's Hospital, Boston, MA; ³Renal, Brigham and Women's Hospital, Boston, MA; ⁴Massachusetts General Hospital, Boston, MA. (Control ID #4064150)

SETTING AND PARTICIPANTS: Residents and faculty preceptors at Med-Peds clinic in the Northeast.

DESCRIPTION: Chronic kidney disease (CKD) impacts 37 million Americans, yet primary care physicians (PCPs) frequently fail to screen, diagnose, manage, and counsel patients who are at risk for it. Moreover, cystatin C (cysC) remains an underutilized diagnostic tool for CKD, despite its improved accuracy in many patients and emphasis in recent guidelines.

During our resident-led quality improvement project, we used an educational toolkit including didactics, handouts, and point-of-care decision aids. Topics included CKD screening, diagnostic criteria, indications for cysC testing, race-free kidney function estimation guidelines, and medications to slow CKD progression. We also facilitated panel management by finding patients with hypertension, type 2 diabetes mellitus (T2DM), and CKD Grade 2-4 who did not meet quality goals.

EVALUATION: We evaluated our intervention across several Kirkpatrick levels. Clinician surveys indicated greater self-reported confidence (pre mean 2.5 on 5-point Likert scale [SD 0.9], post 3.9 [0.8]) and knowledge (pre 2.7 [0.9], post 4.0 [0.8]) with CKD guidelines and increased understanding and use of cysC (post only 4.0 [0.9]).

We identified 372 patients with CKD2-4 seen within the last year at our clinic. Patients had a mean age of 68.6 years (SD 12.4) were mostly female (61%); Hispanic (36%), White (35%), or Black (25%); spoke English (63%) or Spanish (32%); had Medicare insurance (53%); and had comorbid hypertension (73%) and/or T2DM (33%).

Among 65 patients with CKD G3a by eGFR-Cr, cysC testing increased from 11% to 32%. Fifteen out of 21 (71%) had discordance between eGFR-Cr and eGFR-cysC with 5 restaged as G2, 7 restaged as G3b, and 3 restaged as G4. Albuminuria screening improved slightly among patients with hypertension (N=246, 38% to 44% ever) and diabetes (N=116, 38% to 49% within 1 year).

DISCUSSION / REFLECTION / LESSONS LEARNED: We implemented a resident-led CKD education and QI initiative at our Med-Peds primary care clinic. Over 9 months, our intervention tripled the proportion of target patients re-staged with eGFR-cysC and slightly improved albuminuria screening among patients with hypertension and diabetes. We also increased PCP understanding of CKD diagnosis and management guidelines.

Our project identified opportunities to further improve kidney care as only 44% and 72% of patients with hypertension and diabetes were screened for albuminuria. While cysC use increased, 68% of patients with CKD G3a didn’t receive this confirmatory test. We plan to examine how our interventions impact racial inequities in CKD care when deployed across other clinics, especially for Black patients whose care may be most impacted. Overall, our evaluation highlights an educational and panel management intervention to improve CKD screening, diagnosis, and management that can be implemented in primary care practices.

ONLINE RESOURCE URL: https://shorturl.at/dpx48

CONSENSUS ON CLINICIAN EDUCATOR TRACK TEACHING SKILLS FOR INTERNAL MEDICINE RESIDENTS: A MODIFIED DELPHI STUDY

Andrew J. Klein¹; Allie Dakroub²; Melissa McNeil³; Scott D. Rothenberger⁴; Sarah B. Merriam⁵. ¹Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²Internal Medicine/Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA; ³Brown University, Providence, RI; ⁴Medicine, University of Pittsburgh, Pittsburgh, PA; ⁵Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh , PA. (Control ID #4064296)

SETTING AND PARTICIPANTS: Over 60 Internal Medicine (IM) or Medicine-Pediatric faculty from around the country who are a current or prior director of a Clinician Educator Track (CET) within an IM residency program have been identified and invited to participate in an online modified Delphi survey. Based on the literature, we defined a CET as a longitudinal program occurring over at least 1 year of training with the primary goal of developing clinician educators.

DESCRIPTION: Over the past decade, the number of IM residency programs that have instituted longitudinal tracks to help interested residents prepare for a future career as a clinician educator has increased steadily. These CETs vary widely in structure, content, and overall goals. While some of this variability is dictated by differences in local curricular time, resources, and expertise, there exists no guidelines or prioritized list of teaching skills to guide CETs in their aim of cultivating a community of skilled, aspiring clinician educators upon completion of training. We aim to use a two-round modified Delphi to determine a consensus recommendation for a prioritized set of teaching skills for IM CET residents to achieve by the end of residency training.

EVALUATION: An initial list of CET teaching skills was developed via a systematic literature review of previously published CETs and reviews. Participants will be asked to rank each of these teaching skills based on importance for IM CET residents to achieve by the end of residency from 1 (less important) to 4 (most important). Participants will be provided with the group’s mean, standard deviation, and percent of participants ranking each item important or most important, along with all comments and their personal ranking after each round. This process will be repeated in round two. We defined consensus a priori as any topic with 80% or higher agreement that it is “important” or “most important” (Likert scale 3 or 4) at the end of the 2nd round. The final list of teaching skills will be comprised of all those meeting this consensus definition. Results will be available by the end of February 2024 and, if accepted, presented at the national meeting in May 2024.

DISCUSSION / REFLECTION / LESSONS LEARNED: We anticipate our results will create a prioritized consensus list of teaching skills that are most important for CET residents in IM programs. This aim has the potential to provide guidance to programs launching new CETs, improve the quality of existing CETs, and strengthen the shared goal of programs around the country to train the next generation of skilled clinician educators. By uniting leaders of CETs across the country, we also hope to strengthen this community of educators and foster future collaborations.

CULTIVATING CONFIDENCE: THE IMPACT OF A NOVEL CLINIC COACH PROGRAM FOR INTERN CONTINUITY CLINIC

Jessica Valente, Jeffrey Alexander, Stephanie Myers, Christina Rinaldi, Donna Williams. General Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC. (Control ID #4063313)

SETTING AND PARTICIPANTS: Four General Internal Medicine faculty received funded, protected time to serve as Clinic Coaches during the 2022-2023 academic year. Coaches worked with 34 internal medicine interns as they developed skills in outpatient management of their patient panel.

DESCRIPTION: Interns face many challenges as they transition from student to primary care physician. Continuity clinic is difficult, as interns must learn key clinical and communication skills in a time-limited setting with growing autonomy. Preceptor time for coaching has become more limited as preceptors juggle resident supervision and clinical expectations. The COVID pandemic led to fewer preceptor-led direct observations, prompting the creation of the Clinic Coach program. The Clinic Coach program provides interns with a core outpatient faculty mentor for additional clinical oversight, direct observations in the ambulatory setting, and mentorship to support professional development. We hypothesize that the Clinic Coach program enhances intern comfort and efficiency in primary care while fostering increased direct observations and feedback.

EVALUATION: Clinic coaches hosted 3 individual meetings with interns on topics such as navigating clinic and EMR, agenda setting, electronic inbasket, and panel management. All coaches performed direct observations and documentation review for their intern cohort. Interns completed pre-meeting assessments to reflect on learning goals and track progress in clinic. Clinic coaches completed post-meeting assessments to document feedback from direct observations and meeting outcomes. Qualitative data from coach and intern meetings were collated and reviewed to identify overarching themes. Pre-post data was analyzed using descriptive statistics.

DISCUSSION / REFLECTION / LESSONS LEARNED: From 2022-2023, twenty-one interns (61.7%) completed pre-meeting assessments; clinic coaches hosted 71 individual intern meetings (70%). Coaches conducted direct observations of entire clinic encounters for 25 unique interns (73.5%), a significant increase from only 1 full encounter directly observed by preceptors in the previous year. Interns reported 2-5 times more required direct observations in essential skills like pap smears, physical exams, Medicare wellness visits, lifestyle counseling, and results management compared to 2021-2022. Interns reported increased confidence with EMR, clinic workflows, and inbasket management. Clinic coaches predominantly offered feedback on managing EMR, results, patient communication, and total visit time, including precepting. Interns requested future sessions incorporate ambulatory knowledge, an EMR playground for simulating unique visit types, and one-on-one intern clinic reorientation.

The clinic coach program demonstrated a substantial increase in total direct observations. Interns highly valued feedback, noting improvements in clinic efficiency and confidence. Next steps include gathering preceptor perspectives on the clinic coach program and aligning ambulatory knowledge topics with coaching sessions.

EMPOWERING INTERNAL MEDICINE RESIDENTS: A MULTIDISCIPLINARY READMISSION CONFERENCE FOR ENHANCING CLINICAL COMPETENCIES AND IMPROVING PATIENT CARE

Shiromini Herath, Jennifer D. Baldwin, Robert Nardino. Medicine, UConn Health, Farmington, CT. (Control ID #4064827)

SETTING AND PARTICIPANTS: This conference is conducted by internal medicine residents during their 4-week inpatient hospital medicine rotation. It is attended by Internal Medicine Residents, Hospital Medicine Faculty, Subspecialists, Emergency Medicine Faculty, Hospital Administrators, and a multidisciplinary team, including Case Managers, Social Workers, Nursing Staff, and Quality Department Staff.

DESCRIPTION: Healthcare institutions face the challenge of reducing preventable readmissions. In response, a multidisciplinary conference led by internal medicine residents was developed to identify and analyze the causes of readmissions. The main objectives of the conference are to educate healthcare teams about factors leading to readmissions and to promote process improvement. Residents collaborate with faculty and specialists to learn root cause analysis where they conduct comprehensive investigations that include medical record reviews, and patient and care team interviews. The conference creates an educational environment to understand readmission dynamics and to develop improvement strategies. The discussions cover systemic issues, cognitive errors, cost-effective care, and readmission penalties. This initiative enhances resident development, fosters a learning culture, and improves patient care and the healthcare system.

EVALUATION: The conference is key in identifying systemic and cognitive errors leading to improvements: A few Examples are listed below.

Individualized Care Plans For patients with frequent readmissions: Plans developed with hospitalists, primary care physicians, and specialists, to reduce readmissions.

D-Test for Inducible Clindamycin Resistance: For effective antibiotic treatment for MRSA isolates.

Standardization of Urine Collection: To improve diagnostic accuracy.

Surveying Regional Skilled Nursing Facilities on capabilities and quality: To help with appropriate patient referrals.

Reviewing/Updating Care Paths and Order Sets: To enhance The Electronic Medical Record for optimal care.

Improving Discharge Planning: To streamline processes and educational tools in collaboration with IT.

Quality Improvement Projects: To improve the recording of vital signs, weights, and input-outputs.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our readmission conference serves as a model for instructing residents in identifying and resolving systemic and cognitive errors within the healthcare continuum. It is especially effective in highlighting and addressing issues such as fragmented care during hospital stays and in the crucial phases of patient care transitions. This initiative not only enhances the learning experience of residents but also significantly contributes to the improvement of the healthcare system's efficiency and effectiveness in patient care

This initiative directly addresses three of the six focus areas outlined by the ACGME’s Clinical Learning Environment Review (CLER), specifically targeting resident participation in hospital initiatives that enhance quality and safety.

ENHANCING DIVERSITY IN CLINICAL REASONING EXERCISES: AN INTERNATIONAL PEER-MENTORSHIP PROGRAM

Oumaima Outani¹; Amanda R. Ferreira²; Yazmin A. Heredia Allegretti³; Saman Nematollahi⁵; Maria J. Aleman⁴. ¹Medicine, Universite Mohammed V de Rabat Faculte de Medecine et de Pharmacie de Rabat, Rabat, Rabat-Sale-Kenitra, Morocco; ²Medical Doctor, Centro Universitario FIPMoc, Montes Claros, Minas Gerais, Brazil; ³School of Medicine, Universidad Autonoma de Yucatan, Merida, Yucatán, Mexico; ⁴Department of Community Medicine, Universidad Francisco Marroquin Facultad de Medicina, Guatemala City, Guatemala, Guatemala; ⁵Medicine, The University of Arizona College of Medicine Tucson, Tucson, AZ. (Control ID #4064950)

SETTING AND PARTICIPANTS: A nonprofit organization dedicated to clinical reasoning education, introduced a Case Review Committee (CRC) to address the lack of diversity in clinical reasoning exercises (CRE). A recent article revealed that less than 0.5% of CRE articles were authored by physicians in low and middle income countries. The CRC assists learners in case presentation for the Virtual Morning Reports (VMR), a clinical reasoning conference hosted by the organization. The program offers peer mentorship to enhance oral presentation skills and case redaction with a focus on learners with limited educational opportunities for oral case presentations at their home institutions. Twenty-four CRC members actively engage in peer and traditional mentorship forms. The majority are medical students, and post-graduate trainees (20.83% and 70.83% respectively).

DESCRIPTION: Between May and December 2023, the group circulated invitations via social media and email with a focus on early learners and international participants. Once participants reached out they were paired with a CRC mentor. Mentees and mentors met on online video calls to refine case content by assessing for its completeness and organizing the oral presentation to promote reflection for the audience. Additionally, mentees chose teaching points from the case they elaborated on at the end. VMR sessions are held on Zoom with a live participation average of 40 people, and average 354 asynchronous viewson YouTube. Both VMR sessions and the case review process were free of cost.

EVALUATION: Since the CRC launched, 62 participants from 24 different countries were paired with CRC mentors to have their cases reviewed and presented at VMR. Sixty (96.77%) participants were trainees. Sixteen participants (24.81%) were from lower middle-income countries (LMIC), 28 (45.16%) from upper-middle-income countries (UMIC), and 18 (29.03%) from high-income countries (HIC), the geographic distribution of mentees is illustrated in figure 1. Additionally, 72.58% (45) of the submissions were from countries where English is not an official language.

DISCUSSION / REFLECTION / LESSONS LEARNED: As a viable model of peer-mentorship, the CRC addresses the lack of representation in CRE by providing mentorship to a diverse group of individuals particularly in countries outside of the US. As clinical reasoning educators are scarce in low and middle income countries, online forms of peer-mentorship can bridge the educational gap. The amalgamation of formal and informal interactions in the peer-mentorship relationship, coupled with the mentors and mentees having similar or near training levels, fosters psychological safety enhancing knowledge exchange and the overall learning experience. Furthermore, to foster a safe space for international mentees, adequate representation with geographically and culturally diverse mentors is necessary. The free-of-cost participation and the flexibility of this online format addressed the geographic and financial barriers trainees can encounter.

ENHANCING MEDICAL EDUCATION & RESEARCH: LEVERAGING THE AI REVOLUTION

Gaetano E. Di Pietro¹; Suzanne El Sayegh¹; Wassim Diab¹; Daniel Gaballa¹; Mario Castellanos². ¹Internal Medicine, Staten Island University Hospital, Staten Island, NY; ²Medicine, Staten Island University Hospital, Staten Island, NY. (Control ID #4063982)

SETTING AND PARTICIPANTS: One-hour interactive workshop in a Northeast university affiliated hospital. Residents and faculty of the Internal Medicine department completed a pre- & post-workshop survey.

DESCRIPTION: Teaching hospitals, both community and academic medical centers, have a responsibility to offer innovative scholastic activities for residents and fellows. Increasing clinical responsibilities compete with time allocated for education and research. AI is rapidly being integrated into numerous clinical and educational platforms and presents an opportunity to leverage AI to enhance medical residency education and research activities. We developed an AI introductory workshop and conducted a pre- and post- survey with the goal of designing successive LLM workshops & AI curriculum.

EVALUATION: We evaluated participants' knowledge, opinions, and perceived limitations regarding AI and LLMs in medical research, resident education and clinical applications. We included questions of open and closed-ended formats such as multiple-choice and 1-5 Likert scale questions. We present results from both pre (n=43) and post (n=33) surveys. Amongst attendees were 22 medical residents, 9 medical students and 2 attendings of which 79% had no formal computer science training. The survey revealed significant findings: AI knowledge in medicine rose by 54%, clinical AI application awareness by 35%, and the perceived importance of AI in medicine by 15%. Post-workshop, 81% felt it influenced their view on AI's role in their medical career, 54% felt better prepared for AI-related challenges, and 66% believed AI would assist clinicians within 5 years. Data privacy concerns increased by 19%, but AI accuracy concerns and worries about physician over-reliance on AI dropped by 13% and 9% respectively. Lastly, 84% were motivated to engage with AI during residency/future practice after attending the workshop.

DISCUSSION / REFLECTION / LESSONS LEARNED: AI will have a significant impact on medicine, but exposure to these technologies is limited in residency training. We devised an approach to begin understanding current knowledge, perceptions and willingness to use AI in medical education and research. 81% of participants reported a changed perception of AI's role in their medical career and 54% felt more prepared to face AI-related challenges, demonstrating the workshop's success in engaging residents. Interestingly, concerns about AI accuracy and physician over-reliance decreased while concerns over data privacy rose. Our initiative findings affirm the critical role lectures & workshops can play in fostering an informed and proactive approach to AI integration in medical education.

ENHANCING OUTPATIENT PROCEDURES COMPETENCY: A CURRICULUM IMPLEMENTATION FOR INTERNAL MEDICINE RESIDENTS

Mary Fok, Alan S. Chu. Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4062362)

SETTING AND PARTICIPANTS: The internal medicine residents participated in a single procedure workshop at the University of California, Los Angeles (UCLA). These sessions took place over five weeks with 30 residents each week to include all the residents on their ambulatory blocks.

DESCRIPTION: Residents feel gaining more hands-on experience to outpatient procedures enriches their ambulatory curriculum. This workshop provided residents the knowledge and experience of performing trigger point injections (TPIs), a valuable primary care procedure. This eighty-minute interactive workshop included thirty minutes of introducing the concept of TPIs followed by hands-on practice with models including oranges and human volunteers. The residents worked in groups, enabling peer teaching. Pre- and post-intervention surveys with unique identifiers were given to assess the impact of this intervention across several domains.

EVALUATION: Of 150 residents who completed the workshop, 135 residents completed the pre-intervention survey and 91 completed the post-intervention survey, with a total of 83 matched pre- and post-survey responses. The surveys assessed knowledge and confidence levels with performing these procedures and a question on how to improve future sessions. The matched responses pre- and post-training were compared using t-test analysis. When asked how important outpatient procedures were to their ambulatory clinic experience, residents’ responses were rated highly pre- and post-intervention out of a 5 point scale, (1 = completely agree, 5 = completely disagree) (1.7/1.3, p<.01). Residents rated their confidence with knowing the medical indications for TPIs to be higher after the intervention from 4.2 to 1.4 (p<.01) and with performing TPIs from 4.7 to 1.8 (p<.01). Increased experience ratings on a 5-point scale (1 = more than 10 TPIs, 5 = 0 TPIs) for observing (4.7/3.5, p<.01) and performing TPIs (4.9/4.1, p<.01) reflected improved competence. Overall, residents found the intervention to be very effective, enhancing readiness for outpatient procedures.

DISCUSSION / REFLECTION / LESSONS LEARNED: Based on surveys of graduating UCLA internal medicine residents, residents considered ambulatory procedures important but felt they performed them infrequently. In another study, academic general internists considered ambulatory procedures important but performed fewer procedures, received less training, and were less confident in teaching these procedures compared with family physicians. This project focused on improving curriculum for outpatient procedures for internal medicine residents at UCLA. This intervention was positively received by the residents, improved competency, and highlighted the importance of education and exposure to outpatient procedures. Future directions include workshops on commonly performed outpatient procedures or implementing similar sessions periodically to reinforce skills.

FOSTERING PROFESSIONAL DEVELOPMENT AND COLLEGIALITY: A SUCCESSFUL MODEL OF GIM EARLY CAREER FACULTY PEER MENTORING

Eduardo A. Mulanovich, Heather Wainstein, Rachel Bonnema. General Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4057558)

SETTING AND PARTICIPANTS: Nine GIM early career faculty with less than 10 years at the faculty position participating in monthly, in-person meetings in 2023.

DESCRIPTION: One quarter of faculty have considered leaving academic medicine due to high levels of dissatisfaction from feeling isolated and disconnected, low engagement, low self-efficacy, and lack of administrative support for faculty advancement. Finding the right mentors can be challenging due to differences in seniority, career path, and experiences. Clinical and administrative duties can hinder finding time and space for mentoring. Peer mentoring has the potential to create close professional relationships, build a collegial culture, foster collaboration, and improve faculty retention.

Our institution’s GIM Peer Mentoring Group (PMG) was formed in 2021 as a monthly, online meeting where members presented topics to enhance teaching skills and help with personal goals. In 2022, an anonymous online survey was distributed to group members. Most members agreed that participation in the group improved precepting skills and they would recommend the group to junior faculty. However, less than half agreed that the group fostered connections with other faculty.

Based on this feedback, in 2023 the group was changed to in-person meetings to improve interaction and collegiality. Session time was increased to 2 hours for content and transportation. Clinic time was blocked if needed. Lunch was provided by the division. Presenters were both group members and guest speakers to gain a diversity of perspectives and enhance content expertise if needed. Session content was focused into three categories: teaching skills, scholarly activities, and career advancement.

EVALUATION: In October 2023, an anonymous online survey was distributed to the nine group members to determine if the PMG helped with professional development and collegiality. There was a 100% response rate. All group members (100%) agreed or strongly agreed that the group helped with the development of teaching skills, connecting with junior faculty, and that they would recommend the group experience to junior faculty. Eight of nine (88.9%) agreed or strongly agreed that the group helped with professional development related to scholarly activities and career advancement, as well as their increased scholarly activity in 2023. The number of workshop submissions, abstract submissions to medical journals, and topics lectured to residents increased among group members.

DISCUSSION / REFLECTION / LESSONS LEARNED: Enhancements to the GIM Peer Mentoring Group based on feedback were well received. All group members felt the peer group helped them connect with other junior faculty, compared to less than half the year prior. Nearly all members felt their scholarly activity increased due to participation in the peer group. Future directions include implementing strategies to help with project accountability, growth in membership within GIM, as well as assisting other divisions within Internal Medicine in establishing their own peer mentoring groups.

HEALTHCARE DISPARITIES AND THE CRIMINAL JUSTICE SYSTEM: AN INTERACTIVE CASE-BASED CURRICULUM FOR RESIDENTS

Drew Miller^1,2; Elizabeth Jean-Marie²; Olivia Rizzo^1,2; Megan McNamara². ¹Internal Medicine, UH Cleveland Medical Center, Cleveland, OH; ²Internal Medicine, VA Northeast Ohio Healthcare System, Cleveland, OH. (Control ID #4063706)

SETTING AND PARTICIPANTS: Setting: VA health system. Participants: internal medicine residents, nurse practitioner residents, pharmacy residents, social work intern

DESCRIPTION: Pre-Didactic Survey & Knowledge Assessment

We developed a five-question survey to assess the initial knowledge of our residents and to provide a baseline for our post-intervention survey. These questions were about common terminology in the criminal justice system, health risk factors unique to prison, and the delivery of healthcare in the prison system.

Didactic Session with the Chief Resident

The session consisted of a 40-minute didactic session about healthcare delivery during and after incarceration. It began with a discussion about the difference between jail and prison and the difference between misdemeanors and felonies. This was followed by an overview of U.S. incarceration rates and healthcare disparities for those incarcerated. We reviewed the way healthcare is delivered to patients as they navigate the justice system and highlighted common gaps in care. Finally, we discussed the challenges of re-entry after time in prison or jail, and the community and VA-based resources available to help with re-entry.

Interactive Session with Virtual Cases

After the didactic, the residents split into groups of 7 and participated in two cases in a “Choose Your Own Adventure" format. In this format, the learner makes choices that determine the actions and the outcome of the case. These cases are based on real stories and are designed from the perspective of the patient and the provider. This curriculum walks the learners through transitions of care after incarceration with the goal of immersing them in the hard choices that patients face. The use of this format gamifies the cases and has been shown to improve engagement in similar case-based curriculum experiments.

Group Reflection

This group reflection session was designed to help learners understand how legal involvement affects a patient’s physical and mental health, social well-being, and opportunities for housing. We discussed their thoughts on the results of each case and discussed the barriers in each example. We ended the reflection with an explanation of the real-life resources available to those with these barriers.

EVALUATION: We administered the same five-question knowledge assessment from before the didactic and found an average score improvement from 53% to 81% (p=0.04). Post-session feedback showed that the curriculum was very well received, with 95% of residents strongly agreeing that they found this learning session to be beneficial. The "Choose Your Own Adventure" format received excellent feedback with 95% of residents strongly agreeing that it improved their learning experience.

DISCUSSION / REFLECTION / LESSONS LEARNED: We will continue to utilize this session in the future. Based on resident feedback, we plan to use smaller groups and invite real patients to speak at future sessions. The “Choose Your Own Adventure” format was successful, and we plan to expand it to other learning activities.

HIDDEN IN PLAIN SIGHT: RESIDENTS’ POST-DISCHARGE SKILLS IN A TELEMEDICINE VISIT WITH AN ANNOUNCED STANDARDIZED PATIENT

Renee Heller¹; Elizabeth Hillier²; Jeffrey A. Wilhite¹; Sondra R. Zabar¹; Daniel Sartori³; Rachael Hayes¹. ¹Division of General Internal Medicine, New York University Grossman School of Medicine, New York, NY; ²School of Osteopathic Medicine in Arizona, A T Still University, Kirksville, MO; ³Division of Hospital Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4063667)

SETTING AND PARTICIPANTS: 31 Residents in the Internal Medicine (IM) Residency Program participated in a telemedicine visit at two urban FQHC clinics.

DESCRIPTION: Post-discharge follow-up is essential for safe transitions in care, in order to obviate preventable problems and decrease the risk of clinical deterioration, readmission and mortality. For many patients, telemedicine follow-up is more accessible than in-person care, and virtual visits have the additional benefit of giving physicians a glimpse of patients in their home environment. We implemented a virtual, post-discharge visit with announced standardized patients (ASPs) as a teaching tool for residents during their continuity clinic. The case was designed to highlight telemedicine skills and best practices for collecting information in the virtual setting.

Residents participated in a video visit with an ASP, a 60-year old woman recently discharged after a hospital admission for chronic obstructive pulmonary disease (COPD) exacerbation. Case objectives included: taking a focused history and performing a virtual physical exam including checking pulse oximetry; recognizing the patient was not using supplemental oxygen and counseling them on safe use and monitoring; identifying a social need for meal delivery and connecting the appropriate services, discussing smoking cessation, and making a management plan including medication adjustment and triage decision. After the visit, ASPs provided verbal feedback to the resident and completed a behaviorally anchored checklist to evaluate resident’s skills in 6 domains on a scale of not, partly, or well done (WD). Residents debriefed with their preceptor, received their performance checklist for feedback, and completed a program evaluation survey.

EVALUATION: Overall, residents performed well on information gathering (96% WD) and relationship development (89% WD), less well for care transition skills (77% WD) and least well for the domains of education/counseling, telemedicine and case-specific skills (61%, 57% and 53% WD, respectively). Behaviors that were commonly not done included asking the patient to check their oxygen level with a pulse oximeter, counseling the patient to use their supplemental oxygen device, and discussing smoking cessation.

75% of residents indicated in the post-program survey that the ASP encounter contributed to their ability to gather information only available in a video setting.

DISCUSSION / REFLECTION / LESSONS LEARNED: This study indicates that there are frequently missed opportunities to maximize the effectiveness of virtual discharge follow-up visits. Through the SP feedback and preceptor debrief, residents learned ways to improve their transitional care management skills in order to achieve high-quality, virtual post-discharge care. This will be tested through another ASP visit designed to require similar telehealth-specific skills in the spring.

HOCUS POCUS: GRASSROOT EFFORTS TO ENHANCE MEDICAL RESIDENT’S EDUCATION

Dominic Parfianowicz¹; Arjan Ahluwalia¹; Michael Milligan¹; Bharani Pusukur¹; Lucas Gitzel¹; Baijukumar Patel¹; Kathryn Zaffiri⁴; Jeffrey Debuque¹; Thomas W. Doherty¹; Daniel Schwed-Lustargten²; Andres Zirlinger²; Nael Hawwa^3,1; Justin Guthier^3,1. ¹Internal Medicine, Lehigh Valley Health Network, Allentown, PA; ²Pulmonary & Critical Care, Lehigh Valley Health Network, Allentown, PA; ³Cardiology, Lehigh Valley Health Network, Allentown, PA; ⁴Clinical Quality, Lehigh Valley Health Network, Allentown, PA. (Control ID #4056889)

SETTING AND PARTICIPANTS: The novel introduction of a POCUS curriculum to an ACGME-accredited large community based internal medicine residency featured sixty-nine residents. Residents of all years participated (PGY levels 1-3) and were taught by attending physicians from internal medicine, cardiology, and pulmonary critical care departments.

DESCRIPTION: In this pilot program conducted at an ACGME-accredited internal medicine residency, we developed a curriculum for residents to gain familiarity and comfort with POCUS to help enhance daily patient care. Sessions were held both in the inpatient setting as well as in a state-of-the-art simulation center. A total of 24 sessions were held; 10 with a focus on cardiology, 8 on pulmonary, and 6 on the abdominal survey. These sessions were led by specialists from cardiology, pulmonary and critical care, as well as POCUS-trained hospitalists. Sessions lasted roughly 90 minutes and were limited to four residents per session to maximize hands-on learning. Competence was assessed both during these sessions with immediate feedback as well as with a short multiple choice assessment of 32 questions given prior to initiation of the curriculum and then again prior to conclusion six months later.

EVALUATION: A total of 36 residents took the initial evaluation with 31 residents completing the exit evaluation six months later. Responses were anonymous. Four categories were tested in the evaluation: ultrasound basics, as well as basic POCUS knowledge in pulmonary, cardiac, and abdominal. The primary outcome was the number of questions answered correctly. Secondary outcomes included the number of questions answered correctly by individual categories. The results were then compared using a student's T-test. The primary outcome showed a significant positive change (+12.0%, p=0.00033). The greatest degree of improvement was seen in the cardiac category (+19.1%, p=0.00019) followed by the pulmonary category (+13.0%, p=0.005).

DISCUSSION / REFLECTION / LESSONS LEARNED: We realize that the degree of POCUS utilization in clinical practice may vary amongst the various medical specialties. However, it is no question that POCUS use will continue to grow and ultimately become a standard part of the internist’s skill set.

As such, the goal of this program was to expose and familiarize medical residents with manipulation of the ultrasound probe as well as identification of normal anatomy and some basic pathology. Through this endeavor, we aimed to enhance the overall internal medicine residency experience and provide a building block for those residents pursuing specialties with a more regular use of bedside ultrasound imaging. The degree of improvement in each category correlated with the number of respective sessions dedicated to that organ system. Future analyses can look into growth in subjective confidence in the use of POCUS as well as stratification by PGY level.

IMPLEMENTATION AND ASSESSMENT OF A RESIDENT AS PRECEPTOR CURRICULUM FOR INTERNAL MEDICINE RESIDENTS IN OUTPATIENT CONTINUITY CLINICS

Dylan D. Fortman¹; Rongrong Wang⁵; Scott D. Rothenberger⁵; Matthew N. Metzinger³; Tanya Nikiforova⁴; Deborah DiNardo². ¹Internal Medicine, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ³Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁴Internal Medicine, University Of Pittsburgh Medical Center, Pittsburgh, PA; ⁵Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4058617)

SETTING AND PARTICIPANTS: Outpatient residency continuity clinics with participating PGY1-3 residents and continuity clinic attending preceptors

DESCRIPTION: Resident-preceptor curricula have been explored to enhance skill and confidence in outpatient teaching and satisfaction with ambulatory training. We describe a resident-preceptor curriculum implemented with 3^rd year IM residents at a single institution and characterize feasibility and acceptability from multiple vantage points.

EVALUATION: PGY3 residents on their Ambulatory rotations completed a 1-hour workshop on precepting skills between January and May 2023. Each resident worked with a faculty mentor to precept junior residents for up to 4 half-day sessions with progressive autonomy guided by structured curriculum learning objectives. Pre and post-curriculum surveys regarding perceptions of ambulatory training were completed by PGY3 residents using a Likert Scale. Faculty members and junior residents completed post-curriculum surveys to assess feasibility and impact on the continuity clinic learning environment. Responses were summarized using means and standard deviations (medians and interquartile ranges as appropriate). One-sided Wilcoxon signed-rank tests assessed for changes in PGY3 residents’ perceptions with a 5% significance level.

DISCUSSION / REFLECTION / LESSONS LEARNED: Fourteen PGY3 residents participated; of these, 71.4% (n=10/14) completed post-curriculum surveys. A median of 2/4 sessions were attended and a median of 5 patients were precepted each half day. PGY3 residents reported precepting in clinic positively impacted their views of resident continuity clinic, felt comfortable providing feedback to junior residents, and found faculty feedback to be valuable on post-curriculum surveys (median value=4/5); they also reported higher ratings of faculty use of evidence-based practice (mean 3.6/5 pre-curriculum vs. 4.5/5 post-curriculum, p=0.0156). There were no other significant differences in PGY3 resident perceptions. Among faculty and junior residents, 15/23 (65.2%) and 13/44 (29.5%) completed the post-curriculum surveys, respectively. Overall, faculty and junior residents provided neutral-positive ratings for curriculum impact on resident autonomy, mentoring, and teaching opportunities. Responses were also neutral-positive regarding curriculum impact on use of clinic space, precepting efficiency, impact on clinic flow, and adequacy of attending-resident ratios. Qualitative feedback included positive comments regarding value of faculty-resident mentorship opportunities, perception of PGY3 feedback, and resident autonomy, while constructive comments included concern about limitations of near-peer precepting and lack of PGY3 experience and comfort level with outpatient precepting compared to inpatient.

Implementing a ‘Resident as Preceptor’ curriculum in outpatient residency continuity clinics is feasible without additional faculty or facility resources and is perceived as a valuable addition to ambulatory training by faculty, resident preceptors, and junior residents.

IMPLEMENTATION OF AN EDUCATIONAL TOOL TO ADDRESS FOOD INSECURITY IN THE PRIMARY CARE SETTING

Carter Baughman¹; Gianna Aliberti¹; Son Quyen H. Dinh¹; Kelly Graham²; Katherine Wrenn². ¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4064074)

SETTING AND PARTICIPANTS: Participants included internal medicine residents, faculty, and nurse practitioners at a large, urban, academic medical center. Between November and December 2023, 247 clinicians were contacted to complete a survey regarding their understanding of food insecurity (FI), comfortability addressing FI, and knowledge of resources available for patients with FI before and after reviewing an educational tool.

DESCRIPTION: We conducted an initial needs assessment, surveying PCPs in the practice regarding knowledge, attitudes, and perceptions of FI, in anticipation of implementing FI screening. We learned that providers felt screening for FI was important, but were unaware of how to screen or what to do with a positive result. From this, we developed an education tool to increase provider knowledge around FI screening and resources, with the aim of helping them better navigate FI screening and management of positive results. In the tool, to address identified knowledge gaps, we included information about FI rates in our state, FI rates in our practice, and impacts of FI on health. We then used a case-based algorithm to follow a patient who screened positive for FI, followed by sharing local and national resources available to patients with FI. We administered provider pre- and post-test surveys via REDCap to evaluate efficacy of the tool.

EVALUATION: To date, we have had 65/247 (26%) respondents for our pre-test survey, including 26 faculty physicians, 4 nurse practitioners, and 35 residents (71% female, 78% White, 89% non-Hispanic). 93% were familiar with FI and 95% felt it was important for FI to be addressed in primary care, but only 22% felt comfortable addressing FI with their patients. 25% were aware of the prevalence of FI in their patient population, 43% had received education on FI, and 35% had received training on screening for FI. 25% knew of practice resources for FI, and 23% knew of community resources for FI.

14 participants thus far have completed the educational tool and post-test survey, including 6 faculty physicians, 1 nurse practitioner, and 7 residents (86% female, 86% White, 100% non-Hispanic). Following the module, providers more consistently agreed or strongly agreed with the statements, particularly in terms of comfort with addressing FI (78%), awareness of prevalence of FI in the patient population (92%), awareness of practice resources (100%), and awareness of community resources (93%) for FI. Data collection is ongoing.

DISCUSSION / REFLECTION / LESSONS LEARNED: We developed and implemented an educational tool to address provider knowledge gaps regarding FI screening and resources in a primary care practice. Preliminary findings suggest that this brief tool can be an effective way to increase provider comfort with addressing FI with their patients. We hope that increased provider education regarding FI screening and resources will reduce barriers to discussing FI with patients, and that this tool can be adapted and implemented in other primary care settings.

IMPROVING RESIDENT COMMUNICATION THROUGH SERIOUS ILLNESS COMMUNICATION TRAINING

Mary Fok, Neil Wenger, Anne Walling. Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4023774)

SETTING AND PARTICIPANTS: Internal Medicine and Medicine-Pediatrics residents participated in a Serious Illness Communication Training during their ambulatory blocks, conducted virtually due to the COVID-19 pandemic. Each session consisted of 10-14 residents.

DESCRIPTION: While physicians recognize end-of-life conservations to be crucial in patient care, few receive formal training on conducting these conversations. The Serious Illness Communication Training was designed in collaboration with Palliative Care physicians. 38 residents participated in the training sessions and completed two Center to Advance Palliative Care (CAPC) online clinical training curriculum modules on Discussing Prognosis and Clarifying Goals of Care prior to the sessions. The interactive sessions included an hour of didactics with the entire group on frameworks for goals of care conversations and strategies for responding to emotional and cognitive aspects of patient communication followed by an hour of role play with actors as patients in small group breakouts. A previously validated quality improvement survey was provided anonymously before and after each training, assessing communication ability, readiness to improve their communication, self-efficacy to improve, and the need for help to improve in these areas. We compared matched pre- and post-survey responses using a paired t-test. The participants were also surveyed post-training about quality of the training and intended practice changes.

EVALUATION: A total of 38 residents participated in the training intervention with a high level of engagement in role play with the actors. 35 residents completed the pre-intervention survey and 13 residents completed the post-intervention survey, with 13 matched pre- and post-survey responses. Residents rated their communication ability higher after the training from 5.8 to 7.1 on a 10-point scale (p<0.01). Residents expressed a desire for continued high-quality communication ability. Similarly, on a 4-point scale (1 = a lot, 4 = not at all), self-efficacy (pre 1.5/post 1.3) and need for help to improve (1.3/1.3) were consistently rated highly. The CAPC modules received positive pre- and post-training feedback. All respondents reported they would recommend the course to others. Residents planned to incorporate into their practice the frameworks and communication strategies discussed, recognizing and responding to emotions, focusing on patients’ wishes, and initiating earlier advanced care planning discussions.

DISCUSSION / REFLECTION / LESSONS LEARNED: Residents rated their ability to communicate with patients higher after attending the Serious Illness Communication training and found the session valuable. Incorporating the communication training and CAPC modules into residents’ curriculum may enhance their confidence in practice and address the need for formal training on conducting goals of care conversations. Future directions include expanding the training sessions to include more residents and beyond the residency programs to include fellows in various subspecialties.

IMPROVING RESIDENTS' PERCEPTION AND CLINICAL KNOWLEDGE OF MOTIVATIONAL INTERVIEWING THROUGH DIDACTIC LEARNING

Thao A. Nguyen¹; Michael L. Setteducato³; Melanie G. Hagen¹; Paulette Hahn²; Margaret C. Lo¹. ¹Internal Medicine, University of Florida College of Medicine, Gainesville, FL; ²Rheumatology, University of Florida College of Medicine, Gainesville, FL; ³Sleep Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4058558)

SETTING AND PARTICIPANTS: Motivational Interviewing (MI) is a collaborative, goal-oriented communication style underutilized by resident physicians to affect patients' behavioral change. Given the positive impact of MI on patient behavior modifications and the growing interest in MI education in clinical training, this project aims to teach MI skills through didactic learning to internal medicine (IM) residents at the University of Florida (UF) training program. We studied the impact of the MI lecture on residents’ perspectives and knowledge of the benefits of MI, long-term adherence, and adoption of MI.

DESCRIPTION: IM residents received a 45-minute lecture on MI principles and skills (5A's, SMART goals, and assist toolbox) during their routine noon conference time. No incentive or financial reward was offered. Participants completed a pre-and post-perception survey and a post-knowledge quiz on MI. The same follow-up knowledge quiz will be delivered in 6 months to assess long-term knowledge retention. All survey completion was voluntary and anonymous. UF granted IRB exemption for this study. Data were analyzed using the Wilcoxon Signed-Ranked test Software and Excel functions.

EVALUATION: Of 115 IM residents, 37 attended the MI lecture. The pre-survey response was 32%. The post-survey response was 100%. A significant improvement was seen before and after the lecture on residents’ comfort level in motivating patients to change behaviors (Z=3.6, p<0.01, R=0.08). No statistical difference occurred in residents' belief that MI can be beneficial to patient care (Z=0.3, p=0.790, R=0.09). Most residents stated that they would implement the skills they learned with a mean of 4.54, the mode and median of 5 (1=strongly disagree, 5=strongly agree). The mean score in rating the usefulness of the MI teaching session was 4.7, with the mode of and median of 5. Residents demonstrated high-level knowledge after the lecture with a quiz average of 80%. MI skills mastered by residents are affirmation, confidential ruler, and evocation. MI skills challenging for residents are reflective listening, partnership, and permission.

DISCUSSION / REFLECTION / LESSONS LEARNED: A one-time MI didactic learning has the potential to improve residents’ comfort level with MI but does not impact their existing belief that MI can be beneficial to patient care. This one-time intervention can also increase residents’ knowledge of MI benefits and principles, which in turn can strengthen their clinical skills over time. Long-term retention of knowledge is uncertain and will be reassessed at 6-month intervals. Nonetheless, a one-time didactic intervention is likely insufficient to improve residents’ long-term clinical skills. Longitudinal education and active learning (e.g. small group workshops) are necessary for sustained application by residents of any learned MI skills in clinical practice.

ONLINE RESOURCE URL: 1. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior.

2. https://www.statskingdom.com/175wilcoxon_signed_ranks.html

IMPROVING TRAINEES’ OUTPATIENT PROCEDURAL SKILLS THROUGH A TWO-HOUR SKILLS TRAINING AND A VA BASED PROCEDURE CLINIC

Kaleb Keyserling, Max Rusek. Department of Hospital and Specialty Medicine, Portland VA Medical Center, Portland, OR. (Control ID #4043409)

SETTING AND PARTICIPANTS: A medium sized academic residency program with a VA specific procedure clinic. Those participating in the curriculum are all PGY1s.

DESCRIPTION: Procedural skills are a core ACGME competency, however, take additional training and time to supervise. While our program has a well-defined inpatient procedure rotation, currently there is little focus on procedural skills in the outpatient setting. It has been shown that residents feel less comfortable with outpatient procedures than inpatient, and limited outpatient faculty expertise can reduce opportunities for learning these important skills. Patient also frequently must wait for weeks to months, travel far distances, and pay more for procedures performed in specialty clinics.

We developed a two-hour skill building session including hands on simulation of common outpatient procedures. The session started with reviewing the indications and contraindications for common outpatient procedures, and how to have an informed consent conversation with patients. Residents then rotated through stations where faculty reviewed anatomy, procedural skills, and evidence for each procedure prior to giving residents an opportunity to practice on models in our sim center.

In addition, we have started a procedure clinic at our VA primary care site that all VA clinic PGY-1s rotate through for three sessions during their PGY-1 year. Referrals come from our general academic practice, with scheduled patients being revaluated day-of for the appropriateness of the procedure prior to being completed.

EVALUATION: On a Likert scale evaluation of the two-hour skills session with 1 being not useful and 5 being very useful for skills needed for residency, PGY-1s gave the session a 4.5/5 rating. They noted appreciation for the opportunity for hands on practice and to learn multiple procedures they had not performed before.

Through three months of the VA procedure clinic, we have performed 30 total and 9 different types of procedures. We performed procedures on 87% of patients who came to their appointments, with 78% of total procedure slots filled and a no-show rate of 7%.

DISCUSSION / REFLECTION / LESSONS LEARNED: The procedure skills session and clinic have allowed our residents to gain valuable outpatient procedure knowledge. Through helping residents learn these skills, we are also improving access for needed procedural care for our patients. We have shown that incorporating outpatient procedure skills into residency curriculum is manageable and look forward to sharing our success with others.

Through starting the procedure clinic, we have identified the importance of carefully considering the strategy for publicizing the clinic to colleagues, as well as a process for reviewing the appropriateness of consults, and ensuring patients get scheduled in clinic. It is also important to have a process in place for reviewing procedure technique with residents prior to the visit and ensuring the facilitation of follow up care after the procedure.

INCORPORATING THE UNINCORPORATED: INTEGRATION OF US TERRITORIES’ POPULATION HEALTH, POLICY, AND DISPARITIES IN THE PRE-CLERKSHIP MEDICAL CURRICULUM

Marinna Okawa¹; Sarita Warrier². ¹Medical Education, Brown University Warren Alpert Medical School, Providence, RI; ²Division of General Internal Medicine, Warren Alpert Medical School of Brown University, Providence, RI. (Control ID #4062575)

SETTING AND PARTICIPANTS: This innovation included a curriculum review of coverage of US territory health pre-clinical lecture content for first-year medical students in an academic medical institution in the Northeast region. First-year medical students then received an enhanced curriculum and their response to the innovation was compared to fourth-year medical students and faculty. This innovation was done to evaluate how well the current pre-clerkship curriculum prepares students to take care of patients from the territories, and after curriculum development, to understand if students recognize health disparities and find it relevant to patient care as compared to those not exposed to the curriculum intervention.

DESCRIPTION: A curriculum review was conducted with an iSeek keyword search of first-year lectures on Canvas, followed by two manual reviews to identify whether additional content was relevant to the lecture material, and feasible to attain given limited data on US territory health. The reviews were presented to course leaders to coordinate individualized plans for curriculum development. Developments included submissions of slides to lecturers and coordination of a panel/mini-lecture series on US territory health and Indigenous health. Of the approximately 500 lectures, 203 had at least one positive keyword search. To date, 155 have been manually reviewed, 35 deemed relevant and with sufficient information, and 29 have had edits submitted to lecturers or course leaders.

EVALUATION: To evaluate the initial impacts of curriculum development on perceptions and knowledge of US territorial health, a 10-question Likert-scale survey was administered to first-year medical students (MS1) in the first month of classes, and compared to fourth-year medical students (MS4) and faculty responses (Kruskal-Wallis). We will repeat this survey for MS1s at the end of the academic year to see how individual responses change (paired t-test) and diverge from control responses (Kruskal-Wallis). MS1s strongly disagreed that US territories receive similar healthcare access and quality as the states versus MS4s and faculty (P=0.005). Faculty and MS4s felt less confident discussing territory health disparities (P=0.02). MS1s and MS4s strongly agreed that it was important to understand US territory health and relevant to a medical career (P=0.046).

DISCUSSION / REFLECTION / LESSONS LEARNED: These results suggest that initial incorporation of US territory health in the pre-clerkship curriculum can impact confidence in acknowledging and discussing health disparities. Presenting background information on US territories to course leaders and coordinating individualized development plans was useful in curriculum implementation across courses. Designing pre-made slides tailored to lecturers’ styles and underscoring their relevance to the overarching objectives assisted with content integration. Future iterations of this intervention could include additional lecture edits and qualitative feedback sessions from students, course leaders, and lecturers.

INCREASE IN STUDENT CONFIDENCE UTILIZING COMMUNITY-BASED BLOOD PRESSURE SCREENINGS

Emma Burke¹; Neelima Thati²; Rima Charara¹; Ali Turfah³; Jennifer Mendez⁴; Cole Sabinash¹; Chayton Fivecoat¹; Adrienne-Denise V. Bilbao¹. ¹Medical School, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Wayne State University, Detroit, MI; ³University of Michigan, Ann Arbor, MI; ⁴Medical Education, Wayne State University School of Medicine, Detroit, MI. (Control ID #4064715)

SETTING AND PARTICIPANTS: National data demonstrates that approximately half of the adults in the United States have hypertension, with only 1 in 4 adults reporting having their hypertension under control. The Riverwalkers Blood Pressure Screening program is a mutually beneficial program for community members and students of Medical and Pharmacy Schools. This program offers students an interprofessional opportunity in the summer to provide blood pressure screenings, health education, and resources in the community. The aim is to effectively perform blood pressure measurements while interacting with community members to provide students with hands-on education.

DESCRIPTION: Students complete the American Medical Association blood pressure module online before arrival. Participation in each session requires students to take a pre-survey to gauge their confidence level in taking blood pressure. Faculty from schools of medicine and pharmacy perform on-site training on measuring blood pressure, blood pressure ranges, and therapeutic interventions for hypertension. Students individually take the patient's blood pressure, record it in the participant's blood pressure log, and counsel the patient on lifestyle interventions to help lower their blood pressure. The faculty supervising the sessions provide professional guidance to students and participants as needed. Students are instructed to complete a post-survey. Each survey utilized Likert scales from 1 (strong disagreement) to 5 (strong agreement) to assess students’ learning experience.

EVALUATION: The pre-survey demonstrated students’ confidence level in obtaining blood pressure measurements prior to participating in the program. The majority of students, 51.5%, selected ‘somewhat confident’ prior to participating in the program. The post-survey demonstrates increased confidence after participating in the program. 80% of students selected ‘strongly agree’ in response to the statement, “I am more confident in my ability to take accurate blood pressure after volunteering at the Riverwalkers program.” Additionally, 87.2% of students responded ‘strongly agree’ that this opportunity enhanced their ability to take blood pressure.

DISCUSSION / REFLECTION / LESSONS LEARNED: Community-based blood pressure screening provides medical and pharmacy students with increased confidence in blood pressure screening through hands-on education. These findings suggest that incorporating community-based learning is a powerful educational tool that is mutually beneficial to the students and community members. The foundation of this program is to build trust within the community. Further research should focus on long-term benefits to student education, interdisciplinary appreciation, and community health improvement.

INEQUITY IN CARE: CREATING EDUCATIONAL MATERIALS TO IMPROVE QUALITY OF CARE FOR INCARCERATED PATIENTS

Emma Newton¹; Nicole Mushero^2,3. ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Department of Medicine, Boston University School of Medicine, Boston, MA; ³Geriatrics, Boston Medical Center, Boston, MA. (Control ID #4042498)

SETTING AND PARTICIPANTS: There are nearly 2 million people incarcerated in jails and prisons on any given day in the United States. Healthcare providers receive limited education regarding best practices and health concerns in this population, leading to disparities in care and confusion around specific care needs. Therefore, there is a critical need for targeted interventions and formal education concerning care for this population.

To design educational materials, a survey was distributed to hospitalists (attending physicians, nurse practitioners, and physician assistants), nurses, and internal medicine residents working in the inpatient setting of a single urban safety-net hospital. Responses will then be used to compile educational resources to improve care for incarcerated patients.

DESCRIPTION: Survey questions included multiple choice responses about the challenges of care for this population, prior education received, understanding of the disparities faced by this population, and free response questions allowing participants to raise further concerns. These responses will then be analyzed, and we will use the results to create educational materials.

EVALUATION: Preliminary results show that only 11% of respondents have had formal education in treating incarcerated patients. Most (91%) encounter incarcerated patients at least monthly in the inpatient setting, and 83% would feel more comfortable treating this population with formal education. A majority (71%) notice disparities in care, noting logistical issues, less provider interaction, shackling, and a lack of privacy. Additionally, most respondents (78%) did not know or were unsure of the rules surrounding correctional officer supervision or shackling policies. Only 8% were aware of resources available to guide practice in this area. Many (68%) have had trouble getting medical information for their incarcerated patients. Free response answers noted that specific information sessions/courses, written guidelines, and policies posted in rooms and websites would be helpful interventions to improve care.

DISCUSSION / REFLECTION / LESSONS LEARNED: Incarcerated patients face disparities in care and present unique challenges in the inpatient healthcare setting and yet education surrounding this group is often lacking. We seek to improve this knowledge gap by creating education targeted at community healthcare workers informed by a needs assessment. Based on our needs assessment, many healthcare workers are unaware of current policies and would benefit from formal education and resources regarding the treatment of incarcerated patients.

JUST-IN-TIME SIMULATION-BASED THORACENTESIS AND BRONCHOSCOPY SESSION IN INEXPERIENCED INTERNAL MEDICINE RESIDENTS

James Qiao, Puja Brahmbhatt, Michael Stokas. Internal Medicine, Loyola University Health System, Maywood, IL. (Control ID #4064509)

SETTING AND PARTICIPANTS: The authors conducted a simulation-based thoracentesis and bronchoscopy session in September 2023. The participants completed a pre- and post- survey. The session was performed in a dedicated simulation center in the hospital affiliated medical school. An unopened Carefusion TPT-1000 thoracentesis kit was used for the thoracentesis demonstration on a chest wall/lung simulator. The simulation center provided a virtual-reality bronchoscopy simulator for the bronchoscopy portion of the session. Nine total participants attended the session and completed the surveys. Participant level of training ranged from internal medicine PGY1 to PGY4 (chief resident).

DESCRIPTION: Several studies in the existing literature suggest that simulation-based sessions increase participant confidence and knowledge specific to performing procedures. However, few of these studies assessed the effect of these sessions on participants without prior experience or new trainees. Our aim is to assess the effectiveness of just-in-time simulation-based sessions on knowledge and confidence in performing thoracenteses and bronchoscopies among internal medicine residents with minimal relevant experience. Survey questions specifically assessed each resident’s sense of confidence and knowledge with regard to thoracentesis and bronchoscopy procedures using a five point Likert scale from "Strongly Disagree" (1) to "Strongly Agree" (5). In addition, we gathered information about the participant's percieved educational value of the session in the post survey session.

EVALUATION: Eight of nine participants had performed zero to one thoracentesis prior to the session. None of the participants had performed a supervised bronchoscopy prior to the session. Survey responses were notable for statistically significant increases in knowledge as assessed by three survey questions (2.2 vs 4.4, p=0.001; 2.7 vs 4.4, p=0.005; 1.6 vs 4.2, p=0.0001) and confidence as assessed by two survey questions (2.4 vs 4.2, p=0.01; 1.6 vs 3.6, p=0.001). All participants answered either “agree” (4) or “strongly agree” (5) to all three post-survey questions regarding the perceived educational value of the session.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our study assessed the effect of a single just-in-time simulation-based session on thoracentesis and bronchoscopy knowledge and confidence among internal medicine residents. The participants had minimal experience with the thoracentesis and bronchoscopy, and we noted a significant subjective improvement in both knowledge and confidence. Limitations of this study include no current validated methods to objectively measure learner knowledge in the thoracentesis or bronchoscopy procedures as well as a limited sample size (nine) and single total session performed. Further sessions would explore methods to objectively measure participant knowledge as well as increase number of participants.

MEDED TAG TEAM: UTILIZING AN ANDRAGOGIC APPROACH AND MULTIMEDIA LEARNING INTEGRATION TO DELIVER CLINICAL TEACHING DEVELOPMENT THROUGH SOCIAL MEDIA

Raj Patel¹; Geoffrey V. Stetson². ¹Department of Medicine, University of Illinois Chicago, Chicago, IL; ²Internal Medicine, University of Illinois Chicago College of Medicine, Chicago, IL. (Control ID #4063630)

SETTING AND PARTICIPANTS: The MedEd Tag Team has gained thousands of followers from around the world, primarily from the U.S. and Canada. Transitioning from pushing content to our audiences on Twitter (now "X") to centralizing our content on a website that instead attracts users via SoMe platforms will likely represent a significant change in audience. X, despite its popularity among medical professionals, was always going to miss a large swath of potential beneficiaries. However, a stand-alone website does not have the cachet nor ubiquity of a brand name. Evaluating our impact and reach in this new format will yield valuable lessons.

DESCRIPTION: The MedEd Tag Team is a collaboration among physicians and trainees focused on providing professional development for individuals that teach in the clinical learning environment. Through weekly posts, we share best practices in various aspects of work-place learning for health professionals. The team began in 2020 as the MedEdTwagTeam with the “w” inserted into the word “tag” because we exclusively shared our content on Twitter.com via the extensive #MedTwitter and #MedEd communities. Since its inception, we have gained thousands of followers and millions of views, while also developing credibility in the field leading to local, national, and international speaking opportunities. We believe that this atypical scholarship distributed via social media (SoMe) has been far more impactful and visible than traditional publications in established journals.

EVALUATION: Google analytics layered onto the website provides us valuable data regarding site usage including number of visitors, time spent on various pages, and country of origin. An open forum embedded within the website allows users to engage in discussions similar to X. These data will help us to understand the number of individuals we are able to reach in this new format. Data from our posts on various SoMe platforms will be less useful as a comparison due to concern of duplicate engagement. A proxy for impact may include invitations for speaking engagements. We anticipate our launch of a stand-alone website, coupled with a varied SoMe advertising approach reaching further than we did on X.

DISCUSSION / REFLECTION / LESSONS LEARNED: The MedEd Tag Team has emerged as a significant advancement in medical education, representing an innovative and accessible professional development resource. We have garnered an engaged, diverse learner audience, earning accolades for its rich educational content and networking opportunities. Transitioning away from the current model, primarily driven by X's declining quality and user base, is risky. However, adopting Andragogy principles, the model of a website that serves as both a repository and a location for additional content better addresses the tenets of self-directed learning and direct applicability of content and may also better leverage pre-existing knowledge. We hope that active learning will continue by engaging with the material through online communities on our site and the various versions of SoMe.

MEDICAL STUDENT PERSPECTIVES ON A UNIQUE CONTINUITY OF CARE PROGRAM AT A STUDENT RUN FREE CLINIC

Juan A. Briano¹; Nicole Palmer¹; Elizabeth K. Benitez¹; Tiffany Merlinsky²; Isaac A. Nathoo¹; Ashita S. Batavia¹; Cecilia E. Nicol¹; Pamela Charney¹. ¹Medicine, Weill Cornell Medicine, New York, NY; ²Community Clinic, Weill Cornell Medicine, New York, NY. (Control ID #4060659)

SETTING AND PARTICIPANTS: A student-run free clinic (SRFC) provides primary care services for uninsured patients living in a mid-Atlantic city. Medical students support this mission by facilitating care under the supervision of a board-certified physician. Medical student participants in a longitudinal patient program within the SRFC were surveyed about their experiences.

DESCRIPTION: At the start of the preclinical curriculum, all students at a mid-Atlantic medical school have the opportunity to enroll in a unique continuity of care program in which they are assigned an SRFC patient for whom they act as the primary point of contact with the SRFC throughout their preclinical years. Students are expected to have monthly contact with their patients, and assist with their care at all SRFC appointments. This fosters discussion and awareness of the challenges faced by disadvantaged patients. An online survey comprising 10 demographic questions, 18 questions on a 7-point Likert scale, and 1 free-response question was administered to all current and past participants in the continuity of care program since 2019 to evaluate how participation in the program influenced their education and professional career goals. Data were analyzed using descriptive statistics in Qualtrics and Microsoft Excel.

EVALUATION: A total of 43 student participants responded across four medical school classes in addition to MD-PhD students currently completing their PhD. 90.7% indicated that their participation in the program was a valuable educational experience. Among survey respondents, 95.3% report they are interested in working with underserved populations after graduation, similarly to the 95.3% who were interested in working with these populations before joining the program. However, 86% agree that their experience in the continuity of care program positively influenced their attitude toward working with underserved populations. 95.3% also reported that participation in the program improved their understanding of the challenges faced by disadvantaged patients. Furthermore, most respondents (67.4%) reported that their participation in the program has influenced their career goals. 74.4% of respondents reported feeling that they had positively influenced their assigned patient’s experience at the SRFC.

DISCUSSION / REFLECTION / LESSONS LEARNED: To our knowledge, this program represents a unique opportunity for medical students to form longitudinal relationships with disadvantaged SRFC patients. Our results show that this continuity of care program positively influenced a majority of medical students in their desire to work with disadvantaged patients, and provides them with experiences that reinforce their interest and equip them to better care for those patients in the future. A limitation of this study is that only current medical students were surveyed. Future work will include surveying medical graduates for post-graduation career outcomes, specialties, and patient population served.

OVERCOMING BARRIERS TO EFFECTIVE IMPLEMENTATION OF FACULTY DEVELOPMENT BY USING A 360 DEGREE APPROACH

Michael Picchioni. Medicine, Brown University, Providence, RI. (Control ID #4064012)

SETTING AND PARTICIPANTS: Internal Medicine Residency Program at a University-Affiliated Hospital where Faculty Development efforts must be well targeted to maximize their effectiveness and efficiency. To achieve this there must be a precise understanding of the needs being addressed from all sides of the issue and sources to feed this understanding must occur contemporaneously. Participants include the Internal Medicine Interns, Senior Residents, and Attending Physicians.

DESCRIPTION: Like many, our institution has identified lack of Feedback and a tension between “Service” and “Education” as factors important to Learners. In addressing these concerns a Faculty Development Program was created using a 360 degree Model. Our Director of Faculty Development created Educational Modules on Teaching and Learning that were designed for small group participation with bi-directional input. Monthly sessions were held separately with Internal Medicine Interns, Senior Residents, and Attending Physicians. Lessons learned from each were shared across groups and misperceptions were addressed directly.

EVALUATION: This model provided tremendous insight that clarified the issues being addressed and allowed for real-time adjustment of messages to and expectations between these various stakeholders. Sessions are well attended and favorably reviewed by the participants. Formal assessment by Surveys is forthcoming and will allow for year-over-year comparison.

DISCUSSION / REFLECTION / LESSONS LEARNED: While communication is the primary vehicle for transmission of new knowledge and understanding in any educational activity, it cannot be assumed that it happens as intended. A number of substantive and fundamental differences occurred between these groups. For example:

- Faculty believe they provide frequent feedback messages and they DO by the traditional definition of Feedback as reported by Learners. However, what learners desire, and are not receiving, is evaluative information about their performance linked to the feedback messages that gives them perspective on where they are within the range of what is expected.

- Learners believe they are not being provided the opportunity to offer their thoughts about clinical decisions while Faculty believe Learners are not offering these impressions.

While a gap remains in these areas, participants report a notable improvement during the one year time frame of this Innovation. It is likely that similar large disparities in expectations and understanding of basic topics exist beyond our Learning Environment and that these can account for the inability to address things such as the Feedback Gap that Medical Educators have been working feverishly on for decades. Greater input from all members and all levels of the Educational Team could greatly improve the effectiveness of Clinical Training.

PILOT: "HOSPITAL ADMISSION" CURRICULUM IN THE INTERNAL MEDICINE SUB-INTERNSHIP

Nabeel Akhtar, Nicholas Duca, Brandon R. Peterson. Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA. (Control ID #4049119)

SETTING AND PARTICIPANTS: We piloted the curriculum in the Internal Medicine (IM) sub-internship (sub-I) rotation at an academic tertiary hospital associated with a medical school. The curriculum was open to all rotators enrolled from July-December 2023; 12 IM sub-interns participated.

DESCRIPTION: In 2019, 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. However, it has not been widely adopted amongst medical schools. Therefore, we implemented a skills session based on the recommendations of the AAIM guide.

A local needs assessment identified the hospital admission process as a competency for targeted education. To address this need, we piloted a curriculum in the IM sub-I to improve medical students' skills in admitting patients to the Internal Medicine service.

We focused on patient-evaluation-based entrustable professional activities (EPAs) 2, 3, 4, & 10 from the AAIM guide needed for hospital admissions, which includes: Developing a differential diagnosis, interpreting diagnostic tests, entering admission orders, and recognizing patients who need immediate care as well as triaging level of care. We delivered a 90-minute long workshop in the 3^rd week of the 4-week long rotation. The workshop featured an interactive discussion of orders needed for admission, a simulated case of a patient with diabetic ketoacidosis (DKA), and a review of DKA. During the simulated case, participants received a handout of a history, physical exam, and initial workup of a patient with hyperglycemia in the emergency department. The handout asked participants to work together to make a differential diagnosis, consider additional diagnostic tests, and put in admission orders on the electronic medical record training module. Participants voluntarily provided feedback after the session via SurveyMonkey. The survey asked 4 questions regarding the session: 2 free responses pertaining to strengths and areas of improvement and 2 close-ended questions about the usefulness of the session and if it should be recommended to another IM sub-intern.

EVALUATION: Preliminary data showed that 12/12 participants found the session to be useful. 12/12 participants would recommend it to other sub-interns. A central theme was that the objectives of the session were pertinent to their responsibilities on the rotation and for residency.

DISCUSSION / REFLECTION / LESSONS LEARNED: We piloted an innovative, EPA-based curriculum in the IM sub-I. Participants were receptive to the classroom-based approach as it focused on skills required for residency training. Based on the responses, we will offer the curriculum year-round to anyone enrolled in the rotation. We plan to expand our evaluation by measuring participants’ attitudes on the hospital admission process and implementing a checklist of admission orders.

PILOTING A NOVEL EDUCATIONAL EXPERIENCE IN ADVOCACY AND COMMUNITY ENGAGEMENT FOR INTERNAL MEDICINE RESIDENTS – THE PACE ELECTIVE

Nichole Smith¹; Deepa R. Nandiwada²; Amber Bird³. ¹Internal Medicine Residency, Hospital of the University of Pennsylvania, Philadelphia, PA; ²General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ³Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4056247)

SETTING AND PARTICIPANTS: Internal medicine residents at an academic center in the Mid-Atlantic region

DESCRIPTION: Despite growing attention towards the impact of racism, poverty, and structural inequality on health outcomes, few curricula tailored towards experiential learning with advocacy and community engagement exist at the medical trainee level. At our institution, residents have increasingly indicated interest in protected time for advocacy and community engagement projects to better understand the lived experience of underserved patients. As a response to this feedback, our team of educators -including senior residents and members of program leadership- partnered with our institution’s organization for community health workers to develop a 2-week immersive elective experience focused on social/structural determinants of health. The educational intervention was a blended model of online self-directed and immersive experiential learning. Online modules covered the following core content areas: Introduction to Advocacy, Community Asset Mapping, Networking, Program Development, Cultural Effectiveness, and Public Presentation. In addition, residents selected between provided opportunities to participate in local community engagement or legislative advocacy. Experiential learning was collaborative with leadership at local community organizations, care management nurses, and social workers. Impact was assessed via short reflective writing prompts submitted by residents. This presentation will focus on the identification of core competencies in advocacy for internal medicine trainees and our model for community-based educational intervention.

EVALUATION: Residents who participated in the pilot advocacy and community engagement elective provided qualitative evaluation for the rotation. Key themes highlighted in these reflections included greater appreciation for the role of interprofessional collaborators in the care of underserved communities as well as the diverse options for incorporating advocacy into health careers. Participants indicated interest in further education regarding equity in research, narrative medicine, and facilitating safe transitions of care. Our team also continues to solicit and place great value on feedback from community partners regarding this educational intervention.

DISCUSSION / REFLECTION / LESSONS LEARNED: Based on preliminary feedback from early resident participants, the opportunity to engage closely with the collaborating stakeholders providing direct service to patients was highly appreciated. This educational experience may facilitate higher levels of trainee empathy in clinical encounters and ultimately provide a pathway for greater interest in health equity and advocacy careers. Our aims for future growth regarding this elective experience include expanding the network of community partners, bolstering participation in local and state policy discussions, and creating a didactic space for resident participants to educate their colleagues about community engagement and advocacy topics.

PRACTICAL APPLICATION OF ARTIFICIAL INTELLIGENCE TO GLOBAL MEDICAL EDUCATION

Elan Shahrabani^1,4; Ivan Nenadic^2,4; Sara Aristizabal^5,4; Kristin M. Collier³. ¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Duke Heart Center, Duke University, Durham, NC; ³Internal Medicine, University of Michigan, Bloomfield Hills, MI; ⁴Rosetta Technologies LLC, Raleigh, NC; ⁵Delos LLC, New York, NY. (Control ID #4043467)

SETTING AND PARTICIPANTS: Medical students domestically and internationally who use the program Anki

DESCRIPTION: Anki is a popular open-source software program designed for spaced repetition learning using digital flashcards.

Spaced repetition is a study technique that optimizes the retention of information over time by spacing out the review of material at increasing intervals. This technique is particularly effective for memorizing facts, vocabulary, concepts, and other knowledge that requires long-term retention.

AnkiBrain is an extension we have developed for Anki. It is an AI-powered education platform that uses the large language models GPT 3.5 Turbo and GPT 4 by OpenAI. AnkiBrain supports 49+ languages and can explain any topic at user-defined levels of detail and expertise while citing a student's documents.

AnkiBrain can make AI-guided flashcards out of source text or an uploaded document (lecture notes, textbooks, UpToDate, audio files, etc.) AnkiBrain can import documents to allow GPT to answer questions by citing sources from documents. Students can import entire textbooks, class notes, audio files, videos, personal notes, PowerPoints, and more.

EVALUATION: Evaluation is performed by an optional survey of users with statistics collected. In addition, post-use evaluation is elicited as freeform text feedback.

N = 673. 68.5% said they use Anki daily. 43.2% said they use Anki for medical school. 27% said they use Anki for university. 64.2% said that AI-guided flashcard generation is the most useful feature. 10% said that document analysis is the most useful feature. Over 20 countries are represented, including United States, Canada, Mexico, Brazil, Peru, Venezuela, UK, Ireland, Italy, Spain, Portugal, Turkey, Iran, Iraq, Syria, China, Japan, South Korea, Madagascar, Zambia, Australia, and New Zealand.

DISCUSSION / REFLECTION / LESSONS LEARNED: Harris et al. (2022) estimates that 70% of first-year medical students at UCF College of Medicine used Anki. At University of MInnesota, Wothe et al. (2023) found that 84% of students reported using Anki for at least one semester with 87% using flashcard decks made by others. Deng et. al (2015) demonstrated a one-point increase in USMLE Step 1 score for every 1,700 Anki flashcards studied), while Gilbert et al. (2023) found a significantly improved performance among self-reported Anki users on the NBME Comprehensive Basic Science Exam (12.9% improvement; p = 0.003).

AnkiBrain is useful in two readily identifiable domains. First, AnkiBrain allows students to convert lecture material and other forms of study materials into digital flashcards, with which the student can leverage the proven efficacy of spaced repetition for enhanced learning. Second, AnkiBrain allows students to explore topics in depth by interacting with an AI “content expert” that has access to the student’s materials and can provide citations for its factual claims. This process enables iterative and interactive learning prior to, during, and after any review of flashcards.

ONLINE RESOURCE URL: https://github.com/RosettaTechnologies/AnkiBrain

PREPARING NEW INTERNS AS EDUCATORS- INTERDISCIPLINARY WORKSHOP ON MATTERING AND FEEDBACK

Kathlyn E. Fletcher^1,2; Amy H. Farkas⁵; Devarati Syam³; Alicia Pilarski⁶; Kristina Kaljo⁴; Vivian Dondlinger³. ¹Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; ²VA Milwaukee Healthcare System, Milwaukee, WI; ³Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ⁴Ob/Gyn; Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ⁵General Internal Medicine, Medical College of Wiscponsin, Milwaukee, WI; ⁶Medical College of Wisconsin, Milwaukee, WI. (Control ID #4064525)

SETTING AND PARTICIPANTS: Interns from 11 residency programs participated in a half-day workshop and networking lunch during residency orientation .

DESCRIPTION: Residents play a key role in medical education particularly in the clinical learning environment (CLE) where they often spend more time with medical students than faculty. Positive interactions between residents and medical students can foster a positive CLE, improve student satisfaction, and influence career choice. However, residents receive little preparation on how to create a positive CLE. We developed a workshop given during intern orientation with two specific objectives:

1) Develop intern skills at a) creating a positive learning environment; and b) providing feedback to medical students; and

2) Create an opportunity for new interns to network with interns outside their departments.

All residency programs were invited;11 programs out of approximately 32 total programs enrolled their interns. The interactive workshop was divided into two topics: how to show medical students that they matter to the team and how to give high quality feedback. These topics were intentionally paired because we felt that if students believed they mattered to the clinical teams, then feedback would be more likely to be seen as formative and helpful rather than summative and punitive.

EVALUATION: Using a pre-post assessment, we evaluated intern confidence in their skills as educators broadly and specifically in their ability to foster a positive learning environment and provide effective feedback to students. Out of the approximately 120 interns who attended, 92 completed the pre-survey and 48 completed the post-survey. Interns indicated statistically significant improvement in their confidence as an educator (51% pre to 87% post reported being at least somewhat confident, p<0.001), and in their confidence giving feedback (63% pre versus 83% post reported being at least somewhat confident, p<0.001). We saw a non-significant improvement in establishing a positive CLE (85% to 90%). Eight-eight percent strongly or somewhat agreed that the lunch was good for networking with peers, and 93% somewhat or strongly agreed that the session was good for their professional development.

DISCUSSION / REFLECTION / LESSONS LEARNED: The goals of this workshop were to improve intern skills at creating a positive CLE through demonstrating that students matter and giving feedback, as well as providing a networking opportunity. The unique aspects of this program were the interdisciplinary nature of the sessions and the focus on both mattering and feedback. Confidence creating a positive CLE started out high, and we saw significant gains in giving feedback. Future work will attempt to document the impact of these sessions on the perceived teaching skills of the residents who have participated. Additionally, we plan to expand our curriculum by offering additional workshops on different teaching topics identified by the intern participants.

PREPARING STUDENTS FOR TRAUMA-INFORMED CARE: A WORKSHOP ON COMMUNICATION SKILLS TRAINING USING SIMULATION

Martina Jelley¹; Frances Wen²; Julie Miller-Cribbs³; Kristin Foulks⁴; Juliana F. Meireles². ¹Internal Medicine, The University of Oklahoma - Tulsa, Tulsa, OK; ²Family and Community Medicine, The University of Oklahoma - Tulsa, Tulsa, OK; ³Social Work, The University of Oklahoma, Norman, OK; ⁴The University of Oklahoma - Tulsa, Tulsa, OK. (Control ID #4064456)

SETTING AND PARTICIPANTS: To address the educational gap regarding the knowledge and skillset needed to discuss the effects of childhood trauma on adult patient’s health, three skills workshops were conducted with a total of 64 medical and PA students at two campuses of a medical school in the Mid-West. The largest session was done with third-year medical students and second-year PA students as part of their monthly day-long student academy.The two smaller sessions were done with third and fourth year students who volunteered for additonal training.

DESCRIPTION: Pre-training assignments included journal articles and videos, emphasizing addressing trauma in healthcare settings.The workshop began with didactics on ACEs’ impact on adult health. A case demonstration was conducted with one faculty member portraying the primary care provider and another as the patient. Following this, each student participated in a simulated office visit, using cases based on clinic patients with chronic disease. Simulated patients (SPs) were trained to ensure a consistent and effective learning experience. Encounters included a 15-minute SP visit with PCP and a 5-minute debrief with formative feedback from faculty, SP, and peers. Anonymous pre- and post- surveys were conducted to assess the impact of the training, with questions on knowledge, attitudes, and confidence.The responses were on a 4-point Likert scale with 0 lowest and 3 highest.The survey included an open-ended question for likes/dislikes/suggested improvements.

EVALUATION: Fifty-eight students completed the pre- survey and 53 completed the post- survey. Baseline scores were lowest on the question of knowledge on resources to support patients with a history of trauma (M=1.10±0.69). Following the session, the highest scores were in attitudes regarding discussion of patient strengths and resiliency during routine visits in primary care (M=2.66±0.55). We observed a significant increase in general knowledge on ACEs and TIC, confidence in applying TIC principles, and the perceived importance of TIC aspects. Of the 26 students who provided qualitative feedback, 65% (n=17) expressed positive opinions about the training, highlighting the case demonstration, simulated encounter, and immediate feedback. However, 11% (n=3) felt uncomfortable with peer observation during the simulated encounter. Suggestions for future training included scripted structure for simulations, distributing cases beforehand, and adding more on treatment options.

DISCUSSION / REFLECTION / LESSONS LEARNED: We were able to demonstrate a positive impact of training using patient simulation to teach knowledge and communication skills around addressing ACEs in adult health. The students showed appreciation for examples of how to have this challenging conversation with their patients and felt more confident that they could incorporate such discussions in the future.Two most appreciated components were the demonstration of a simulated encounter by faculty prior to the student simulations and the immediate feedback from an experienced faculty.

PROCEDURES GROUP CHAT: A RESIDENT-DRIVEN APPROACH TO INCREASE PROCEDURAL COMPETENCY

Anusha Majagi, Karthik Ramaseshan, Sanaa Ahmad, Tiffany T. Le, Asim Kagzi. Internal Medicine, Detroit Medical Center, Detroit, MI. (Control ID #4044478)

SETTING AND PARTICIPANTS: The group chat was implemented in January 2023 at a 700-bed academic medical center with 108 internal medicine (IM) resident physicians at an academic program in the Midwest.

DESCRIPTION: In 2007, the American Board of Internal Medicine (ABIM) shifted mandates away from requiring completion of procedures during residency training and towards emphasizing knowledge of indications, contraindications, and complications of common procedures. As a result, bedside procedures, such as paracentesis and thoracentesis, are now referred to interventional radiology (IR). We sought to address this deficiency through a resident-driven initiative by creating a voluntary group chat in January 2023 for all IM residents to reach out to fellow co-residents already certified in various procedures. Certified residents would volunteer to help teach and perform the required procedure. All communications through the chat were Health Insurance Portability and Accountability Act (HIPAA) compliant.

EVALUATION: A short two question survey was sent to the entire residency program asking residents if they were a part of the group chat and if they found it helpful. 64 out of 108 residents responded to the survey (59% response rate). 90% of respondents stated that they were part of the group chat. 76.6% of residents responded strongly agree/agree to “Have you felt like the procedures group chat has been helpful?”. The impact of the initiative was measured through procedures logged in New Innovations, a website used by graduate medical education to log completed procedures. We chose five procedures (paracentesis, thoracentesis, central lines, arterial lines, and lumbar punctures) to compare changes in procedure volume performed by IM residents. Residents logged 124 procedures in the year prior to the initiation of the group chat compared to 240 procedures logged the year after (a 94% increase). There was a 93% increase in paracenteses and a 500% increase in the number of thoracenteses completed.

DISCUSSION / REFLECTION / LESSONS LEARNED: Medicine is often a see one, do one, teach one field. Our initiative created stream-lined opportunities for residents to have access and reach out to certified residents to develop their procedural skills, allowing for faster diagnostic and therapeutic interventions in addition to increasing procedural competency and provider autonomy. Objectively, there is a clear increase in the number of procedures completed and logged by residents. Future goals include instituting a procedure elective to dedicate time for solely learning and teaching procedures. Because starting a proceduralist service can be costly and difficult to staff, we propose having a group chat as an initial step for procedure opportunity and education.

QUALITATIVE ASSESSMENT OF THE EDUCATIONAL VALUE OF A FORMALIZED FEEDBACK INTERVENTION FOR INTERNS ON OVERNIGHT CROSS COVER SHIFTS

Kaitlyn McLeod³; Dorothy E. Loy³; Joshua Raines⁴; Angela Keniston¹; Sarah Mann¹; Christine D. Jones²; Julia Limes¹. ¹Division of Hospital Medicine, University of Colorado, Aurora, CO; ²Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ³Medicine, University of Colorado, Denver, CO; ⁴Medicine, VA Eastern Colorado Health Care System, Aurora, CO. (Control ID #4064760)

SETTING AND PARTICIPANTS: Night float schedules in graduate medical education increase cross cover burden, decrease feedback, and lead to less traditional formal education. At our institution, onsite nocturnists are available for decision making support, yet intern education has historically not been prioritized. We sought to enhance education on cross cover shifts for interns by creating a formalized intern-attending feedback process. All interns cross covering on internal medicine ward services at a VA Medical Center (VAMC) and an academic hospital center in the Mountain West region were included on an opt-in basis.

DESCRIPTION: Rotation blocks were randomized to control or intervention group with the same number of cross cover shifts and interns in each group. The intervention group was asked to submit a brief online form of up to 3 decisions they discussed with the attending nocturnist each night. The form assessed the discussion topic and the impact of the discussion on their differential diagnosis and management. The control group had access to nocturnists but did not complete the form. Both groups were sent a post-survey to assess the perceived educational value of cross cover shifts. Inductive thematic analysis was used to generate themes in post-survey free responses and written explanations on the nightly cross cover forms. Discussion topics identified by interns were described further using summative content analysis.

EVALUATION: We collected 62 cross cover forms from 35 unique interns during the 2022-2023 academic year; 58.1% were submitted from our academic hospital site and 41.9% from the VAMC. Most interns indicated that they had done 1-2 cross cover rotations at the time they were completing the survey. In total, 129 discussion topics were submitted. Differential diagnosis and management changed 27% and 46.5% of the time, respectively. The three most common discussion topics were hypotension and shock (n=12), cirrhosis complications (n=7), cardiac arrhythmias (n=7). Discussions focused on an overall approach to management most often, but it was also common for interns to order medication or interpret a diagnostic test with nocturnists. We received 75 post-surveys from 43 intervention and 32 control participants. Both groups expressed that there were inherent challenges of cross cover shifts, a desire for more formal overnight education, and the importance of clear communication with nocturnists. Nocturnist initiating an introduction early in the night was helpful, regardless of additional discourse later in the night. The control group noted a need for debriefing and feedback more often; the intervention group stated cross cover was valuable more often.

DISCUSSION / REFLECTION / LESSONS LEARNED: Education on cross cover shifts should be prioritized. Our study indicates both common topics and approaches to supporting interns on cross cover. They note that clear communication with nocturnists, support in interpreting and ordering diagnostic testing, and discussing approaches to management of common topics was most helpful.

REAL-TIME, BRIEF REFLECTIONS AS A TOOL TO FOSTER CHARACTER AND PROFESSIONAL IDENTITY DEVELOPMENT IN MEDICAL STUDENTS

Noah Miller¹; Mary Hoeschen¹; Rachele Harrison²; Zachary Hovis²; Brian C. Hilgeman³. ¹internal Medicine, Medical College of Wisconsin, Milwaukee, WI; ²School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI; ³General medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4064381)

SETTING AND PARTICIPANTS: From August–December 2023, more than 300 first-year medical students and 80 fourth-year medical students at a Midwest academic medical center voluntarily reflected during their rotations. First-year medical students completed their reflections during their first clinical experience rotating with a supervising physician for 8 clinics over the semester. They were instructed to complete a reflection following each session with their preceptor. Fourth-year medical students were introduced to the tool during a mandatory orientation for their 4-week medicine acting internship. Students were randomized 1:1 to either complete 2 reflections per week or not complete any reflections.

DESCRIPTION: Real-time, brief reflections consist of short (280 character) written reflections completed by students via Qualtrics during or immediately following their days in clinic. Students are prompted to “Write a reflection about your experience with a patient.” The Qualtrics interface is intuitive, ensuring straightforward navigation for students to articulate their reflections in a thoughtful and comprehensive manner and can be completed on a laptop or cellphone.

EVALUATION: Students completed pre/post Jefferson Scale of Empathy scores alongside a post-rotation survey designed to evaluate the efficiency, familiarity, and contextual significance of the tool. The post-rotation survey also assesses how reflection affects students’ analysis and recollection of patient encounters as well as its influence on patient care skills such as listening and addressing patients’ emotions.

DISCUSSION / REFLECTION / LESSONS LEARNED: Clinical learning in medical school relies on students’ ability to process and extract meaningful lessons from their patient encounters. However, few educational tools are available to help students navigate this form of learning. Narrative reflection has been shown to foster empathy, promote cultural humility, advance professional identity formation, and more (1, 2, 3). Medical schools across the country use narrative reflection in their curricula, but most iterations include lengthy, essay-based writing assignments that are time-consuming and detached from the clinic (4). Our tool aims to eliminate these barriers and provide students a more accessible space to digest their patient encounters. Despite the brevity of the reflections, early data shows a progressive decline in student usage. Various methods being explored to increase participation include monetary incentive, incorporating the reflections into the required curriculum, and providing protected time for the students to reflect during academic half days. At the time of presentation, process data along with post intervention quantitative feedback and pre/post empathy scores will be available for presentation.

ONLINE RESOURCE URL: The following link directs the user to the reflection platform via Qualtrics.

https://mcwisc.co1.qualtrics.com/jfe/form/SV_3QPUmnF6NtpNqtM

REDISTRIBUTING REQUIRED SCIENCE LEARNING TO THE POST-CLERKSHIP PHASE TO SPIRAL LEARNING AND ENHANCE CURIOSITY

Chad R. Stickrath¹; Shanta M. Zimmer¹; Tai Lockspeiser². ¹Internal Medicine, University of Colorado System, Denver, CO; ²Pediatrics, University of Colorado, Denver, CO. (Control ID #4064517)

SETTING AND PARTICIPANTS: One hundred seventy medical students at a public medical school during the 2023-2024 academic year.

DESCRIPTION: Our medical school recently revised its curriculum to: 1) better integrate basic medical, clinical, and health system sciences, 2) spiral learning throughout the four years, 3) shorten the pre-clerkship phase, and 4) enhance curiosity among learners. Curriculum leaders, faculty, and students reviewed all learning topics and decided on several domains where advanced content could be most effectively redistributed from the pre-clerkship to post-clerkship phase resulting in the creation of four courses in a 13-week “Advanced Science Course (ASC)” curriculum (Cardiovascular (CV), Immunological (IG), Neuroscientific (NS), and Global Health & Underserved Populations (GHUP)). This allowed the pre-clerkship phase to be shortened to one year, the core clerkship phase to occur in year two, and for the implementation of the ASCs at the beginning of year three before taking USMLE Step 1.

The ASC curriculum consisted of four individual courses (CV, IG, NS, GHUP) that students completed at the same time. To spiral content, employ spaced/interleaved learning, and maximize clinical opportunities, students engaged in clinical experiences related to one course each week and then switched to clinical experiences in a different course the next week for a total of three 1-week clinical sessions in each course. Students had didactic learning one day per week, with courses alternating didactics for a half day every other week. Students completed three reflections, one Capstone presentation, mid-term and final multiple-choice exams, a Comprehensive Basic Science Exam (CBSE), and post-course evaluations.

EVALUATION: Among students, >70% rated the overall quality of the courses as very good/excellent for CV, IG, and NS. Greater than 60% of students in CV, IG, and NS reported that a) didactic sessions and clinical experiences were very/extremely well-aligned, b) clinical experiences highlighted the science learned in the classroom very/extremely well, c) that the three scientific pillars were very/extremely well- integrated, and d) clinical experiences were very/extremely effective in encouraging curiosity. GHUP was not rated as positively with only 30-60% of top box responses in each item. At the end of the ASC curriculum, students achieved a mean NBME CBSE score of 62.

DISCUSSION / REFLECTION / LESSONS LEARNED: We were able to successfully implement a required 13-week curriculum following the clerkship year that provided required advanced science learning among selected content domains in a spiraled, integrated manner while fostering curiosity. The GHUP course may have rated consistently lower than the other three courses due to the unique type of didactic content and less congruent clinical experiences. Course updates to address the GHUP course and other opportunities for improvement are underway while we await more longitudinal data/outcomes from the curriculum.

RESIDENT PERSPECTIVES ON A CLINICIAN EDUCATOR TRACK: 4 YEARS IN REVIEW

Kerry Benton, Virginia Malatack, Stephanie D. Cardella. Hospitalist, MedStar Georgetown University Hospital, Washington, DC. (Control ID #4064523)

SETTING AND PARTICIPANTS: A two-year Clinician Educator Track (CET) was created for Internal Medicine and Internal Medicine-Pediatrics residents at an academic institution in the Mid-Atlantic region in 2019. The CET consists of 12 protected didactic half-days annually, direct teaching experiences, faculty mentorship, and completion of a medical education capstone project. In the first two years of the CET, there were 14 participants annually, expanding to 22, 29, and 28 in the three subsequent years. To assess the residents’ perspective on the CET's successes and areas for improvement, participants were surveyed after each didactic session and annually.

DESCRIPTION: At the end of each didactic, residents responded to the survey question “How much will the session influence my practice?" using a 5-point likert scale. An annual survey assessed the program’s strengths and areas for growth using a 5-point likert scale as well as free-response questions. Free responses were preliminarily coded by two authors. The authors then categorized these preliminary themes using the framework of the six domains of medical educators: Direct Teaching (DT), Curriculum Development (CD), Advising/Mentoring (A/M), Educational Leadership (EL), Learner Assessment (LA), and Educational Scholarship (ES). Themes of Community of Practice (CoP) and Programmatic Logistics (PL) were also identified.

EVALUATION: Annual Surveys: In 2020-21, 2021-22, and 2022-23, CET participants rated their development of new skills as an effective educator as 4.9, 4.6, and 4.4, respectively. Themes identified in response to “What is/was your favorite part about the CET?” focused on DT, CoP, and A/M (41, 28, and 9 responses respectively). Less commonly noted themes included the domains of ES, EL, and CD (3, 1, and 1 responses respectively). Free-responses to “What would you like to see changed or improved for the future?” emphasized DT, PL, A/M, and ES (22, 16, 11, and 7 responses respectively). Less commonly noted themes were EL, LA, and CD (4, 2, and 2 responses respectively).

Didactic Surveys: In 2019-20, highest rated topics included Bedside Teaching and a Faculty Panel (rated as 5.0). In 2021-22, highest ranked topics were Chalk Talk Introduction, Thinking about your CV, and Adult Learning Theory (all rated as 5.0). In 2022-23, Teaching on Rounds (5.0) and Teaching Procedures (4.9) were rated highest.

DISCUSSION / REFLECTION / LESSONS LEARNED: The CET is highly rated annually, and residents most strongly value learning direct teaching skills (DT) and building a community with co-residents (CoP). While the other domains of medical education are integrated into the track, these domains were less of a focus of the CET and also less desired by its participants. The emphasis on DT may reflect the residents' current focus on the direct education of their intern and student learners. Comments also emphasized that protected time helped foster peer discussion and community-building (CoP). The most consistent resident feedback was for additional opportunities to practice direct teaching skills.

REVAMPING AN OUTPATIENT CURRICULUM RELATED TO SOCIAL DETERMINANTS OF HEALTH

Cladimar Vasquez, Elizabeth "Betty" Kolod. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4061494)

SETTING AND PARTICIPANTS: This project is proposed for internal medicine PGY1 residents in a clinic in the Mid Atlantic region.

DESCRIPTION: The ACGME requires internal medicine residents to understand system based practices by assessing social determinants and being aware of community resources available to their patients. Our current curriculum in the resident clinic contains a lecture that exposes internal medicine residents to poverty related issues in our patient population, including food insecurity, housing, insurance, transportation, and health literacy. To improve our current curriculum, a needs assessment was created to evaluate internal medicine residents' (PGY1, PGY2, and PGY3, n=24) self-perceived attitude and knowledge on screening and making referrals to community based resources. The outcome of this evaluation helped in creating didactic materials that will expand the current social determinants curriculum.

EVALUATION: For our needs assessment, we distributed a survey to the internal medicine class. A Likert scale was used to assess for the following: residents’ desire to discuss social determinants in clinic, comfort with screening/making referrals to address social determinants, barriers to screening/making referrals for social determinants, interest in learning the various types of social determinants, and the resident’s preferred learning method. A total of twenty four residents participated in the survey. The results of the survey revealed that the residents wanted to improve their ability to discuss social barriers with their patients. It also showed that less than 50% of the residents did not know how to find relevant community resources or when to refer to social work. Residents also believed that time (95%) and lack of awareness of helpful resources (75%) prevented them from addressing their patient’s social barriers. Overall, residents wanted to gain the ability to screen/make referrals for housing (79%), food security (63%), and transportation (58%). The preferred teaching method to execute this curriculum was to have the following: an interdisciplinary discussion with SW (71%), common resources in the mobile app (92%), and Epic dot phrases with helpful resources (79%).

DISCUSSION / REFLECTION / LESSONS LEARNED: This needs assessment created the foundation to improving internal medicine residents' attitudes and comfort with screening and making referrals for their patients. In the Spring of 2024, we plan to pilot didactic material that may help reduce time constraints and difficulty in navigating our clinic resources. In our didactic session, we will refer to literature that reveals ways to screen for social barriers, inform residents of available resources at our clinic (e.g. social work, case management, and community based referrals), and discuss a case that ties together the various social domains. Pre- and post-curriculum surveys will be administered to assess the change in attitudes and self-perceived knowledge on social determinants.

REVOLUTIONIZING MEDICAL EDUCATION THROUGH AI-ENHANCED GLOBAL MENTORSHIP WITH [NAME REDACTED]

Geoffrey V. Stetson^1,2; Adam Rodman^4,5; Gregory Ow^3,2. ¹Internal Medicine, University of Illinois Chicago College of Medicine, Chicago, IL; ²MedEdMENTOR LLC, Chicago, IL; ³Internal Medicine, University of California San Francisco, San Francisco, CA; ⁴Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ⁵Harvard Medical School, Boston, MA. (Control ID #4036507)

SETTING AND PARTICIPANTS: [Name Redacted], launched in September 2023, serves a global audience, targeting clinicians transitioning to academic roles, scholars in underrepresented regions, and medical educators seeking comprehensive theoretical and practical guidance.

DESCRIPTION: [Name Redacted] is an online platform designed to democratize access to guidance pertaining to medical education scholarship. It offers educational primers, a database of over 250 summaries of relevant theories, a literature search tool, and [Name Redacted] AI. This AI component, tailored for medical education, provides advice on research design, theory application, and manuscript preparation. To evaluate the impact of [Name Redacted], a postpositivist paradigm framed a combined approach, involving website analytics to assess user engagement and a comparative study of Large Language Models (LLMs).

EVALUATION: The platform's user interaction data were analyzed for insights into its global reach and impact. For the comparative study, recent publications from 24 medical education journals (MEJ-24) were analyzed to create a dataset of phenomenon-theory pairs, which were used to test the effectiveness of [Name Redacted] AI against other LLMs in theory selection.

[Name Redacted] has gained significant traction, with over 15,000 page views, 550 registered users from 42 countries, and extensive user engagement in its first six weeks. The platform's AI component, [Name Redacted] AI, outperformed other LLMs in theory selection, achieving a 55% match rate compared to 49% with OpenAI's ChatGPT-4. This highlights [Name Redacted] AI's specialized capability in aligning with theoretical choices in medical education research.

DISCUSSION / REFLECTION / LESSONS LEARNED: [Name Redacted] has emerged as a pivotal resource in medical education scholarship, providing comprehensive guidance and resources alongside AI-driven mentorship. The platform's global popularity and the superior performance of [Name Redacted] AI in theory selection demonstrate its potential to significantly enhance the rigor and diversity of medical education research. Future updates will focus on expanding its foundational content as well as better targeting its theoretical framework database to medical education, further empowering researchers, particularly those from underrepresented regions, to contribute diverse perspectives to the field.

ONLINE RESOURCE URL: www.mededmentor.org

TAILORING COMMUNITY ENGAGEMENT COURSES TO OPTIMIZE BENEFITS AND MINIMIZE BURDENS OF COMMUNITY PARTNER PARTICIPATION

Shreya Ganguly⁴; Abhi Kole¹; Amy Zeidan²; Ameeta Kalokhe³; Eudora Olsen⁴; Elizabeth Manguso⁴; Kimberly A. Curseen⁵; Maura George¹. ¹Internal Medicine, Emory University, Atlanta, GA; ²Emergency Medicine, Emory University School of Medicine, Atlanta, GA; ³Infectious Diseases, Emory University School of Medicine, Atlanta, GA; ⁴Emory University, Atlanta, GA; ⁵Family and Preventive Medicine, Emory University, Atlanta, GA. (Control ID #4024312)

SETTING AND PARTICIPANTS: Each year since 2016, ~140 Emory University medical students are matched with ~40 different community partner (CP) sites in the greater Atlanta area. CPs are engaged in a variety of health-adjacent activities including after-school programs, assisted living, HIV care, immigrant support, nutritional support, housing services, mental health services, and trauma support services.

DESCRIPTION: In 2016, Emory University School of Medicine (EUSOM) implemented an 18-month service-learning course entitled “Community Learning and Social Medicine (CLSM).” In this course, first and second year students work directly with a CP site to learn about nonprofits working on health equity across Atlanta, gain skills to engage with these organizations as future healthcare providers, and understand the needs of unique communities. Students have a minimum requirement of 40 hours of community engagement. Four faculty leads cultivate and maintain relationships with the CPs, and all CPs are invited to an annual Community Engagement Day where the collaborations forged over the past year are celebrated. Interspersed with site visits to the CPs, students get didactic lectures on a variety of social medicine topics.

EVALUATION: While ample research supports the benefits of this type of service-learning course on future community engagement among healthcare providers, few studies explore the benefits or burdens these courses bring to the CPs and the populations they serve. During the 2021-2022 academic year, we conducted a qualitative study that utilized focus groups with CP site leads to explore their experiences of participating in the CLSM course. Questions explored general experiences participating in the course, benefits and challenges of engaging students with their organization, perceived impact on students after participating, and future opportunities for course improvements. We then conducted qualitative data analysis using Dedoose software on the transcripts from the focus groups to identify, analyze, and report prominent themes within the dataset.

DISCUSSION / REFLECTION / LESSONS LEARNED: Qualitative analysis of the focus group interviews revealed eight major themes. CPs identified three major benefits to the course: medical students as community assets, use of clinically relevant skills such as active listening by the medical students, and effectively bridging the healthcare system at EUSOM with community members. CPs also identified three challenges: community work does not always align with the students’ schedules, students sometimes acted as experts rather than learners, and a lack of clarity on the course content and expectations. CPs did come with solutions for many of these challenges. Finally, CPs also saw themselves as extension of the medical school faculty, mentoring students and contributing to their professional growth.

ONLINE RESOURCE URL: https://urbanhealthinitiative.emory.edu/education/otherevent/index.html

THE FAVORABLE PERCEPTION AND EDUCATIONAL IMPACT OF A FIELDWORK AND LODGING TRIPS FOR MEDICAL STUDENTS WITH SCHOLARSHIPS AND OBLIGATIONS TO WORK IN RURAL AREAS

Michito Sadohara¹; Taito Kitamura¹; Kunihiko Matsui². ¹General and family medicine, Kumamoto Daigaku Byoin, Kumamoto, Kumamoto, Japan; ²General Medicine and Primary Care, Kumamoto Daigaku Byoin, Kumamoto, Kumamoto, Japan. (Control ID #4061371)

SETTING AND PARTICIPANTS: Medical students from a Japanese university, recipients of municipal scholarships with an obligation to work in rural areas, participated in a two-day special program involving fieldwork and a lodging trip to a rural area as an extracurricular activity. The objective of this trip was to motivate students through actual visits to and engagement with the community. We conducted a questionnaire survey to assess the educational impact of the trip and the students' perception of the community.

DESCRIPTION: In 2023, 20 medical students (1st to 6th grade) participated in this trip. The schedule included preliminary research based on administrative materials, visits to medical and care facilities, and town offices as part of fieldwork, followed by presentations. The questionnaire covered demographics, 10 statements on their perspectives regarding the area and community medicine (rated on a 4-grade scale), and self-evaluation of knowledge comprehension (17 keywords, rated on a 5-grade scale). All participants completed the questionnaire both before and after the trip.

EVALUATION: Regarding views on the community, scores significantly increased for nine out of ten statements, including "community medicine has some dream," "want to work in an area facing a doctor shortage," "ready to take on roles in rural medicine in the future," and "highly expected by the community." The statement "life in the area seems enjoyable" was the only one not statistically significant. Confidence in knowledge significantly increased for 16 out of 17 keywords, encompassing community-based integrated case systems, regional healthcare vision, medical cooperation between facilities, multi- and inter-professional collaboration, team-based healthcare, home and visiting care, shortages, and maldistribution of doctors in rural areas, an aging society with fewer children, and health promotion campaigns. Only the keyword "advanced care planning," unrelated to the trip's focus, did not show statistical significance.

DISCUSSION / REFLECTION / LESSONS LEARNED: Some research suggests that rural exposure for medical students is effective for retaining rural doctors. Our survey results indicate that actual visits to and immersion in the area where they will work promote a favorable perception of the community and encourage them to assume their roles. Despite this trip was an extracurricular activity, there were increases of confidence in knowledge concerning community medicine. While we conducted these trips over two nights and three days before COVID-19 pandemic, this particular instance involved one night and two days, yet the the survey results remained consistent. It is crucial to expose students to rural communities, even in the short term. Further investigation and follow-up are necessary to comprehend the long-term effects based on career paths.

USE OF COMICS TO ORIENT LEARNERS TO BEDSIDE ROUNDING: A PROSPECTIVE QUASI-EXPERIMENTAL STUDY

Rebekah Gardner¹; Anne Vera Cruz²; Evan Ames³; Vinald Francis⁴; Melissa McNeil¹. ¹Department of Medicine, Alpert Medical School of Brown University, Providence, RI; ²Alpert Medical School of Brown University, Providence, RI; ³Rhode Island Hospital, Providence, RI; ⁴Dartmouth College Geisel School of Medicine, Hanover, NH. (Control ID #4056047)

SETTING AND PARTICIPANTS: Medical students, residents, and attendings at an academic medical center.

DESCRIPTION: When bedside rounding, an inpatient team presents clinical information and discusses the care plan in front of the patient, instead of in a hallway or at a conference table. Although bedside rounding may benefit clinical care and medical education, many teams are reluctant to try it because they fear bedside rounding will be awkward and inefficient.

To address these concerns, we designed a comics-based orientation to bedside rounding for inpatient teams. Comics were selected as a pedagogical strategy because they can explore complex concepts efficiently and engagingly. Using faculty expertise and best practices from the literature, we created a comic book that visually demonstrates a typical wards team doing bedside rounds. It also included scripts, tips to improve teaching, and ways to troubleshoot common obstacles.

We asked the following research question: Does use of comics to orient physicians to bedside rounding improve learner self-efficacy, compared to usual practice?

EVALUATION: We randomly assigned half of attendings (along with their teams) to use the comics-based orientation (intervention) and half to continue their usual orientation practice (control). We administered pre- and post-rotation surveys to both groups. Self-efficacy was assessed by asking how comfortable and how competent learners felt doing bedside rounds using a 5-point scale. Here we report results for interns/sub-interns from the first 5 months of the study.

Among learners surveyed pre-rotation (N=67), 18% were mostly or very comfortable doing bedside rounds, and 22% felt mostly or very competent. Among learners surveyed post-rotation (N=24), higher proportions in the intervention group felt comfortable and competent, compared to the control group (83% vs 67% and 75% vs 67%, respectively).

Learners reported the comic book was “easier to follow,” “approachable,” “entertaining,” “realistic,” and “easy to understand.” When asked what they would change, 83% indicated no changes, and the remainder suggested condensing the material.

DISCUSSION / REFLECTION / LESSONS LEARNED: We believe this study is the first to systematically test comics for orientation in a clinical setting. Comics have been deployed successfully in other aspects of medical education, including processing challenging clinical experiences, aiding in professional identity formation, and illuminating a patient’s experience of living with illness.

Comics may be an ideal format for teaching communication skills such as those used in bedside rounding because they can visually show multiple perspectives (e.g., patient, student, attending) simultaneously, including both spoken and unspoken thoughts. Compared to videos and shadowing, comics are relatively quick and economical to produce, revise, and disseminate.

Our results suggest that a comics-based orientation is acceptable to learners and that it may improve learner self-efficacy related to bedside rounding, compared to usual orientation practices.

USING STORY EXCHANGE TO ENGAGE EMPATHY SKILLS IN MEDICAL STUDENTS

Suchismita Datta²; Colleen Gillespie¹; Maura Minsky²; Lee Keylock³; Jennifer Adams². ¹PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; ²NYU Langone Health, New York, NY; ³Narrative 4, New York, NY. (Control ID #4064602)

SETTING AND PARTICIPANTS: 3 years of incoming medical students at orientation

DESCRIPTION: Incoming students are introduced to empathy as an essential clinical skill - one that promotes equitable and effective care through self-awareness, active listening and observation, engaged curiosity, and attention to emotions. Empathy is first taught with an immersive art museum experience focusing on observation and perspective, followed by seminars addressing the interplay of implicit bias and empathy, and then a Story Exchange.The Story Exchange is a novel approach (facilitated by Narrative 4 ) which uses the currency of stories to foster deep listening, perspective-taking and empathy and has parallels to narrative medicine’s conceptual model of attention, representation, and affiliation; building reflective practice and employing critical pedagogy and experiential learning. Participants respond to a prompt with a story they share with a partner, and in turn, actively listen while their partner shares their story. In small groups, each participant retells their partner’s story in the first-person and then all explore how listening to their own story being told by someone else feels--especially critical since this is the foundation for students developing their history-taking and note-writing skills.

EVALUATION: 247 participants in the Story Exchange (incoming classes 2021-23; N=315), completed an anonymous survey providing feedback. Almost all (95-98%) agreed (somewhat or strongly) that sharing personal stories in this way helped them connect to others, increase their ability to listen to understanding and improve their perspective-taking ability. When asked to share open-ended feedback most described positive impact: “I found that hearing my story told from someone else in a first-person view was a profound experience as it allowed me to see which details people tend to recall and emphasize. It has deepened my appreciation for how every single person you meet ultimately has extensive histories and stories of their own that might not be expressed to others in the most nuanced and detailed manner, and it is our jobs to be conscious of that.” Some focused on how it helped them get to know their peers better. A few emphasized good facilitation: “I just want to highlight how great our facilitator was in setting clear expectations but also creating an open and comfortable environment to share our stories. She definitely played an important role in the success of our activity.”

DISCUSSION / REFLECTION / LESSONS LEARNED: Story Exchange proved to be a meaningful experience for incoming medical students. By improving students' ability to listen, reflect, and understand the value of perspective, the Story Exchange prepares students to be empathetic physicians. Skilled facilitators are imperative to ensure a high yield and safe environment. We continue to explore how to scaffold additional Story Exchanges to enhance and sustain empathy and reflection.

ONLINE RESOURCE URL: https://narrative4.com/story-exchange/

WE’RE ALL JUST BIG KIDS: LESSONS LEARNED FROM A TEACHING SKILLS WORKSHOP DELIVERED BY A FORMER CREDENTIALED TEACHER

Rachel S. Tenney¹; Peggy B. Leung². ¹Medicine, Weill Cornell Medicine, New York, NY; ²Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY. (Control ID #4064702)

SETTING AND PARTICIPANTS: The session was delivered to residents (PGY1-3) during an ambulatory morning report at an urban academic medical center. The session was also delivered at a regional academic conference with attendees ranging from medical students to attending physicians.

DESCRIPTION: A 1-hour workshop, created by credentialed teachers turned medical residents, introduced 4 instructional techniques to attendees: defining roles, backwards planning, scaffolding, and cognitive modeling. The workshop creators utilized these techniques in their former careers as K-12 educators and during the workshop defined the techniques and provided examples from the K-12 and medical education realms to demonstrate applications in medical education. Attendees then applied the strategies to upcoming teaching experiences of their choosing.

EVALUATION: Following the session, participants rated several statements on a 5-point scale, where 1=strongly disagree, 2=disagree, 3=neither disagree nor agree, 4=agree, 5=strongly agree.

After the session, 22 of 43 resident participants completed a session evaluation. Mean responses among resident participants are below:

- I find the resident as teacher role enjoyable: 4.41

- I find the resident as teacher role rewarding: 4.59

- I feel well prepared to teach learners: 3.34

A total of 34 participants (a mix of students, residents, and attendings) completed a session evaluation; mean responses are below:

- I learned about teaching strategies that I did not know before: 4.41

- I found this session helpful: 4.71

Evaluations included free text responses. Participants most appreciated the planning/application aspects of the workshop and noted a desire for more opportunity to plan for implementation of the strategies discussed. Representative quotes include:

What did you like or find useful about this session?

“Really liked the planning aspect- imagining how we will use these strategies immediately in our next teaching encounter.”

What do you recommend to be changed for future iterations?

“Actually plan out a lesson!”

DISCUSSION / REFLECTION / LESSONS LEARNED: 1. Evaluation responses suggest that residents find the resident-as-teacher role enjoyable and rewarding but may not feel well prepared to teach.

2. Workshops to develop teaching skills may support residents so that teaching remains an enjoyable part of their job.

3. Evaluation responses indicate that attendees learned new techniques and found the session helpful, suggesting that it is feasible to complete the learning objectives of this pilot-phase workshop in a 1-hour session.

4. Traditionally focused on medical knowledge and clinical reasoning, morning reports may be opportune times to develop teaching skills among residents.

5. Dedicated time to plan for future teaching experiences is valuable to participants and additional time and opportunities may be beneficial.

“DEVELOPING DISCREPANCY” AROUND RESIDENT-LED TEACHING THROUGH A QI WORKSHOP

Justin T. Gasper^2,1; Alfred Burger²; Anqi Zheng⁴; Christina M. Cruz¹; Hayato Mitaka³; William Loughney⁵; Minira Aslanova⁶; Yasir Saeed⁷; Sreekala Raghavan². ¹Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Medicine, Mount Sinai Beth Israel Hospital, New York, NY; ³University of Washington, Seattle, WA; ⁴Weill Cornell Medicine, New York, NY; ⁵Geisinger Commonwealth School of Medicine, Scranton, PA; ⁶Inova Fairfax Hospital, Falls Church, VA; ⁷Montefiore Medical Center, New York, NY. (Control ID #4054692)

SETTING AND PARTICIPANTS: In our internal medicine residency program based at a single, university-affiliated hospital a cultural drift in prioritizing clinical tasks led to a decrease in resident-led teaching. A 2021 internal survey reflected this trend; residents disagreed with the statements, “the program is organized in a way to meet my educational needs,” and “the variety of patients I see is sufficient for meeting my educational needs.”

In Winter 2022, only 17% of total inpatient medicine admissions were done by PGY-1’s, which did not foster resident-led teaching, yet prior program and resident initiatives to increase supervised PGY-1 admissions were unsuccessful. Developing discrepancy is a key component of motivational interviewing which builds awareness of the gap between current behaviors and desired outcomes. We developed a QI workshop to address discrepancy in resident-led teaching related to admissions done by PGY-1's.

DESCRIPTION: In March 2022, four workshops comprising 73 categorical residents were led by chief residents and program leadership with an introduction to quality improvement, the internal survey results, and decline of resident-led teaching on admissions. Each session was divided into small groups of 3-4 residents with one PGY-1 per group. These groups drew fishbone diagrams to identify factors behind the low number of PGY-1 admissions, then wrote aim statements proposing ways to increase PGY-1 admissions.

Residents presented fishbone diagrams highlighting the volume of admissions on a shift, tasks required in advancing patient care, and timing of admissions close to shift change. Senior residents were concerned that assigning admissions would burden preliminary or inexperienced categorical PGY-1 residents and result in extending hours, disrupting team dynamics, as well as delays in care or discharges.

Next residents proposed aim statements to bolster PGY-1 admissions. This fostered a resident-led dialogue around time constraints; PGY-1’s wanted more admissions while seniors offered to manage nurse messages and inpatient care. When experience or efficiency was cited, PGY-1’s noted that they could not improve without doing supervised admissions.

EVALUATION: Drawing on themes from the aim statements, program leadership announced a goal to have PGY-1’s participate in all admissions after July 1st, 2022. In July 2022, 38% of admissions were done by PGY-1’s. This rate increased to 53% by December 2022. Over a six-week period in Fall 2023, the rate of PGY-1 admissions was 72%.

DISCUSSION / REFLECTION / LESSONS LEARNED: In this workshop, we developed discrepancy by aligning resident and program goals while pointing out the discrepancy in outcomes. This discussion resulted in durable change around supervised PGY-1 admissions. More importantly, senior residents reimagined their role in teaching their team and guiding the admission process. While it remains to be seen how long these changes last, the sustained results thus far prove a potential model for residency programs facing similar challenges in resident-led teaching.

“THERE IS A LOT OF WORK TO DO, BUT I AM HOPEFUL FOR THE FUTURE” - REFLECTIONS ON EQUITY-ORIENTED HEALTHCARE AND INCARCERATION: INTEGRATING INSIGHTS INTO MEDICAL EDUCATION

Lauren Eisner²; Antoinette Nguyen²; Felicia B. Guo²; Diane Morse¹. ¹University of Rochester Medical Center, Rochester, NY; ²School of Medicine and Dentistry, University of Rochester, Rochester, NY. (Control ID #4054194)

SETTING AND PARTICIPANTS: Cohorts of second year medical students reflected on their experience in a medical humanities elective course focused on the intersection of health and incarceration. Participants were 28 students completing the course in 2021, 2022, and 2023 who provided written reflections.

DESCRIPTION: The elective consists of four two-hour sessions covering an overview of the U.S. carceral system and four key themes: systemic contributors to incarceration and its impact, the re-entry process and barriers, substance use and incarceration, and women’s health in incarceration. Sessions involve presentations and discussions with previously incarcerated individuals, community-based providers, Re-entry Community Health Workers, and medical providers experienced in equity-oriented care for this population. Pre-meeting podcasts, documentaries, and readings primed participants with contextual knowledge.

EVALUATION: Submitted student reflections were anonymized and thematically analyzed within the Health Equity Implementation Framework (HEIF). Written responses were coded using an iterative process and subsequently organized according to themes. Study personnel came to consensus on coding and major themes. HEIF domains included medical students, future patients, and presenters (recipients), elective characteristics (innovation), healthcare and carceral systems (inner context), and barriers to re-entry and stigma (societal context).

DISCUSSION / REFLECTION / LESSONS LEARNED: In 28 reflections, health equity relevant factors in medical student experiences (N=58) revealed themes of hope for the future, advocacy, and trauma-informed care. Within the innovation domain, accounts (N=35) focused on the benefit of learning from those with lived experience. Accounts of the carceral system, within the inner context domain (N=34), highlighted themes of injustice and recidivism. Some students discussed reconsideration of biases (N=21). Students reflected upon a “responsibility to reach across aisles and close care gaps” by “[advocating] for change, on the individual patient level and on a larger societal level,” stating that “these stories and reminders about shared humanity will help drive me to be the provider I want to be.” Students described patients as their “greatest teachers” writing “how much I have left to learn in order to become the physician I hope to be.”

Current literature illustrates that medical student attitudes toward criminal legal-involved patients are poor but can improve through experiential learning. Our findings suggest that exposure to previously incarcerated individuals and those providing biopsychosocial care to this population fosters greater understanding of this group through a more personal lens. This can prompt self-reflection and motivation to incorporate equity-oriented healthcare advocacy in future practices. Next steps may include pre-post course quantitative evaluation of medical student knowledge, behaviors, and intentions for healthcare provision to patients with a history of incarceration.

Innovation in Medical Education (IME) - Medical Ethics and Humanities

DEVELOPING A MEDICAL HUMANITIES COURSE FOR INTERNAL MEDICINE RESIDENTS: A PROOF OF CONCEPT

Nicholas B. Safian. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4065018)

SETTING AND PARTICIPANTS: This abstract outlines a pilot medical humanities course delivered to internal medicine residents in the primary care track at an urban academic medical center.

DESCRIPTION: The course consisted of three workshops, held during scheduled, protected didactic sessions for primary care track residents between January and November 2023. Workshops were sixty minutes. Each workshop began with a pre-session survey, which consisted of two parts. The first part was the Mini Z Resident, an adaptation of the Mini Z Survey, a validated tool to assess burnout. The second part provided a space for residents to creatively reflect on the experiences of their prior rotation in the form of writing a poem (haiku). The workshop then consisted of reading and reflective group discussion of a poem or literature excerpt that related to medicine. Following the workshop, residents completed a post-session survey providing feedback on the session via three Likert-scale based questions.

EVALUATION: The workshops were evaluated with both quantitative and qualitative measurements. Quantitative data included both Mini Z Resident scores and post-assessment Likert scale responses. Qualitative data included resident haikus. The intention for collecting the Mini Z Resident is to track these scores over time to assess the impact of medical humanities workshops on resident burnout. These data have not yet been analyzed (but will be by the time of the conference). In post-assessment feedback, residents overwhelmingly felt the workshops to be a positive experience. 80% of residents either agreed or strongly agreed the sessions were a good use of time. 73% of residents either agreed or strongly agreed they were interested in attending another session. 80% of residents either agreed or strongly agreed they would recommend this session to a college. (N = 15) Participant haikus also provided insight into residents’ experience and reflections of recent rotations. (Sample of haikus will be included in presentation.)

DISCUSSION / REFLECTION / LESSONS LEARNED: While not traditionally incorporated into medical training, the medical humanities can provide trainees with opportunities for personal reflection, empathic practice, interpersonal communication, and more. For this reason, the medical humanities represent a burgeoning area of interest in medical education. There exist several small-scale studies that demonstrate the positive impact of humanities-based interventions––most commonly narrative medicine––on trainees. Still, there is no definitive standard for how best to incorporate the medical humanities into medical training. Furthermore, determining the optimal measures by which to assess a medical humanities intervention remains difficult. The above outlined medical humanities course demonstrates a feasible intervention that was positively received by participants. Additionally, it provides two innovative methods of assessing such an intervention: tracking quantitative burnout scores and collecting residents' reflections via creative writing.

HUMANITIES IN MEDICINE GALLERY: A COLLABORATION OF ART AMONG THE MEDICALLY MINDED

Olivia Z. Mobarakai, Christine Palazzolo, Colin M. Kulick-Soper, MariaLisa Itzoe, Alexander Glaser, Sonia Shah. Medicine, Pennsylvania Hospital, Philadelphia, PA. (Control ID #4064002)

SETTING AND PARTICIPANTS: An art gallery served as the inaugural event for a resident-led Narrative Medicine Club, titled “Unscripted Medicine”, at a university-affiliated community-based hospital in a major city. The 3-hour event took place in an open space on campus on a weekday evening in the spring. All hospital faculty, residents, and staff were invited to submit their work and/or attend. The event was funded by a small grant from the hospital’s executive committee, which covered the cost of setup, printed materials, and refreshments for attendees.

DESCRIPTION: The art gallery, organized and hosted by the founding members of the “Unscripted Medicine” club, displayed nearly 50 pieces of artwork centered around the theme of “connections”, showcasing the connections between individual artists and the world they live in through visual, literary, and performing arts. Featured art included live henna designs, live classical music performed by a university-affiliated chamber orchestra, an artificial intelligence graphic recognition exercise, audio stations for interactive poetry and short stories, and the display of paintings, fused glass, handmade clothing, and photography. Attendees were encouraged to read, listen, reflect, and discuss. Pamphlets with artist information and descriptions of each piece were distributed to attendees. Light refreshments were provided, and a hospital-employed professional photographer was present to capture moments throughout the evening.

EVALUATION: Since the inaugural art gallery, interest and participation in arts & humanities-focused events has noticeably increased. The club has since held monthly events, including narrative medicine workshops, yoga classes, and quarterly outings to an art museum. While the events are organized and led by Internal Medicine residents, many other groups have expressed interest and participated, including the hospital librarian/archivist, medical student body, and faculty from other specialties. Future directions include hosting an annual art gallery, creating a hospital-wide literary arts journal, and performing qualitative assessments of interpersonal communication pre- and post-events.

DISCUSSION / REFLECTION / LESSONS LEARNED: The inaugural art gallery allowed our residents, faculty, and staff to explore their artistic talents, learn more about each other’s interests outside of work, and gain a brief window into each other's reflections on the challenges and joys of modern medicine. Art served as the vehicle to inspire conversation, connect providers, and highlight the diverse backgrounds of the colleagues we work with and the patients we serve. These are important conversations to foster as medicine has evolved into a complex interdisciplinary profession. By practicing honest communication to strengthen our healthcare community, we will be better prepared to provide empathetic patient care. This collaborative event had deep meaning for our group and has kicked off both our longitudinal Narrative Medicine Club and a wave of reflective interest throughout the department.

TEACHING THE FOUR BOXES APPROACH TO INTERNAL MEDICINE RESIDENTS AND SUBPECIALTY FELLOWS

Karl Wallenkampf¹; Justin Vincent¹; Patricia Kao^1,2. ¹Washington University in St Louis John T Milliken Department of Medicine, Saint Louis, MO; ²Nephrology, Washington University in St Louis, St Louis, MO. (Control ID #4065099)

SETTING AND PARTICIPANTS: Internal medicine residents and subspecialty fellows at an academic medical center

DESCRIPTION: The Accreditation Council of Graduate Medical Education (ACGME) requires resident physicians to demonstrate competence in adhering to ethical principles and instructs programs to incorporate methods to advance trainees' knowledge of ethical principles. While familiarity with ethical principles is established at the undergraduate medical education (UME) level, in GME trainees see ethically challenging scenarios and must characterize them, offer solutions, and communicate the solutions patients, families, and other professionals to ensure equitable care. Yet, there is a gap between students' understanding of ethical principles and trainees' comfort with tackling ethical conundums. We thus developed a 1-hour session using the Four Boxes approach (developed by Albert Jonsen, Mark Siegler, and William Winslade) targeted to common issues of informed consent, surrogate decision-making, and end-of-life-care using cases. The session aimed to familiarize trainees in GME with a reliable and widely applicable approach to ethical scenarios. The session included a brief lecture followed by the provision of analogue (handout) supports to address cases, which were then examined in teams. Time was then provided to discuss the issues and resultant solutions in a larger group. Finally, electronic versions of supplied aids were provided which could be included as template text in an electronic medical record (EMR) and used by trainees.

EVALUATION: The session was assessed for fesibility first with internal medicine (and other specialty) residents and in a second session with medicine subspecialty fellows. Of some 26 participants, 24 responded to a survey following the sessions. Respondents identified the Four Boxes with 96% accuracy. Asked to agree or disagree with confidence in their ability to use an ethical frameowrk to characterize eithcal issues in a clinical scenario before and after the session, before the session 6 of 24 responded that they either strongly or somewhat disagreed and 7 of 24 neither agreed nor disagreed. After the session, all respondents either somewhat agreed or strongly agreed they were confident in their ability to use an ethical framework to characterize ethical issues; 23 of 24 agreed that working with trainees from different disciplines enahnced their experience; and all aggreed that the session met its objectives.

DISCUSSION / REFLECTION / LESSONS LEARNED: There is insufficient training in GME for trainees to confidently characterize ethical challenges. Our session effectively exposed trainees to a memorable model that improved confidence and met its learning objectives. GME ethics initiatives have been established, mostly in pediatrics. Internists and subspecialtists will be better able to treat patients equitably and achieve goal-concordant outcomes with accessible, memorable, and simple ethical frameworks.

ONLINE RESOURCE URL: https://drive.google.com/drive/folders/1hRrGi2Q-_rQIn3a4ayfrndIZZXN6_Mx8?usp=sharing

UNTOLD STORIES: A MULTIFACETED INTERDISCIPLINARY HUMANITIES INTERVENTION TO REKINDLE EMPATHY IN MEDICINE

Jeffrey Lee¹; Katherine Henderson²; Elissa Nickolopoulos³; Michelle Tang⁵; John D. Ike⁴; Jane Gagliardi¹. ¹Internal Medicine-Psychiatry, Duke Medicine, Durham, NC; ²Chaplain Services & Education, Duke University Health System, Durham, NC; ³Case Management, Duke University Health System, Durham, NC; ⁴Internal Medicine, Duke Medicine, Durham, NC; ⁵Duke University School of Medicine, Durham, NC. (Control ID #4043071)

SETTING AND PARTICIPANTS: The Stories Project comprised two parts. Part one included semi-structured interviews and photographs of patients at a medically underserved clinic. Eight patients were recruited by word-of-mouth and flyers. Part two engaged a multidisciplinary healthcare team. Eighteen participants, including physicians, office staff, and allied health professionals, took part in a 60-minute intervention.

DESCRIPTION: The Stories Project investigated the impact of an interdisciplinary visual art and narrative-based intervention at a safety-net primary care clinic. We hypothesized this intervention would enhance measures of empathy and increase understanding of underserved patient populations. In part one, semi-structured patient interviews were guided by dignity therapy, which addresses existential distress among severely ill individuals. Next, a professional photographer took portraits of the patients. Themes from stories included grief, trauma, and experiences in the healthcare system. Part two involved the creation of a 60-minute intervention utilizing the patient’s electronic health record, audio interview excerpts, and portraits. This intervention adhered to the PRISM model for medical humanities curricula and utilized Visual Thinking Strategies (VTS). Post-session surveys assessed the intervention’s impact through qualitative and quantitative measures.

EVALUATION: All participants (n=18) completed the post-session survey. Participants included five internal medicine residents, four internal medicine attendings, one pharmacist, three social workers, two registered nurses, one patient care representative, one chaplain, and one healthcare student. On a five-point Likert scale, most participants “agreed” (6 of 18) or “strongly agreed” (11 of 18) that the intervention promoted empathy toward patients. Furthermore, most participants “agreed” (8 of 18) or “strongly agreed” (9 of 18) that the intervention would positively alter their patient care approach. Qualitative evaluation demonstrated that participants valued hearing multidisciplinary perspectives, felt energized to care for marginalized patients, and expressed desire to conceptualize patients as whole individuals within a fragmented healthcare landscape.

DISCUSSION / REFLECTION / LESSONS LEARNED: A genuine interest in the lives of our patients creates meaning in healthcare work, staves against burnout, and improves clinical outcomes. Our pilot study demonstrates the effectiveness of a single multifaceted medical humanities intervention at a safety-net primary care clinic in humanizing and increasing empathy toward patients through art and storytelling, highlighting the structural healthcare barriers patients must navigate, and promoting interdisciplinary collaboration. Future directions include recruitment of additional patients, collaborating with art venues to showcase stories, and expanding the intervention to reach other multidisciplinary groups. Ultimately, these conversations will cultivate conversations that will transform and revitalize patient-centered care.

Innovation in Medical Education (IME) - Mental/Behavioral Health and Substance Use Disorders

ADDRESSING PREVALENCE OF ANXIETY IN FIRST AND SECOND-GENERATION AMERICAN MEDICAL STUDENTS

Nina Brahmbhatt¹; Karina Haleblian¹; Cyrus Amirfazli¹; Adam Chaban¹; Aminah Fayyaz¹; Ajay Pradhan¹; Dana Kabbani². ¹Student, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4061296)

SETTING AND PARTICIPANTS: Self identified 1st and 2nd generation American students at a urban mid-west medical school

DESCRIPTION: Recognizing the unique challenges faced by diverse student populations is crucial for fostering equitable medical education. At an urban midwest medical education institution, a significant portion of the student body comprises immigrants or children of immigrants to the United States.

Existing literature emphasizes a heightened prevalence of anxiety among medical students. Additionally, a significant prevalence of stigmatization of mental health within immigrant households has been found. We believe that the convergence of the rigors of medical education with the additional stressors surrounding cultural identity formation and stigmatization of mental health may cause disproportionate levels of anxiety in this population.

This study aims to address the underexplored prevalence of anxiety among 1st and 2nd-generation American medical students, and lluminate their experiences by examining the interplay between cultural identity and the challenging landscape of medical school. We aim to contribute valuable insights to the existing literature, advancing our understanding of the unique stressors faced by this population and facilitate the development of tailored support mechanisms.

EVALUATION: Medical students will be invited to participate in an anonymous Qualtrics survey aimed to assess their experience with anxiety. The survey asks participants to self-identify as an immigrant or child of immigrants and collects demographic information such as graduation year, age, gender, and ethnicity. It also includes a standardized Generalized Anxiety Disorder-7 Screening Tool which evaluates anxiety symptoms within the last 6 months, and asks participants about perceived stigma towards mental health. Based on self-identification, students will be divided into two cohorts. An analysis between both cohorts will allow for researchers to gain a deeper understanding of the intersectionality of mental health illness and immigration history.

DISCUSSION / REFLECTION / LESSONS LEARNED: Given the documented high rates of anxiety in both medical students and children of immigrants, we anticipate a significant prevalence of anxiety among 1st and 2nd generation American medical students. The findings can shed light on the specific challenges that this demographic face, and identify unique stressors that are encountered over the course of their medical education. The goal is to enhance the existing mental health support systems available by paving the way for more targeted interventions that are beneficial to the diverse needs of its students. Identifying and analyzing the unique stressors faced by this population can allow American medical institutions to cultivate a more inclusive and supportive environment for their students to thrive. The application of these findings extends beyond academia, informing policies and practices to enhance the well-being and mental health of future generations of healthcare professionals.

AN ANTI-STIGMA CURRICULUM FOR MEDICAL TRAINEES CARING FOR HOSPITALIZED PEOPLE WHO USE DRUGS

Molly Perri, Mim Ari. Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4057915)

SETTING AND PARTICIPANTS: Starting in July 2023, students and residents on the opioid use disorder consult service elective were asked to participate in an asynchronous anti-stigma curriculum. Seven residents and seven students rotated on the consult service between July and November 2023.

DESCRIPTION: A 45-minute asynchronous anti-stigma curriculum was created and deployed on the EdPuzzle platform. It includes a narrated PowerPoint with interactive multiple choice questions and written reflections. At the beginning of the curriculum, trainees investigate their own internalized stigma towards people who use drugs (PWUD) with a personal bias assessment. Then through case-based learning, trainees complete sections on 1) examples of different types of stigma in the healthcare system, 2) stigmatizing language in the medical record, and 3) health implications of stigma on PWUD. An 18-item pre- and post-assessment was administered through RedCap to evaluate if the learning objectives for the course were met as well as measure changes in attitudes and beliefs towards PWUD. The responses were measured on a Likert-type scale ranging from 1 – 5 (strongly agree to strongly disagree). A paired-sample t-test was conducted to compare answers before and after the curriculum.

EVALUATION: To date, thirteen participants have completed the pre- and post-assessment for the course including 6 medical students and 7 residents (completion rate: 13/14, 93%). When assessing for change in attitudes, there was an increase in comfort when talking with PWUD (pre=2.62, post=1.31; p=.002), satisfaction with working with PWUD (pre=2.08, post=1.23; p=0.002), and belief that PWUD have challenging medical and social issues that trainees can learn from (pre=1.46, post=1.00; p=0.02). There was a significant inverse change regarding the belief that there is little trainees can do to help PWUD (pre=4.46, post=4.85; p=0.05) and that utilization of suboxone or methadone is replacing one addiction with another (pre=4.31, post=4.69; p=0.02). Curricular objectives were met with a significant change in self-reported ability to avoid language that is stigmatizing to PWUD (pre= 3.08, post=1.46; p = 0.0001) as well as the ability to identify and describe ways that stigma causes health disparities in PWUD (pre=2.23, post=1.15; p=0.002).

DISCUSSION / REFLECTION / LESSONS LEARNED: A brief online asynchronous course to address stigma has had high completion rates, met curricular objectives, and demonstrated a significant change in attitudes towards PWUD. Given healthcare workers generally hold negative views of individuals with substance use disorders that can lead to marginalization, avoidance of the healthcare system, and adverse health outcomes, addressing stigma is of paramount importance. This brief, replicable curriculum shows promise in addressing this issue and could be expanded beyond the consult service rotation to other institutions or members of the patient care team.

ONLINE RESOURCE URL: Visit ‘https://edpuzzle.com/join/jahunoj’ and sign-in to an account to join the class. Use code 'jahunoj'

A STIGMA-DISRUPTING ADDICTION MEDICINE CURRICULUM IMPROVED INTERNAL MEDICINE RESIDENT ATTITUDES TOWARDS AND PREPAREDNESS TO CARE FOR PEOPLE WITH SUBSTANCE USE DISORDERS ACROSS SITES AND FORMATS

David Lawrence^1,2; Katharine F. Marshall³. ¹VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³Addiction Medicine, Northwest Permanente, Portland, OR. (Control ID #4064319)

SETTING AND PARTICIPANTS: Amidst the worsening United States drug overdose crisis, the Accreditation Council for Graduate Medical Education instituted requirements for internal medicine (IM) residency programs to implement substance use disorder (SUD) instruction and clinical experiences. Negative provider attitudes towards people with SUDs, however, present a significant barrier to learning and providing standard-of-care treatment.

DESCRIPTION: Responding to this call, the senior author (KM) designed a curriculum for IM residents utilizing 4 stigma-reducing messaging strategies to teach 11 core competencies in SUD care. The curriculum was implemented in 2 iterations: in 2021-22 as a longitudinal series of 9 monthly live didactic sessions without structured clinical exposure in a Northwest region community IM residency program, and in 2022-23 as a 5-day core clinical rotation with pre-recorded didactics at a California-Hawaii region academic IM program.

EVALUATION: Methods: Residents exposed to the curriculum received voluntary pre- and post-experience surveys measuring perceived preparedness to diagnose and treat SUDs on a 4-point Likert scale and attitudes towards people with opioid and alcohol use disorder on the Medical Condition Regard Scale (MCRS). Responses were linked by a unique identifier and compared using paired t-tests. The study was classified as exempt by each program’s Institutional Review Board.

Results: Fourteen of 29 (49%) longitudinal and 18 of 46 (39%) core rotation participants completed both the pre- and post- survey. Of residents completing both, self-reported preparedness to diagnose SUDs increased (longitudinal 57% to 100%, core 39% to 100%), as did preparedness to treat (longitudinal 43% to 86%, core 22% to 89%). Resident regard for patients with SUD also increased in both cohorts, as shown by mean MCRS score for opioid (longitudinal 45.6 to 51.0, p=0.04; core 41.9 to 47.2, p=0.003) and alcohol use disorder patients (longitudinal 45.9 to 50.9, p=0.01; core pre=41.3, post=47.1, p<0.001).

DISCUSSION / REFLECTION / LESSONS LEARNED: Our findings suggest that stigma-reducing educational strategies can increase resident regard for people with SUDs as well as self-reported preparedness to diagnose and treat when implemented either longitudinally or in a short rotation, and with or without added clinical exposure. Future studies evaluating sustainment of these improvements and their correlation with indicators of SUD care quality are needed.

ONLINE RESOURCE URL: http://tinyurl.com/3fkr8fnt

DEVELOPMENT OF AN INTERACTIVE, EXPERIENTIAL CURRICULUM TO INTRODUCE PRE-CLINICAL MEDICAL STUDENTS TO ADDICTION MEDICINE AND HEALTH

Hallie Rozansky^1,2; Alyssa Peterkin^1,2. ¹Internal Medicine, Boston Medical Center, Boston, MA; ²Boston University Chobanian & Avedisian School of Medicine, Boston, MA. (Control ID #4058626)

SETTING AND PARTICIPANTS: Preclinical (i.e. first- and second-year medical students) at a large, urban, essential hospital, who have elected into an “Addiction and Health” focus track.

DESCRIPTION: At medical schools nationwide, there has been a shift away from didactic learning and toward experiential and flipped classroom learning models. At our institution, in the summer of 2022, the medical school implemented a new preclinical curriculum with a focus on health equity education; as part of this, students select one interest area for additional study. One such area is the “Addiction and Health” track, designed to increase exposure to key concepts in health equity and substance use disorders. Here we describe the design, implementation, and evaluation of the Addiction and Health track, which includes self-guided learning sessions, community organization visits, book clubs, and interfacing with local experts and people with lived experience, among others. The course culminates with the development of an Op Ed piece to submit for publication.

EVALUATION: At the end of each health equity week, students are asked to submit reflection pieces. We designed reflection questions specifically targeted to assess changes in knowledge, attitudes, and beliefs about health equity concepts in line with the learning objectives of the curriculum. NVivo software will be utilized for qualitative analysis of reflections. Students had the opportunity to opt out of having their responses included.

DISCUSSION / REFLECTION / LESSONS LEARNED: Nationally, there is a growing interest and recognition of the importance of teaching social determinants of health and health equity concepts in medical schools; the new health equity curriculum at our institution was in fact developed in response to trainee requests. In addition, it is key for trainees to learn best practices for caring with individuals for substance use disorders (SUDs) and minimizing stigma, given the ongoing addiction and overdose epidemics in the United States. Whichever field trainees ultimately pursue, they will almost certainly provide care for individuals with SUD. Teaching fundamental concepts of health equity and addiction medicine, and ways to approach patients that will carry forward into any medical career, is thus key in the education of future medical trainees. With our curriculum, we aim to deliver these fundamental concepts and study their delivery to refine our educational methods for the years ahead.

EVALUATION OF AN ORIENTATION TO DRUG USER HEALTH FOR RESIDENT PHYSICIANS IN A COMMUNITY-BASED HARM REDUCTION PROGRAM AND OVERDOSE PREVENTION CENTER

David S. Edelman^1,2; L Synn Stern²; Risha Khetarpal¹; Erin Goss¹; Mary Gover¹; Shwetha Iyer¹; Benjamin Hayes^1,2. ¹Division of General Internal Medicine, Montefiore Medical Center, New York, NY; ²OnPoint NYC, New York, NY. (Control ID #4057555)

SETTING AND PARTICIPANTS: Nine second-year primary care residents attended a 90-minute orientation at a community-based harm reduction program with an overdose prevention center (OPC) in an urban neighborhood, where many people who use drugs (PWUD) consider local healthcare inaccessible due to stigma and mistreatment. The OPC is the first government-sanctioned site for supervised consumption of drugs in the US, with immediate access to overdose reversal from trained paraprofessionals. The program also offers syringe exchange, meal provision, laundry, showers, holistic health center, case management, and drop-in medical clinic.

DESCRIPTION: Residents received an immersive orientation to drug use and drug user health from the lead clinical nurse with over 30 years’ experience in harm reduction and supervised consumption. Program staff designed the content to prioritize expertise and perspectives of community stakeholders with lived experience in drug use and harm reduction. The orientation involved hands-on demonstration and discussion of drug preparation and consumption, including equipment and techniques for safer use; fentanyl and xylazine contamination and testing; the role of OPCs; and the use of non-stigmatizing language. Residents also toured and met with participants and staff.

EVALUATION: We designed and administered a post/pre survey to test change in self-efficacy counseling on 9 harm reduction topics: syringe exchange, safer injection, safer sniffing, reducing risk of infections and wounds, fentanyl and xylazine contamination, fentanyl and xylazine testing, overdose prevention strategies, naloxone as reversal agent, and OPCs. We also used a pre/post survey to assess descriptive knowledge of harm reduction techniques, supervised consumption, and interventions to reduce stigma. All 9 residents completed the survey 4-7 days after the visit.

Residents improved self-efficacy on all topics (p < 0.05) with large effect sizes (mean Cohen’s D 1.4, range 0.77-2). Counseling on syringe exchange, safer sniffing, fentanyl and xylazine contamination, and OPCs had the largest change, while naloxone as reversal agent had the highest baseline self-efficacy and smallest change. The proportion of knowledge questions completed by residents (3 satisfactory answers) increased from 51% to 69%, with the largest increases for supervised consumption, overdose reversal, and tools for safer use.

DISCUSSION / REFLECTION / LESSONS LEARNED: Community-based harm reduction programs offer PWUD opportunities for safer use and low-threshold supportive services. OPCs also reduce morbidity and mortality from drug use in a supervised setting with overdose reversal. These community-based interventions exist beyond traditional healthcare systems and present opportunities for PWUD, often with chronic medical needs, to re-engage in care. Exposing residents to this environment with an immersive orientation to drug use, drug user health, harm reduction, and overdose prevention can train physicians to better counsel PWUD and promote harm reduction, destigmatization, and access.

HANDS-ON TEACHING TO BOOST INTERNAL MEDICINE INTERNS' COMFORT WITH HARM REDUCTION

Reema Navalurkar, Jocelyn R. James, James Darnton, Judith I. Tsui, Jared Klein. Internal Medicine, University of Washington, Seattle, WA. (Control ID #4061225)

SETTING AND PARTICIPANTS: Internal medicine interns participate in half-day didactics during orientation to primary care at a large, multi-site internal medicine residency in the Pacific Northwest. This one-hour workshop is part of a half-day dedicated to addiction medicine, during which they also learn about diagnosing substance use disorders (SUDs), motivational interviewing, and medications for SUDs. These small-group sessions are a unique opportunity to provide new residents with harm reduction skills tailored to regional substance trends and local resources.

DESCRIPTION: Internal medicine interns (N=52) explored overdose prevention and harm reduction fundamentals by rotating through two stations: (1) naloxone administration and fentanyl test strips and (2) injection equipment and alternatives to injection use. Each station, led by an attending or senior resident preceptor, provided hands-on equipment including intranasal naloxone, testing kits, needles, cookers, filters, and pipes. Preceptors prompted interns to familiarize themselves with supplies as well as with common lingo in the community. Interns were challenged to consider how various substance use behaviors may inform clinical decision making if patients develop endocarditis, "cotton fever," or skin and soft tissue infections. Finally, interns brainstormed counseling that would be helpful for their patients to avoid such complications.

EVALUATION: Participants completed a baseline survey immediately after the workshop, which asked them to provide demographic information (eg, age, gender, and geographic location of their medical school) and prior pertinent education or experience. Using a five-point Likert scale, interns rated their comfort level with managing SUDs, discussing substance use habits, and prescribing medications/supplies with harm reduction principles in mind. Finally, they rated satisfaction with the workshop itself. They will be asked to complete a follow-up survey in January 2024 to assess integration of these skills into practice.

DISCUSSION / REFLECTION / LESSONS LEARNED: Residents are expected to screen for, diagnose, and manage SUDs with a harm reduction approach, but often lack the knowledge and comfort to skillfully engage in such discussions. Our baseline survey (N=31, response rate 60%) revealed that only 20 (33%) interns had previously completed a clinical rotation pertaining to addiction. At the end of this session, the majority of interns (N=23, 74%) agreed or strongly agreed with “I feel confident in my ability to talk to patients about safer ways to use substances.” Approximately half of these interns (N=13, 42%) agreed or strongly agreed with feeling confident prescribing medications/materials to help patients use in a safer manner. As rates of substance use rise across all age groups, it is crucial for physicians to address specific use practices with their patients. This workshop is a low-cost intervention to teach interns about substance use behaviors, language, and harm reduction.

ONLINE RESOURCE URL: https://tinyurl.com/HarmReductionPreceptorGuide

IMPROVING ADOLESCENT UNDERSTANDING OF MENTAL HEALTH THROUGH A BOARD GAME

Hafsah Umerani¹; Issac Anderson¹; Katie Clark¹; Amjad El Othmani¹; Bethany Lyche¹; Nikhil Navathe¹; Dana Kabbani²; Jennifer Mendez³. ¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Wayne State University School of Medicine, Detroit, MI; ³Internal Medicine and Medical Education, Wayne State University School of Medicine, Detroit, MI. (Control ID #4064874)

SETTING AND PARTICIPANTS: This board game was designed for middle and high school aged individuals, ranging from 10-18 years old. The game was administered online, utilizing a board made on Google Slides and flashcards on Quizlet. Participants were recruited by reaching out to the community as well as individual teachers. While the game itself is designed for 2-4 players, participants were also given the option of playing through the game on their own.

DESCRIPTION: With the rise of social media platforms in recent years, adolescents have been exposed to increasing amounts of misinformation about their general as well as mental health. The goal of this board game is to dispel myths about mental health as well as improve understanding of a wide range of mental health disorders. The board game format (modelled off of Chutes and Ladders, a popular childhood board game) was designed to be familiar and easy to adapt to. Similarly, the online administration of this board game makes it an easy resource for teachers, physicians, and others working with adolescents to utilize. Many of the game questions were designed using the DSM-V, thus providing an avenue for participants to learn the scientifically accepted definitions and diagnostic criteria of mental health disorders.

EVALUATION: Participants were asked to fill out an anonymous survey on Google Forms regarding their experience with the game. At the time of this submission, data collection is in its preliminary stages. The feedback form is available in the Online Resource URL section of this submission form.

DISCUSSION / REFLECTION / LESSONS LEARNED: Results thus far indicate that participants (n=2) found the game to be beneficial to their understanding of personal as well as general mental health. One of the respondents had previously heard that all individuals with mental health disorders are violent, but playing the game helped dispel that myth. Both participants also felt that the game was engaging and retained their attention for the time they were playing. These preliminary results indicate that adolescents, despite their access to information on the internet, are not very knowledgeable about mental health, and that initiatives like this game prove beneficial to their understanding of their own health in addition to that of their peers and community. Making this board game and other educational resources like it widely available would be of great benefit to adolescents.

ONLINE RESOURCE URL: Feedback form: https://docs.google.com/forms/d/e/1FAIpQLScMT51usFswp2kqhszABwxheOyaN7M3kv_2jTGHJoeYhldwlg/viewform

Board game template: https://docs.google.com/presentation/d/1j87rTglZkmQMz8usdKVPipyVWHnZdiUiNuei0aGmy1E/edit#slide=id.g2645be97055_0_17

Board game flashcards/questions: https://quizlet.com/846509595/flashcards?funnelUUID=3169cab6-ca16-4157-85ea-0691a239870e

STRENGTHENING RELATIONSHIPS BETWEEN INTERNAL MEDICINE (IM) RESIDENTS AND PATIENTS WITH SUBSTANCE USE DISORDER (SUD) VIA DEVELOPMENT OF AN ADDICTION MEDICINE (AM) TRAINING TRACK

Kenneth L. Morford^2,3; Jeanette Tetrault^1,3; Emma Biegacki^1,3; Rebecca Minahan-Rowley^1,3; Stephen Holt^1,3; Dana Cavallo^4,3; John Encandela^4,3. ¹Internal Medicine, Yale School of Medicine, New Haven, CT; ²Internal Medicine, Yale University School of Medicine, New Haven, CT; ³Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; ⁴Department of Psychiatry, Yale School of Medicine, New Haven, CT. (Control ID #4064238)

SETTING AND PARTICIPANTS: The AM training track complements an IM/primary care (PC) residency program in New England; two interns are recruited annually and participate concurrently with 3-year residency training.

DESCRIPTION: Since 2019, with support from the Health Resources and Services Administration, the track has been part of a broader program providing IM residents, health professions students, and faculty with enhanced training in AM. Clinical experiences include inpatient AM consultation, an academic AM clinic embedded in a federally qualified health center, a community opioid treatment site, a clinic for patients transitioning from jail/prison, and street medicine outreach. Training track residents are assigned a longitudinal PC panel of patients (50% with SUD and other behavioral health needs); they are trained in motivational interviewing and cognitive behavioral therapy with weekly direct supervision from a licensed clinical psychologist. They attend monthly addiction medicine grand rounds, research meetings, journal clubs, and are small group facilitators for AM teaching activities. AM board-certified faculty are assigned as mentors.

EVALUATION: A case-study approach is used whereby each resident’s goals and experiences are documented with an entrance survey; ongoing data collection on rotations, supervision, educational activities, assessments of behavioral counseling; and an exit interview at graduation. Content analysis of qualitative data is performed by two investigators coding for descriptive and phenomenological information to identify themes about medical knowledge, patient care and career trajectories. Additional data are being collected by a cross sectional survey evaluating attitudes, confidence, and knowledge regarding SUD care comparing residents who participate in the training track to those who do not (results available at conference time).

DISCUSSION / REFLECTION / LESSONS LEARNED: To date, 12 residents have enrolled in the training track with 5 having graduated. Analysis of 5 cases of graduated residents shows improved self-reported medical knowledge of SUD medication management and increased skills in motivational interviewing and harm reduction. Regarding patient care, residents felt SUD treatment was well-integrated in PC, learned effective interprofessional collaboration in AM, and felt better prepared than peers to advocate for patients with SUD. Important for direct application of knowledge and skills in the workplace, all reported acting as a resource for other trainees and faculty caring for patients with SUD in emergency, ICU, and outpatient care and have been asked to recommend referrals and resources for patients. Residents’ career goals evolved from time of enrollment to graduation; 4 of 5 graduates pursued AM fellowships, and one intends to incorporate AM in PC practice.

Innovation in Medical Education (IME) - Quality Improvement and Patient Safety

ENHANCING RESIDENT PHYSICIAN COMPETENCIES FOR PRESCRIBING LIFESTYLE MEDICINE

Charles Vallejo¹; Zadesha Gordon¹; Kushinga Bvute²; Kyle Kelschenbach³; Yousra Gheit⁴; Gabriel Scharf⁴; Michael Dedonno³; Touqir Zahra³. ¹Internal Medicine Residency, Florida Atlantic University, Boca Raton, FL; ²Internal Medicine, Dartmouth Health, Lebanon, NH; ³Internal Medicine, Florida Atlantic University, Boca Raton, FL; ⁴Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL. (Control ID #4056417)

SETTING AND PARTICIPANTS: Internal Medicine Residency Continuity Clinics

DESCRIPTION: Lifestyle Medicine (LM) is an evidence-based, clinical discipline that emphasizes physician counseling on lifestyle modifications. In America, approximately 86% of $2.9 trillion is spent annually on chronic diseases that can be prevented through lifestyle. According to the CDC, heart disease is the leading cause of death in America, with risk factors mainly associated with lifestyle. Amongst attending physicians, residents and medical students, the lack of lifestyle counseling was due to inadequate knowledge and clinical skills. This quality improvement project was designed to provide brief LM training to our residency program, using the ACLM (American College of Lifestyle Medicine) resources, to encourage lifestyle discussion in clinic visits and enhance the knowledge of residents in this area.

EVALUATION: This study was conducted as a clinical trial, and IRB approved as minimal risk, with participants being the Internal Medicine residents of two separate continuity-clinic sites. The intervention group received a training video at the beginning of each clinic week at their continuity clinic for 5 weeks. Lifestyle Medicine flyers, and posters from the ACLM were also displayed in each clinic room and waiting rooms for reference. The control group did not receive this exposure to training at their continuity clinic. Pre and post-intervention surveys were collected from each group. The endpoint of this clinical trial was to increase LM assessments in patient encounters among resident physicians. The secondary end point was to improve physician knowledge and awareness regarding LM and its benefits. Anticipated problems during this trial were timely completion of the online training and compliance by all residents to complete the survey.

To explore the influence of the lifestyle medicine training program, a paired-samples t-test was conducted. The variable of interest was the practice of discussing lifestyle medicine topics with patients. Results of the paired-samples t-test revealed a statistically significant difference between the pre-training lifestyle medicine variable score and post-training lifestyle medicine variable score, t(9) = -2.462, p < .05. Specifically, the average pre-training score was 28.00 (SD=3.02), while the post-training score was 30.60 (SD=2.76). Results also revealed a large effect (d = .778), but low power of .593.

DISCUSSION / REFLECTION / LESSONS LEARNED: Lifestyle medicine training is important for the future generation of physicians to overcome the growing challenges associated with preventable chronic diseases which may, in part, be prevented through lifestyle counseling. Yet studies show that on average, the time spent discussing lifestyle modifications during patient encounters was less than 1 minute per topic. Therefore, reformed medical education and curriculum for residents and medical students may help target the inadequacies that exist in health care and lifestyle medicine as demonstrated through our study.

IMPACT OF MORBIDITY AND MORTALITY CONFERENCE IMPLEMENTATION ON PATIENT SAFETY EVENT REPORTING AND RESIDENT PERCEPTION OF PSYCHOLOGICAL SAFETY

Erin Biringen, Elle Newcome, Leigh A. Goodman, Ruth Franks-Snedecor. Internal Medicine, Banner Health, Phoenix, AZ. (Control ID #4064982)

SETTING AND PARTICIPANTS: MMC was introduced in the existing IM patient safety didactic session both in-person and virtually. An anonymous survey demonstrated baseline engagement with patient safety culture. Voluntary presenters defined a PSE (morbidity or mortality) with audience participating in root cause analysis. Both traditional discussion and anonymous polling were used. After each MMC, surveys monitored engagement with patient safety culture and perceptions of psychological safety.

DESCRIPTION: The traditional Morbidity and Mortality Conference (MMC) is known for punitive aspects. Some programs have met the ACGME Internal Medicine (IM) requirement for MMC and/or Quality Improvement (QI) conference by focusing on general principles of patient safety. We describe the impact of a QI-based MMC on resident perceptions of psychological safety and effect on patient safety event (PSE) reports at the University of Arizona College of Medicine-Phoenix Internal Medicine Residency Program.

The aim of MMC is to create an open environment for discussion of PSE. An additional aim is to track perceptions of psychological safety in three dimensions: risk identification and just culture, team cohesion and engagement with patient safety, and error transparency and risk mitigation.

EVALUATION: Before MMC, 68% of surveyed residents (n = 22) reported lacking knowledge of PSE reporting options. 45% of respondents favored MMC to discuss patient safety concerns within the program. Concerns for starting MMC included limited time in the curriculum, intimidation, lack of a psychologically safe environment, and skepticism about MMC value.

Five MMC sessions were held for which six presenters submitted cases. Reported knowledge of how to submit PSE reports declined by 38.9% but attendance at MMC increased from 7 to 21 participants. Cumulative analysis revealed that 66% of respondents recognized risk identification of PSE within teams and positive perception of just culture. 67% of respondents reported transparency in error reporting and risk mitigation with a decrease of 1.75% from baseline. From cumulative responses, 75% expressed at least moderate willingness to share adverse PSE in settings like MMC, a 5.6% decrease from baseline. 62% of respondents reported team cohesion and positive engagement with PSE. 78% of respondents favored continuing MMC. 22% favored utilizing only polling technology for participating in MMC, 33% favored traditional techniques and 44% favored both approaches.

DISCUSSION / REFLECTION / LESSONS LEARNED: Incorporating PSE reporting education into MMC may increase resident confidence with submitting PSE reports. Confounding factors in cumulative data analysis include repeat survey respondents; MMC may be held more frequently in the next academic year to diversify respondent feedback. Traditional engagement techniques and polling technology will both be used to foster a safe space for discussion. A year-long comparison of PSE reporting to pre-MMC implementation will be useful in quantifying MMC effect on PSE reports.

INVESTING IN THE FUTURE: SUMMER INTERNSHIPS FOR MEDICAL STUDENTS

Archna Eniasivam¹; Martha Ockenfels-Martinez²; Madison Sui²; Molly A. Kantor². ¹Internal Medicine, Pediatrics, UCSF, San Francisco, CA; ²Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4060268)

SETTING AND PARTICIPANTS: Internship leadership included faculty and staff hospital medicine division leaders with expertise in quality improvement (QI), safety, value and health equity. Since 2019, we have had 9 distinct students, the majority participating during the summer between their first and second year of medical school.

DESCRIPTION: We developed a curriculum, recruitment strategy, and selection process for the internship. Structured as an 8-week (including vacation) experience, eligible applicants were US medical students (internal and external) then selected through a holistic review process. Expectations included engaging in at least one project, working closely with an interprofessional team, and pursuing opportunities for scholarly dissemination. In 2023, there were 3 interns. They were provided a stipend to cover living expenses. Interns were also exposed to other facets of academic medicine, including research, medical education, and clinical care.

The primary component of the internship was participation in projects within the fields of QI, value, patient safety, and health equity. Potential mentors and projects were both self-identified and solicited by internship leadership; well-established projects and those with experience mentoring learners given the limited timeline were prioritized. Each intern participated in 2-3 projects, with active mentorship provided throughout the internship. Interns formally presented their work during stakeholder meetings and at Divisional Grand Rounds at the end of their internship.

Interns were also provided with a structured curriculum covering foundational concepts via a didactic series, self-study, and weekly facilitated discussions. Interns were invited to join other meetings relevant to their interests within hospital medicine and the larger health system.

EVALUATION: Informal feedback was solicited from 2019-2022; formal program evaluation with surveys for both mentors and interns began in 2023. In 2023, 100% of the interns rated the overall internship experience as excellent. Qualitative comments showed an appreciation for skill development and application along with building relationships. 75% of mentors found the experience valuable. Qualitative comments included appreciation for help in advancing projects and the importance of appropriate project focus and scope.

DISCUSSION / REFLECTION / LESSONS LEARNED: These internships benefited students, mentors, and the larger division. Students developed meaningful relationships and received time and resources to apply foundational concepts and skills to improve the care of patients, equipping them to better work within health systems to contribute to health equity and improvement efforts in their future careers. Mentors benefitted from help advancing project work. The division benefitted through project work, pipeline development, and educational and mentorship opportunities for faculty. Future considerations include increased support for mentors in tailoring projects to fit the 8-week timeline.

LEVERAGING A GME PROGRAM EVALUATION COMMITTEE (PEC) FOR HEALTH SYSTEMS SCIENCE EDUCATION (HSS) AND PROGRAM IMPROVEMENT (PI)

Jenna Guma¹; Angelica Italiano²; praneeja matta¹; Kevin D'Mello¹; Rachel Nash¹. ¹Internal Medicine, Cooper University Health Care, Camden, NJ; ²Primary Care, Cleveland Clinic Florida, Stuart, FL. (Control ID #4064011)

SETTING AND PARTICIPANTS: IM residents, PGY1-4 and program leadership (PL) in a mid-to-large size University-based residency program

DESCRIPTION: PL and faculty work to optimize the learning environment across all domains. According to the ACGME, the PEC is responsible for reviewing self-determine goals and guiding ongoing PIs. The challenges faced after the start of the COVID19 pandemic (constantly changing workflows, resident call-outs, burnout) provided an opportunity to increase transparency and foster trust in the face of uncertainty. Our PEC that met annually with a small group of residents was re-designed as the Program Evaluation and Improvement Committee (PEIC) which hosts monthly meetings open to all residents. The Committee is led by an APD with input/direction from the PD. Goals for improvement are set at the beginning of the academic year based on the program’s low-performing areas on the ACGME survey. During monthly meetings, progress on these areas is reported and resident feedback on all other aspects of the program are solicited. Residents and faculty are solicited to form work groups to engage projects to improve upon committee-identified opportunities. Importantly, resident volunteers are also educated on improvement science, change management, systems thinking, and other areas crucial to HSS.

EVALUATION: Success evaluated by number of new projects and improvements in ACGME survey

DISCUSSION / REFLECTION / LESSONS LEARNED: The PEIC has transformed the engagement of residents with PL by increasing transparency of issues within the program and involving residents in the solutions. The PEIC also serves as a platform to teach the basics of quality improvement and HSS. Projects utilize PDSA cycles, conduct stakeholder analyses, and teach learners how to work within an interdisciplinary team to accomplish goals. Roadblocks are discussed during and in-between meetings to foster sustainable QI projects. Many PIs have been generated in areas including patient safety and teamwork, resident wellbeing, educational content, and the clinical experience. Examples include standardizing patient handoffs, creation of a wellness committee/ budget, a resident newsletter to promote comradery, and providing strategic free lunch during noon conference to improve attendance. Large scale changes to resident admitting workflows improved geographic patient placement and improved patient safety. Ongoing work includes involving residents in our institution’s Code Blue Teams and improving scholarly activity amongst house staff. Over the three years of PEIC formation, we had sustained increases in the ACGME survey across all domains. Importantly, the resident overall evaluation of and opinion of the program increased above the national mean for the first time in the program's history. Although other changes likely contributed to the improvements in the ACGME survey (i.e. return to normalcy after the COVID-19 pandemic), transforming the PEC into the PEIC has been key to engaging residents in solutions for problems, and teaching key elements of QI work.

MAINTAINING A QUALITY AND SAFETY ELECTIVE: A SEVEN-YEAR SUCCESS STORY

Jessica Donato. Hospital Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4064375)

SETTING AND PARTICIPANTS: We implemented an annual Quality and Patient Safety (QPS) elective in 2017 at our large academic internal medicine (IM) program to provide advanced training and competency for residents interested in QPS. The elective is offered to second- and third-year IM residents and enrolls 6-11 trainees per year.

DESCRIPTION: This one-week nonclinical elective involves a series of core didactics on patient safety, root cause analysis, and quality improvement methods given by the course director. Other course components include guest lectures from institutional experts, such as risk management and informatics. All participants also present a journal club on a quality publication. Experiential learning includes immersion into systems of care with a pharmacy tour and lab tour. Participants also attend a variety of QPS meetings across our health system and write a brief reflection for each observation. The elective also involves completion of a root cause analysis (RCA) on a near miss or adverse event. Residents are provided protected time for this project and work in pairs to complete the investigation and have dedicated check-ins with the course director for coaching. The elective culminates in resident presentations of their RCAs during the program’s morbidity and mortality conferences over the two months following the elective. A rubric is used to assess each RCA presentation. Starting in 2018, a survey was administered to all participants using a 4-point Likert scale to assess self-reported knowledge and skill acquisition and for the purpose of program evaluation.

EVALUATION: Sixty-two residents have participated in the elective, and 94% have completed the survey (range 88-100% per year). All participants agreed or strongly agreed that their knowledge of QPS increased because of the elective. All participants also agreed or strongly agreed that the content of the elective was useful for their future career, and they are more interested in pursuing work on QPS because of the elective. All participants also reported obtaining the skills to complete an RCA by working on the project during the elective (100% agree or strongly agree). Based on learner assessment of the RCA presentations, all trainees showed attainment of competencies in patient safety methodology.

DISCUSSION / REFLECTION / LESSONS LEARNED: We have implemented and sustained a successful QPS elective. Given the selective nature of this rotation, trainees with a specific interest in QPS enroll and note high relevance to their careers and advancing their interest in QPS through participation. The elective also provides learners advanced QPS knowledge and skills, which is supported by trainee self-reports and based on learner assessment. Through seven iterations of the elective, modifications based on surveys have included increasing observations of health system meetings, refinement of guest speaker selections, and incorporation of reflections for observations.

USING QI METHODOLOGY TO DELIVER PRACTICE-BASED LEARNING ON B12 DEFICIENCY SCREENING IN CHRONIC METFORMIN USERS: A LONGITUDINAL RETROSPECTIVE PRE-POST SURVEY

Farhana Begum¹; Maham Ghani¹; Jason Ehrlich³; Lauren Block². 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 #4057773)

SETTING AND PARTICIPANTS: This QI project was conducted in an ambulatory resident practice in Queens, NY over an 8-month period. Participants included approximately 40 internal medicine residents.

DESCRIPTION: There is an association between chronic metformin use (> 6 months) and B12 deficiency. Baseline data from our resident practice showed a 15% screening rate for B12 deficiency. We used QI methodology to increase knowledge and screening for vitamin B12 deficiency in patients taking metformin for > 6 months in our resident ambulatory practice. Using a SMART aim approach, residents developed a specific, measurable, achievable, realistic, and timely goal regarding education of residents and implementation of screening.

Residents were educated over an 8-month period on B12 screening and repletion via live presentations and weekly information sheets emailed and put on display. Using an interdisciplinary approach, the pharmacy team screened patients scheduled for the day and reminded providers which patients were eligible for screening. Residents were also given task reminders to check B12 levels on their patients. One year after the intervention was completed, residents were given retrospective pre-post surveys to assess effectiveness of the intervention in their current practice.

EVALUATION: Of the 293 patients in the practice taking metformin, 42 (15%) had serum B12 levels screened prior to the intervention which increased to 86 (29%) after provider education. The survey distributed one year later had a 58 % response rate (n=22). Resident reported knowledge of metformin-associated B12 deficiency increased from all responding residents reporting no or limited knowledge to 17 (77 %) reporting excellent knowledge after the intervention (p<0.001). Prior to education, only 7 (32 %) of residents checked B12 levels sometimes and 15 (68%) did not check levels at all. Following education, 12 (55 %) residents reported checking B12 levels regularly (yearly) on qualified patients, and 9 (41 %) checking sometimes (p<0.001).

DISCUSSION / REFLECTION / LESSONS LEARNED: Implementation of SMART aim methodology to develop a QI project, and utilization of information sheets and an interdisciplinary approach to execute said project, resulted in a successful increase in screening for B12 deficiency in chronic metformin users over an 8-month period. The project had sustained impact on practice 1 year later. Next steps to improve screening rates include faculty education on metformin associated B12 deficiency as well as continued education in the resident practice. QI methodology was a viable tool to deliver practice-based learning to residents yielding enduring impact.

ONLINE RESOURCE URL: 1. Aroda VR, Edelstein SL, Goldberg RB, et al. Long-term Metformin Use and Vitamin B12 Deficiency in the Diabetes Prevention Program Outcomes Study. J Clin Endocrinol Metab. 2016;101(4):1754-1761. doi:10.1210/jc.2015-3754

Innovation in Medical Education (IME) - Women’s Health, Sex, and Gender-Informed Medicine

FEASIBILITY OF TRANSITIONING A “WOMEN’S HEALTH” INTO “REPRODUCTIVE AND GENDER HEALTH" CLINIC IN A FACULTY/RESIDENT INTERNAL MEDICINE PRACTICE

Zain Alfanek¹; Mindy Sobota²; Manasa Srivilli¹. ¹Internal Medicine, Brown University, Providence, RI; ²Division of General Internal Medicine, Brown, Providence, RI. (Control ID #4053719)

SETTING AND PARTICIPANTS: The clinic takes place one afternoon weekly in 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. The initial participants in the clinic were internal medicine residents interested in learning more about delivering gender affirming care.

DESCRIPTION: Starting in July 2023, we began transitioning a previous “Women’s Health Clinic” into a “Reproductive & Gender Health Clinic” in order to provide gender affirming care to patients. Under the supervision of an attending, 1-2 residents provided care on a weekly basis as part of a continuity clinic to patients referred from the faculty/resident practice. Services offered included trauma-informed pelvic examinations for vaginitis and cervical cancer screening, work-up for abnormal uterine bleeding, family planning including hormonal implants and abortion, and hormone therapy for perimenopausal vasomotor symptoms, low testosterone, and trans/non-binary patients.

EVALUATION: To understand the numbers and types of visits we provide for our trainees and patients, we tabulated the visits, procedures, and services provided in the reproductive-gender clinic from July 2023 - November 2023. There were 110 clinic visits, averaging 5 visits/session. Of these, 20% were procedure visits including contraceptive arm implant insertion/removals (12%), and IUD insertion/removals (5%). Pap smears accounted for 17% of visits. Only 5 visits (4.5%) focused on hormone replacement for transgender patients. The remaining visits addressed other reproductive and gender topics including abnormal uterine bleeding and medication abortion.

The two continuity residents averaged 9.5 sessions/5 months. Clinical teaching covered 5 out of 12 of SGIM’s women’s health competencies. Procedural teaching included all 4 of SGIM’s procedural competencies and the residents are on track to be independent in LARC provision by the end of the year. They created and disseminated gender-care focused didactic teaching topics for other residents through existing educational venues.

DISCUSSION / REFLECTION / LESSONS LEARNED: Within the first 5 months, we were able to recruit sufficient numbers of patients to sufficiently fill our clinic session and meet our residents’ educational needs. By the completion of the full year, we expect them to be competent in women’s health including LARC provision. Barriers to providing more gender-affirming care included our own hesitation to advertise services outside our practice during the pilot phase. Next steps include increasing patient recruitment, networking to collect more information on available resources, and continuing with gender care didactic development for all internal medicine residents.

MAKING VISIBLE THE INVISIBLE: ENHANCING LESBIAN, BISEXUAL AND QUEER WOMEN’S HEALTH CONTENT IN A PRIMARY CARE RESIDENCY CURRICULUM

Gaby Mayer¹; Meredith Lynn²; Richard E. Greene¹. ¹Medicine, NYU Grossman School of Medicine, New York, NY; ²Primary Care, New York City Health and Hospitals Gouverneur, New York, NY. (Control ID #4063547)

SETTING AND PARTICIPANTS: Second-year internal medicine/primary care residents at a mid-Atlantic academic residency program undergoing a 4-week Gender/Health block taking place during dedicated didactic days on their primary care rotation.

DESCRIPTION: Residents in our program have historically participated in a 4-week Gender/Health Block during their second year. The curriculum includes didactic content on gender-specific topics (e.g. prostate health, contraception), sexual health topics (STIs, safer anal-sex practices) and queer health topics (e.g. gender-affirming care). This year, we revised the Gender/Health block curriculum to include specific emphasis on lesbian/bisexual/queer (LBQ+) women's health. Content on STI risk among partners with vulvas, affirming sexual history-taking for LBQ+ women and the complexities of bacterial vaginosis among queer women was incorporated into existing didactic lectures. At the end of the unit, residents applied their knowledge during the block’s culminating OSCE where they participated in a simulated patient encounter centering an LBQ-identified woman presenting for STI counseling.

EVALUATION: At the block’s conclusion, residents completed a survey collecting quantitative & qualitative data. Residents retrospectively rated their comfort and knowledge level with respect to didactic content of the block before/after experiencing the curriculum. After receiving the curriculum, residents perceived themselves as more comfortable with general LGBTQ+ sexual health needs (pre-block: 2.14 vs. post-block: 3.5 on a 1-4 scale) as well as LBQ+ women’s health topics (pre-block: 2.28 vs. post-block: 3.5 on a 1-4 scale). In addition, many residents found the OSCE experiences effective at consolidating LGBTQ+ communication skills (mean score of 3.8 on a 1-4 scale).

When asked what changes they will make when seeing LBQ+ women in clinic, residents mentioned three themes:

1. Strategies to establish a safe atmosphere (open-ended/non-gendered language, permission-seeking prior to asking sensitive questions, telegraphing allyship by asking pronouns).

2. Centering sexual history-taking during clinic visits.

3. Providing counseling around sexual practices specific to the needs of LBQ+ women (e.g. toy hygiene and STI risk).

DISCUSSION / REFLECTION / LESSONS LEARNED: Our findings suggest that incorporation of targeted LBQ+ women’s health content improves residents’ self-reported competence and confidence in caring for this community - one that often feels invisible and overlooked in healthcare spaces despite significant advancements in general LGBTQ+ medicine. Our curricular plan was noteworthy for its use of paired didactic and OSCE content, suggesting that these two components might be best leveraged in combination to enhance learning. Work remains to be done to determine whether learners’ subjective perceptions of their skills correlate to patient experiences - accordingly, future directions include observer checklists during OSCE encounters or real-world patient surveys.

ONLINE RESOURCE URL: https://nyumc.qualtrics.com/jfe/form/SV_d1mzlTzQfygwAOG

PREPARING INTERNAL MEDICINE (IM) RESIDENTS FOR PATIENT CARE IN A DYNAMIC POST-DOBBS LEGAL LANDSCAPE.

Cynthia F. McNamara^1,2; Tracy Rabin¹; John Encandela¹; Mukta Dhond^1,2; Janet Henrich¹. ¹Medicine, Yale School of Medicine, New Haven, CT; ²Medicine, VA Connecticut Healthcare System, West Haven, CT. (Control ID #4064202)

SETTING AND PARTICIPANTS: Following the Dobbs decision, we developed a 2-year curriculum to prepare IM residents to care for patients in a rapidly changing local and national abortion legal landscape. The curriculum was implemented in the Department of Medicine (DOM) at a large New England academic medical center and led by faculty from IM and OB/GYN, with input from legal counsel. Participants included approximately 200 residents in 3 DOM training programs.

DESCRIPTION: Threats to abortion access in the U.S. have bred uncertainty in healthcare. Patients and clinicians struggle to understand imposed limitations on healthcare decision-making in states with restrictive laws. In less restrictive states, clinicians must stay abreast of federal rulings and laws affecting cross-state care. To prepare trainees to navigate these issues, we developed an evidence-based curriculum that is adaptive to quickly changing sociopolitical circumstances and concomitant training needs.

Each year of the curriculum was taught in eight 90-minute sessions to small groups of trainees using diverse interactive teaching methods. Year 1, taught in 2022-23, focused on medication abortion and laws regulating its use. Year 2, taught in 2023-24 and the focus of this abstract, responded to evolving legal and patient care challenges and the role of internists in abortion care. Year 2 centered on two cases, both at 11 weeks’ gestation, presenting to an internist/subspecialist in a setting where abortion is banned, except for medical emergencies. One had a new diagnosis of acute lymphoblastic leukemia for whom necessary chemotherapy would be toxic to the fetus; the other had a VSD, pulmonary hypertension, and mild dyspnea. Teaching included the history and current landscape of abortion regulation, resources for state-specific information, effects of social and identity-based factors on care access and maternal morbidity and mortality, and ethical and legal challenges for clinicians. Trainees discussed the cases in small groups and then as a large group. A panel Q&A discussion included OB/GYN and IM physician faculty and a hospital lawyer who provided interpretation of the cases in the context of state law.

EVALUATION: In Year 2 we used Poll Everywhere to ask the same 3 questions pre- and post-session to gauge change in resident knowledge; 80 trainees participated in Year 2 sessions to date. They were more aware post-session of the need to be familiar with abortion care laws in their state (pre, 33/44 [75%]; post, 43/48 [89%]); better prepared to get information about laws regarding abortion (pre, 4/40 [10%]; post, 31/56 [55%]); and more aware that abortion restrictions do not affect all people equally (pre, 19/38 [58%]; post, 43/50 [86%]).

DISCUSSION / REFLECTION / LESSONS LEARNED: Our curriculum illustrates a rapid response to urgent national issues that affect patient care, training needs, and personal/professional choices. Key to implementation was an interdisciplinary approach and creation of an evidence-based, non-judgmental learning environment.

WOMEN’S HEALTH PEARLS: DEVELOPMENT OF BRIEF HIGH-YIELD VIDEOS TO IMPROVE RESIDENT KNOWLEDGE ABOUT WOMEN’S AND GENDER HEALTH TOPICS

Nadine Pardee^1,2; Ilana Garcia-Grossman¹; Jenny K. Cohen²; Lily Loew²; Abigail Wilson^1,2. ¹Medicine, University of California San Francisco, San Francisco, CA; ²General Internal Medicine, San Francisco VA Health Care System, San Francisco, CA. (Control ID #4063357)

SETTING AND PARTICIPANTS: VA women’s clinic in the California-Hawaii Region Internal medicine PGY2 and PGY3s; nurse practitioner residents; multidisciplinary MD and NP faculty

DESCRIPTION: To deliver quality care across the gender spectrum and to combat gender-based disparities, it is essential that trainees are proficient in health topics relevant to women and gender minorities. However, ambulatory training in VA clinics provides limited exposure to these topics due to a predominantly male-identified population.

Based on a literature review, we developed a list of 30 core women’s and transgender health topics deemed most relevant to our patient population and important for internists to know. We then surveyed trainees’ confidence and interest in those topics. While confidence was greater in all topics among those who had spent time in a dedicated VA Women’s Clinic, all learners indicated relatively low confidence (<3.0 on a 5 point Likert scale) and high interest in most topics queried.

To fill these gaps, we are creating a library of 5-minute videos that are shared in our existing pre-clinic huddle, followed by a brief discussion and additional teaching points with preceptors. The videos are recorded by subject matter experts (SMEs) including Women’s Clinic primary care faculty and colleagues in gynecology, physical therapy, pharmacy, endocrinology, and psychology.

EVALUATION: In informal interviews 6 months into the intervention, residents reported that the brevity of the teaching sessions and delivery during protected time allowed them to focus and learn effectively, becoming more confident in their understanding of core topics. They also appreciated the opportunity to select which topic to explore during weekly huddle, choosing “just in time” content relevant to upcoming cases. More formal semi-structured interviews and post-intervention surveys of satisfaction, confidence, self-efficacy, and acceptability of the intervention will be completed at the end of academic year 2023-2024.

DISCUSSION / REFLECTION / LESSONS LEARNED: Trainee confidence in core women’s health topics was low in our VA setting, even among those assigned to a dedicated women’s clinic. The complex rotation schedules of our trainees and SME availability create barriers to consistent live didactics. Bite-sized teaching with 5 minute videos and a preceptor-led discussion at the onset of clinic are a practical way to close this knowledge gap, account for variable experiential learning, and collaborate with multidisciplinary SMEs. Preliminary feedback has highlighted the following key elements to success: 1) soliciting learner investment in topics; 2) delivering content during protected time; 3) asynchronous recording allows multidisciplinary faculty participation; 4) pairing videos with faculty-facilitated discussion; 5) making the video library available for on-demand, self-directed learning. Challenges include: 1) tracking attendance and avoiding repetition for learners due to variability in schedules; 2) ensuring active participation; and 3) keeping videos updated.

Scientific Abstract - Adolescent Medicine

GPT-4 VS. NLP: ENHANCING CONFIDENTIALITY IN ADOLESCENT HEALTH PORTALS BY AUTOMATED DETECTION OF INAPPROPRIATE GUARDIAN ACCESS

April S. Liang, Shivam Vedak, Alex Dussaq, Dong-han Yao, Wui Ip, Natalie Pageler. Division of Clinical Informatics, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. (Control ID #4064916)

BACKGROUND: HIPAA protects minors’ confidentiality to certain health services, but the 21st Century Cures Act mandates electronic health record access for patients and their legal representatives. By providing separate proxy accounts for guardians, patient portals reconcile these requirements. However, 64-76% of adolescent accounts are directly accessed by guardians, jeopardizing adolescents’ confidentiality. Stanford Children's Hospital (SCH) uses a rules-based Natural Language Processing (NLP) algorithm to detect guardian-authored messages; however, its low sensitivity and manual workflow limit its utility. GPT-4 has demonstrated success in medical tasks, and Epic’s embedded GPT instance provides opportunity for seamless integration. In this study, we assessed GPT-4’s ability to detect guardian authorship of messages originating from adolescent patient portals, as compared to the existing NLP algorithm.

METHODS: 2108 messages from 200 unique adolescent accounts at SCH were gathered and reviewed for authorship. Two GPT-4 classifier prompts were engineered using 20 messages: one focused solely on authorship identification (“single-task”) and another that both generated a response to the patient’s message and identified authorship (“multi-task”). Both versions and the NLP algorithm were tested on the remaining messages.

RESULTS: Of the 2088 messages, 1500 (71.8%) were authored by guardians, and 588 (28.2%) were authored by adolescent patients. Sensitivity, specificity, PPV, and NPV were calculated for the single-task GPT-4 classifier, multi-task GPT-4 classifier, and NLP algorithm; 99% CI were also generated using a normal approximation of the binomial distribution. See attached table for test characteristics.

CONCLUSIONS: GPT-4 can detect whether a patient portal message was authored by an adolescent or their guardian with high PPV and NPV, effectively protecting adolescent confidentiality. This capability has implications beyond adolescent medicine, such as in geriatric care or in the care of individuals with developmental differences. Our results demonstrate the promise of GPT-4 and generative AI more broadly in this important area of protecting patient confidentiality.

SUICIDE DISPARITIES AMONG YOUTH BY RACE AND ETHNICITY AND COUNTY IN THE U.S., 2000-2019

Sana G. Rahman^1,2; Erik Rodriquez¹; Paula D. Strassle³; Laura Dwyer-Lindgren⁴; George Mensah⁵; Ali H. Mokdad⁴; Eliseo J. Perez-Stable³. ¹Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; ²Georgetown University School of Medicine, Washington, DC; ³NIMHD, National Institutes of Health, Bethesda, MD; ⁴Institute for Health Metrics and Evaluation, Seattle, WA; ⁵National Heart Lung and Blood Institute, Bethesda, MD. (Control ID #4031507)

BACKGROUND: Suicide is the 2^nd leading cause of death among individuals ages 15-24. Suicide rates vary by race and ethnicity, with youth rates being highest among American Indian or Alaska Natives (AIAN). We evaluated trends in suicide rates in the U.S. from 2000 to 2019.

METHODS: We used the mortality cause list from the Global Burden of Disease (GBD) U.S. Health Disparities Project with associated ICD codes, deidentified death records from the U.S. National Vital Statistics System, and population estimates from the U.S. National Center for Health Statistics. Methods established by GBD were used to calculate mortality rates per 100,000 population, including cause mapping, bias correction methodologies, and a range of modelling tools. Suicide rates were analysed for 3,110 counties, for ages 15-24, by racial and ethnic populations –– AIAN, Asian, Black, Latino, and White.

RESULTS: From 2000 to 2019, the age-standardized suicide rate among ages 15-24 increased by 32% from 10.7 (95% uncertainty interval [UI]: 10.4-11.1) to 14.1 (UI: 13.7-14.5). Rates increased across all populations, with AIAN having the highest mortality rates in both 2000 (22.1, UI: 17.9-27.3) and 2019 (37.2, UI 30.1- 45.8). Despite the lowest rate, Asians had a 70.9% (UI: 47.2-97.3) increase in suicide rate (7.3 to 12.5). Suicide rates for Latinos in 2019 were higher in counties in Colorado and New Mexico, while high suicide rates among AIAN were centered in Alaska and Arizona counties. From 2000 to 2019, 98.9% (3,045 of 3,079, 55.9% significant) of counties experienced an increase in suicide among individuals ages 15-24 across all populations.

CONCLUSIONS: Our results highlight increases in suicide rates among all youth and young adult populations and the need for policies to address this. Increasing suicide among AIAN 15–24-year-olds is a crisis. There is a need to assess the role of social isolation and socioeconomic factors, and mandate action to address suicide among youth and young adults.

THE ASSOCIATION BETWEEN ADVERSE CHILDHOOD EXPERIENCES AND HEALTH-RELATED SCHOOL ABSENTEEISM AMONG CALIFORNIA ADOLESCENTS

Rebecca K. Tsevat^1,6; Margaret Nkansah⁶; Nicholas Jackson²; Michelle Shankar³; Shannon M. Thyne⁴; Bahareh Gordon⁴; Rebecca Dudovitz⁵. ¹Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Medicine, University of California, Los Angeles, Los Angeles, CA; ³Pediatrics, Yale University, New Haven, CT; ⁴Pediatrics, UCLA Medical Center Olive View, Sylmar, CA; ⁵Pediatrics, University of California, Los Angeles, Los Angeles, CA; ⁶National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA. (Control ID #4062800)

BACKGROUND: Adverse childhood experiences (ACEs) have been linked to poor educational outcomes and increased morbidity from chronic health conditions leading to school absenteeism in adolescents, such as asthma and depression. However, little is known about the impact of ACEs on school absenteeism due to health problems in this population. An understanding of the relationship between ACEs and health-related absences may identify opportunities for collaboration between health systems and schools in the provision of trauma-informed care and the prevention of negative outcomes associated with both ACEs and absenteeism.

METHODS: In this cross-sectional study, we analyzed data from the 2021-2022 California Health Interview Survey, a representative web- and telephone-based survey. Our sample included 12 to 17-year-old respondents who attended school or were home-schooled in the past week. Participants self-reported on 9 ACEs, missed school days due to health problems in the past month, and sociodemographic characteristics. A design-corrected F test was used to evaluate differences between those exposed and unexposed to ACEs. Weighted logistic regressions tested whether exposure to one or more ACEs was associated with health-related absenteeism and health-related chronic absenteeism (defined as absent at least 10% of school days), adjusting for age, sex, race/ethnicity, parental education, health insurance, and poverty.

RESULTS: The unweighted sample included 1418 adolescents. The average age was 14.52 (SD 0.04), and the majority were female (51%), Hispanic (52%), had parents with less than a bachelor's degree (57%), and had employment-based health insurance plans (58%). Over half (57%) reported at least one ACE; 13% missed school in the past month due to health problems, and 8% met the criteria for chronic absenteeism. Those exposed to at least one ACE were more likely to experience health-related absenteeism (18% vs. 8%, p < 0.001) and health-related chronic absenteeism (12% vs. 4%, p < 0.001) than those not exposed to ACEs. After adjusting for covariates, exposure to at least one ACE remained associated with both health-related absenteeism (AOR 2.45, 95% CI 1.47-4.09) and health-related chronic absenteeism (AOR 2.81, 95% CI 1.43-5.53).

CONCLUSIONS: ACEs are prevalent and associated with health-related school absenteeism in California adolescents. These results support the recognition of school absenteeism as a salient ACE-associated adverse outcome. Clinicians responding to positive ACEs screens might focus on addressing health concerns that impact attendance. Additionally, they can partner with schools to identify and co-manage toxic stress across both education and health sectors. Future efforts should be directed toward mobilizing school-based resources and developing trauma-informed interventions to keep adolescents engaged in academic pathways that promote lifelong health and success.

Scientific Abstract - Ambulatory Medicine

A, B, HEPATITIS C: EVERYTHING A PRIMARY CARE PHYSICIAN NEEDS TO KNOW ABOUT HEPATITIS C FROM DIAGNOSIS TO LONG TERM FOLLOW UP

Anusha Majagi¹; Mohamed Khaled Almujarkesh¹; Kassandra S. carter⁵; Alexandra Picardal³; Shweta Kapur⁴; Diane L. Levine²; Prateek Lohia¹. ¹Internal Medicine, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Wayne State University, Detroit, MI; ³Wayne State University School of Medicine, Detroit, MI; ⁴School of Health Sciences, Oakland University, Rochester, MI; ⁵Internal Medicine, TriStar Centennial Medical Center, Nashville, TN. (Control ID #4062687)

BACKGROUND: Hepatitis C virus (HCV) infection is a major public health concern, with more than 58 million people chronically infected worldwide. Traditionally, HCV patients were managed by gastroenterologists and infectious disease specialists. However, with the advent of direct-acting antiviral (DAA) drugs, the treatment of HCV has transformed. To reduce the burden of HCV in the US, emphasis has been placed on the involvement of primary care physicians (PCPs) in the management of HCV patients.

METHODS: A broad literature review was conducted to incorporate information and guidelines from several medical societies including the U.S. Preventive Services Task Force, the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, and the Centers for Disease Control and Prevention. We searched PubMed, Cochrane Library, Google Scholar, and Web of Science Core Collection identifying articles on HCV including systematic reviews/meta-analyses, randomized control trials, and review articles.

RESULTS: All patients should receive HCV screening (anti-HCV antibody testing) at least once in their lifetime and high-risk patients like intravenous drug users should receive periodic testing. The initial HCV antibody test should be followed by HCV RNA testing to confirm if the patient has chronic HCV or has achieved spontaneous clearance. Acute HCV is clinically mild, often goes undiagnosed and is spontaneously cleared in 15-45% of patients.

For patients in whom HCV RNA is detectable, further workup focuses on determining the HCV genotype, pretreatment viral load, degree of fibrosis or the presence of cirrhosis and if the patient has been previously treated for HCV. Additionally, tests should be done to check for active hepatitis B and HIV infection plus a complete medication history to check for any potential interactions. The aim of HCV treatment is to achieve sustained virologic response (SVR), meaning that HCV virus is undetectable 12 weeks or more after HCV treatment has been completed.

Common DAA’s used to treat HCV include Mavyret, Harvoni, Epclusa, Vosevi, and Zepatier.

Post-treatment, long-term follow-up of HCV patients is based upon individual risk factors for reinfection and if the patient had a high degree of fibrosis (F2 or above) or cirrhosis before initiation of treatment.

No long-term follow-up is recommended for patients without cirrhosis. In patients with cirrhosis, regular evaluation for hepatocellular carcinoma (via ultrasound and/or alpha-fetoprotein every 6-12 months) and esophageal varices (via Esophago-gastro-duodenoscopy every 2-3 years) is recommended.

CONCLUSIONS: The role of PCPs in HCV diagnosis and management is important as they are often the first source of care for many patients. To minimize the spread and complications of HCV, it is critical that PCPs understand who is at risk for HCV, screen, promptly diagnose, and link these patients to a provider rendering HCV treatment.

ACUTE KIDNEY INJURY IN PRIMARY CARE: INCIDENCE AND FOLLOW-UP OF ABNORMAL LABORATORY VALUES AND PROGRESSION TO CKD

Talya Salant¹; Scot B. Sternberg²; James Benneyan⁴; Gordon Schiff³; Bradley Denker¹. ¹Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ³Medicine, Brigham and Women's Hospital, Boston, MA; ⁴Northeastern University, Boston, MA. (Control ID #4064784)

BACKGROUND: Early recognition of community acquired AKI (CA-AKI) and appropriate follow-up testing can mitigate loss of kidney function. However, CA-AKI may be under-recognized in primary care as it requires recognizing a change in kidney function from baseline that may be overlooked in patients with creatinine in the normal or slightly elevated range. We sought to identify the incidence of CA-AKI in two primary care practices (hospital-based practice; community health center), and to assess differences between patients whose abnormal results were addressed and those whose were not. We also assessed rates of new onset CKD after the episode of CA-AKI.

METHODS: The incidence of CA-AKI was calculated by searching creatinine lab results at the two practices between 1/1/18-12/31/21 where there was ≥75% increase in serum creatinine from baseline. Rate of CA-AKI follow-up was calculated based on repeat testing within 30 days. Two-sided t-tests were used to compare baseline and index creatinine between the “closed” (followed-up) and “open” (not followed-up) groups. The most recent creatinine result for patients with incident CA-AKI (through 12/31/21) was used to calculate the incidence of new onset CKD.

RESULTS: Of 93,259 creatinine results for 36,593 unique patients, 223 patients (0.61%) had CA-AKI. Follow-up testing within 30 days occurred for 137 (61.4%) of these patients. Patients with follow-up were found to have a significantly higher rate of CKD at baseline (p<.0001) and had higher index creatinine values (p<.0001), despite similar change in GFR across all patients. Among patients without initial follow-up, 23% had a subsequent creatinine and GFR ≤60 indicating new onset CKD.

CONCLUSIONS: CA-AKI is not uncommon in routine primary care. When it occurs, CA-AKI is frequently often not recognized, yet it can herald onset of new chronic kidney disease or progression of existing CKD. Lack of – “delta” - alerts within the EHR may contribute to failure to recognize clinically significant changes in kidney function particularly for patients with low baseline and index creatinine. These findings have major health quality and cost implications.

A RETROSPECTIVE ANALYSIS OF AN ACADEMIC-BASED PRIMARY CARE CLINIC ON COLORECTAL CANCER SCREENING GUIDELINE ADHERENCE

Jessica Sosio, Karla Geisse, Colin Martyn, Adrian Singson. Internal Medicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #4064904)

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer in the United States and the second leading cause of cancer-related death. Average-risk adults aged 45 years and older should undergo regular screening with either a high-sensitivity stool-based test or endoscopic exam. In 2021, adherence was 42% for fecal immunochemical test (FIT) and 28% for colonoscopy, and a systematic review in 2023 suggested adherence as an important factor in CRC-specific mortality. Notably, screening adherence was higher in groups with the highest education and income levels. The population of our Midwestern primary care clinic is composed of individuals with a below state average median household income of $47374, with only 15.2% holding a bachelor’s degree or higher. A 2018 systematic review found that patient education was associated with increased screening completion. In 2020 our clinic was transitioned to an academic team of internal medicine residents, therefore offering more patient-centered education. Considering those changes and the above patient disparities, we decided to retrospectively analyze the adherence of CRC screening before and after the establishment of the internal medicine residency program through a data collection project.

METHODS: Two groups were analyzed. Group 1 includes patients seen between 7/1/2017 and 6/30/2020, prior to the residency. Group 2 includes patients seen between 7/1/2020 and 6/30/202, after the residency. Patients were 50 years or older at the time of data collection and 45 years or older after 5/18/2021 to reflect the guideline change and had an order for colonoscopy or FIT based on the ICD-10 codes for CRC screening listed by the American Gastroenterological Association (AGA). To assess screening adherence, patients were evaluated for the presence of FIT and/or colonoscopy completion using the CPT codes listed by AGA.

RESULTS: There was a significant difference between the number of patients recommended for screening (Z=-16.1, p <0.01), with a 56.55% increase in recommendations. However, there was no significant difference between the number of patients who completed colonoscopy or FIT (Z=0.99, p=0.83).

CONCLUSIONS: The literature identifies patient education as a tool to increase CRC screening adherence. The establishment of an academic environment provides such resources; however, this did not translate into improved adherence in our clinic. Since the residency establishment, the number of screenings ordered largely increased, but the overall screening adherence remained about the same. It is unclear whether educational level and household income are responsible for the unchanged adherence, or whether the clinic may want to revamp patient education. Therefore, it may be worthwhile pursuing a quality improvement project targeted at improving patient CRC screening adherence, with emphasis on following up and following through on recommendations.

ASSESSING THE IMPACT OF A CLINIC STAFF-SUPPORTED VIRTUAL ROOMING INITIATIVE ON PRIMARY CARE QUALITY METRICS IN HISTORICALLY MARGINALIZED SETTINGS

Danielle Rome¹; Lauren Solomon²; Kathleen Evans¹; Michelle A. Benrimon²; Yvette Ortiz¹; Elizabeth Gardner¹; Helen Jan¹; Sujata Malhotra¹; Nathalie Moise¹. ¹Department of Medicine, Columbia University Irving Medical Center, New York, NY; ²New York-Presbyterian Hospital, New York, NY. (Control ID #4058597)

BACKGROUND: Data on clinical quality metrics for telemedicine versus in-person primary care visits in historically marginalized settings have been mixed; in a prior study we found lower rates of blood pressure (BP) and depression screening for telemedicine (vs. in-person) visits. Virtual rooming (pre-visit calls from clinic staff) has been associated with successful connection to video visits, but data on its impact on quality metrics are limited. We assessed whether virtual rooming for telemedicine visits narrows gaps in primary care quality metrics compared to in-person care.

METHODS: We assessed a virtual rooming quality improvement initiative at a primary care clinic in an urban academic medical center, serving a predominantly Hispanic, low-income population. The telemedicine arm consisted of all patients with >1 prior video visit and a scheduled telemedicine visit from November 2022 to April 2023, among 3 providers. Included patients received pre-visit calls from clinic staff to provide tech support and document clinical tasks (e.g., chief complaint, home vitals, depression screen). For the in-person arm, we randomly selected 1-2 clinical sessions per week for the same providers and time period. We calculated a propensity score using multivariate logistic regression (age, sex, race, ethnicity, primary language, Charlson Comorbidity Index [CCI], and completed video visits 1-year prior). We analyzed quality metrics (depression, lab [hemoglobin A1c and lipids], cancer [colorectal, cervical, and breast], and BP screenings) using a generalized linear mixed model with a binary outcome distribution and a logit link to allow for correlated errors to account for clustering by provider, adjusting for propensity score.

RESULTS: We identified 213 unique visits (virtual rooming-supported telemedicine: n=79, in-person: n=134). Mean age was 55 years (SD 17), 87% were female, 81% Hispanic, 11% Black, 61% non-English speaking, and 81% Medicaid enrolled. Mean CCI was 2.3 (SD 2.4) and mean video visits in the past year was 0.80 (SD 1.1). The telemedicine (vs. in-person) arm was significantly more likely to be female, English-speaking, and had greater mean video visits. Virtual rooming-supported telemedicine visits were significantly less likely to be no-shows (5% vs. 21%, p=0.002). In adjusted analyses, the telemedicine arm had marginally greater odds of depression screening (OR=2.36, 95% CI 0.93-6.01, p=0.07), no significant difference in lab and cancer screenings, and significantly lower odds of BP screening (OR=0.11, 95% CI 0.05-0.27, p<0.001).

CONCLUSIONS: Virtual rooming-supported telemedicine (vs. in-person) visits had improved no-show rates and comparable depression, lab, and cancer screenings. As expected, BP screening was inferior, given barriers in access to home BP cuffs and patient ability to obtain home measurements. Limitations include small sample size and observational design. Our findings support studies comparing quality metrics for telemedicine visits with and without virtual rooming.

ASSOCIATION BETWEEN CORTICOSTEROID INJECTIONS AND RISK OF FRACTURE: A POPULATION-BASED COHORT STUDY

Terin Sytsma¹; Shannon Thomas⁴; Karen Fischer³; Laura Greenlund². ¹Internal Medicine, Mayo Clinic, Rochester, MN; ²Internal Medicine, Mayo Clinic, Rochester, MN; ³Quantitative Health Services, Mayo Clinic Minnesota, Rochester, MN; ⁴University of Minnesota Twin Cities, Minneapolis, MN. (Control ID #4030297)

BACKGROUND: Corticosteroid injections (CSI) into joints or bursae are commonly used for many types of musculoskeletal pain. Locally injected corticosteroids have some systemic absorption, potentially placing patients at risk for adverse effects of steroids, such as bone thinning and fracture, and there is no established dose or frequency threshold for safety of CSI. The objective of this study was to determine if cumulative CSI doses increase the risk of subsequent fracture, both osteoporotic and non-osteoporotic.

METHODS: This is a population-based cohort study of adult patients empaneled in primary care who received any CSI from May 2018 through July 2022. Cox proportional hazard models were used to evaluate risk of fracture based on cumulative CSI dose during the study period. The primary outcome was risk of fracture by total triamcinolone equivalents received. Secondary outcomes were risks of fracture based on triamcinolone equivalents received in subgroups of patients not at high risk for fracture and patients with osteoporosis.

RESULTS: 7197 patients were included in the study (mean age 64.4 years, 61.6% female, 92.6% white race). Average total cumulative CSI dose during the study period was 141.8 (SD 159.8, range 2.7-2140.3) mg of triamcinolone equivalents. 346 patients (4.8%) had a new fracture during the study period, and 149 (43.1%) of these fractures were considered osteoporotic. The average time from first CSI to fracture was 329 days (range 2-1422). In the adjusted Cox proportional hazard model, there was no increase in fracture risk based on cumulative CSI dose (HR 1.04, 95% CI 0.96-1.11). There was also no increased risk of fracture in the non-high-risk (HR 1.11, 95% CI 0.98-1.26) or osteoporosis (HR 1.00, 95% CI 0.90-1.11) subgroups. Age, Charleson comorbidity index, and history of previous fracture were the only factors that increased the risk of fracture.

CONCLUSIONS: The results of this study suggest that the risk of fracture, either osteoporotic or non-osteoporotic, does not increase with increasing cumulative doses of CSI. Furthermore, subgroup analysis showed no increased risk of fracture with higher doses of CSI in patients with osteoporosis. Strengths of this study include the large sample size, clinically relevant outcome of new fracture diagnosis, and the comprehensive accounting for CSI administered in all clinical settings. Furthermore, the long follow-up period assessed for delayed effects of CSI on fracture risk. Future studies should include prospective trials in more diverse populations.

Based on these results, clinicians should be reassured that frequent CSI does not increase fracture risk and should not withhold these important pain treatments for concern for bone fracture.

ASSOCIATION OF E-CIGARETTE USE WITH ASTHMA EXACERBATIONS USING NATIONALLY REPRESENTATIVE SURVEY DATA

Felicia Tanu¹; Mario Perez²; Eric Mortensen². ¹School of Medicine, University of Connecticut School of Medicine, Farmington, CT; ²Medicine, UConn Health, Farmington, CT. (Control ID #4063849)

BACKGROUND: Although there is little known information regarding its short- and long-term effects, e-cigarette use is increasing in the United States. It is known that cigarette smoking is associated with a higher likelihood of developing asthma, and it is suggested that e-cigarette use may also similarly increase the risk for lung diseases. Some studies suggest that e-cigarettes worsen asthmatic symptoms, while other studies have indicated that they help to reduce cigarette consumption and overall lead to a decrease in asthmatic symptoms. Our aim was to examine the association between e-cigarette use and asthma exacerbations in known asthmatic US adults.

METHODS: The 2018 Asthma Call Back Survey (ACBS), paired with corresponding data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), was utilized for this analysis. The BRFSS is a health-related survey in which adults aged 18+ were interviewed through random digit dialing in all 50 states, D.C., and three US territories. Individuals who reported a history of asthma during the BRFSS were contacted for a more in-depth interview on their asthma for inclusion in the ACBS. Individuals were divided into three categories: only e-cigarette users, only cigarette users, and dual e-cigarette and cigarette users. A multivariable logistic regression model utilizing a complex survey design was completed to determine the association between e-cigarette use and asthma exacerbations after applying weights for population representation and adjusting for potential confounders, such as demographics, past medical history, and asthma medication use. Additional models were completed to look at the association of e-cigarette use with emergency room visits and asthma symptoms.

RESULTS: There were 3,130 participants that met our inclusion criteria. Of those participants, 143 were only e-cigarette users, 968 were only cigarette users, and 475 were dual e-cigarette and cigarette users. Only e-cigarette users were more likely to be male (55.2%), aged 18 to 34 years (62.9%), and White (58.7%). Only cigarette users were more likely to be female (60.1%), aged 65+ (48.2%), and White (75.3%). Dual users were more likely to be female (56.4%), aged 18 to 34 (28.2%), and White (66.5%). In our multivariable regression model, we found that there was no statistically significant association comparing asthma attacks with only e-cigarette use (OR 1.16; 95% CI, 0.52-2.59), only cigarette use (OR 0.70; 95% CI, 0.42-1.16), or dual-use (OR 0.72; 95% CI, 0.40-1.31) after adjusting for confounding variables.

CONCLUSIONS: We found no association amongst the three categories of only e-cigarette users, only cigarette users, and dual users with asthma attacks among known asthmatic US adults aged 18+. The results emphasize a need to continue e-cigarette use research to further assess future health effects and formulate appropriate public health recommendations.

BREAKING THE ADVERSE DRUG REACTIONS SOUND BARRIER: AUTOMATING ADE SURVEILLANCE IN PRIMARY CARE

Maria Mirica¹; Alejandra Salazar³; Sonam Shah³; Samuel Bennett²; Aneesha Fathima Syed Mohamed⁴; Tewodros Eguale⁴; Pamela Garabedian¹; Lynn A. Volk³; Adam Wright⁵; Gordon Schiff¹. ¹Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Emory University School of Law, Atlanta, GA; ³Mass General Brigham Inc, Boston, MA; ⁴MCPHS University, Boston, MA; ⁵Vanderbilt University, Nashville, TN. (Control ID #4064473)

BACKGROUND: Medication prescriptions are often accompanied by unintended adverse effects. When solicited directly from patients, roughly 25% report new symptoms suggesting “side effects” when starting new drugs. We have conducted a series of projects to automate outreach to patients and provide pharmacist support. In a prior RCT where we used interactive voice response (IVR) systems, patients in the intervention arm were significantly more likely to have a new symptom suggesting a potential ADR documented. To overcome IVR limitations we encountered especially poor response rate, with interruptive synchronous messaging we examined asynchronous secure messaging via a) patient portal and b) texting to reach out to patients to help detect, assess, triage, mitigate, potential ADEs.

METHODS: We evaluated two distinct but related initiatives: a) portal outreach and b) texting to solicit information about any new symptoms experienced, suggesting ADEs from newly prescribed drugs. An automated daily report of new prescriptions was run. In the portal initiative, invitations were sent inquiring whether patients had started the medication, and if “yes,” had they experienced any new symptoms. Reported symptoms evaluated and classified by clinical pharmacists using SOC MedDRA taxonomy; patients were offered additional follow-up and support as desired and needed. In the texting initiative, patients who agreed to receive study-related text messages were contacted by our bilingual study pharmacists, screening for ADEs potentially related to the new prescriptions, and counselled related to any ADEs or other medication issues.

RESULTS: In portal initiative 9,380 patients were messaged, of whom 2,758 (29%) patients responded and 3,186 new prescriptions which were analyzed. At least one ADE was reported for 26% of the new prescriptions. Two-thirds of the patients with symptoms reported one ADE (64.7%), with the rest reporting 2 or more new symptoms. GI disorders accounted for 30% of the total reported ADEs. In the texting initiative 1,657 patient were texted for 1,791 prescriptions. 768/1,657 (46%) patients responded. 26% of the patients who had started new medications (115/438) reported new symptoms. Multiple issues were encountered in the design, including limited # of patients using the portal and responding, obtaining permission to text given regulatory requirements for bi-directional texting, communication with the patients, and clinical assessments, which will be discussed.

CONCLUSIONS: Proactive, automated portal-based surveillance for potential adverse drug reactions was feasible, had higher response rates than with prior methods (such as automated interactive phone calling). We found rates of potential ADEs in roughly 1 in 4 patients, consistent with other methods/studies. Texting appears to have even higher response rates, although permissions to text confound the capabilities to text.

CLINICAL UTILITY OF MONOCLONAL GAMMOPATHY SCREENING IN THE EVALUATION OF FIBROMYALGIA

Mackenzie Maberry¹; Caleb J. Smith²; Ronald Go². ¹Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Division of Hematology, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4063175)

BACKGROUND: Fibromyalgia is a diagnosis of exclusion; however, guidelines vary regarding which diseases to exclude in its evaluation. Given that malignant monoclonal gammopathies (MGs) such as amyloidosis, multiple myeloma, and Waldenström’s are associated with neuropathic and bone pain, some recommend MG tesing in the evaluation of fibromyalgia, despite the rarity of malignant MGs. In contrast, monoclonal gammopathy of undetermined significance (MGUS) is common, but rarely causes neuropathy or pain. Incidental diagnosis of MGUS may cause financial or psychological harm. This study seeks to determine the utility of MG screening in the evaluation of fibromyalgia.

METHODS: We reviewed the medical records of patients who underwent MG screening in the evaluation of fibromyalgia at our institution in 2021. Patients with previously diagnosed MG were excluded. Clinician documentation and electromyography studies were reviewed to determine the etiology of neuropathy and pain in those with newly diagnosed MG.

RESULTS: 835 patients underwent MG screening in the evaluation of fibromyalgia. The median age was 60.0 years and 83.3% of patients were female. 19 (2.3%) patients were found to have a newly diagnosed MG. Of these, none were determined to have neuropathy or pain caused by MG. Neuropathy and/or pain was ultimately attributed to (Table 1) fibromyalgia (31.6%), degenerative joint disease (15.8%), primary neurologic disorders (15.8%), fibromyalgia + rheumatologic conditions (10.5%), peritoneal tumor (5.3%), radiculopathy (5.3%), myofascial pain (5.3%), alcohol abuse (5.3%), and statin-related myopathy (5.3%). One patient in 835 progressed to multiple myeloma 6 months after initial MG screening; this was identified on subsequent monitoring labs. Notably, this patient was asymptomatic and with normal testing at the time of MG screening.

CONCLUSIONS: Routine MG screening has limited utility in the evaluation of fibromyalgia. Of 835 patients screened for MG during the evaluation of fibromyalgia, none were found to have MG as the etiology of their symptoms. While fibromyalgia is a diagnosis of exclusion, these data suggest that MG testing is not warranted in the evaluation of fibromyalgia, unless there are unexplained signs or symptoms suggestive of malignant MGs. Given the potential financial and psychological harms arising from incidental MGUS detection, educational efforts are warranted to guide clinicians and limit the ordering of MG testing to individuals who are most likely to derive benefit.

COMMUNICATION AND PATIENT-CENTERED CARE FOR ACES, TOXIC STRESS AND PSYCHOLOGICAL TRAUMA (COMPASS) STUDY: A DYADIC QUALITATIVE ANALYSIS

Anita S. Hargrave^1,2; Jessica Escober^1,2; Genesis Talavera^1,2; Kelly Knight³; Deirdre Bernard-Pearl^4,3; Dean Schillinger^5,6. ¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Internal Medicine, San Francisco VA Health Care System, San Francisco, CA; ³University of California San Francisco, San Francisco, CA; ⁴Dept Family and Community Medicine, Santa Rosa Community Health Centers, Santa Rosa, CA; ⁵Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ⁶Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA. (Control ID #4053844)

BACKGROUND: Over 70% of adults in the United States have lived through at least one traumatic event during their lifetime. Such traumas, which include adversity during childhood and as an adult, can lead to toxic stress and have long-term physical and psychological health repercussions. There have been increasing calls to screen for and address trauma in clinical settings. However, few studies in primary care settings have evaluated the tenets of effective communication about adverse childhood experiences (ACEs) and adult trauma or its explored impacts on health. To fill this gap in current understanding of how best to communicate with and respond to patients who have experienced trauma we analyzed perspectives of each side of the patient-provider dyad.

METHODS: We purposefully sampled patients and their primary care providers (15 dyads, 30 participants) who had discussed traumatic experiences with each other during clinical visits and had been working together for at least two years (N=30). The same interviewer separately administered semi-structured interviews with each individual within a dyad. The interviews focused on trauma-related communication, relationship-building and health outcomes in primary care. We collected data from April to October, 2023. We used inductive and deductive reasoning to create and apply a codebook using double-coding and with a multidisciplinary team. To analyze our data, we used a modified Framework method which incorporated dyadic analysis methodology.

RESULTS: We identified five primary themes related to: (1) the negative impact of trauma on health, social support and obtaining care within the healthcare system; (2) preferences regarding trauma disclosure, clinic screening and clinician-led direct inquiry about trauma in primary care; (3) communication about trauma positively affecting health-related behaviors, referrals and treatments, and health outcomes; (4) importance of patient-provider relationship and continuity on trauma-related communication and health; and (5) best practices, policies and clinical environments for working through trauma in primary care. We describe both incongruencies and similarities pertaining to these five themes within and between patient-provider dyads, which can help guide future clinical practice in trauma communication.

CONCLUSIONS: Patients and their providers found that communicating about traumatic experiences that occurred during childhood or as an adult could be beneficial to patients’ health and wellbeing. However, these experiences were most successful if the conversations occurred in the context of a longitudinal, trusting relationship and a supportive clinical environment that provided the time and resources to facilitate successful healing and growth.

COMPARING THE IMPACTS OF VIRTUAL CARE AMONG VA’S PATIENT-CENTERED MEDICAL HOME TEAM MEMBERS: A QUALITATIVE ANALYSIS

Alicia Bergman¹; Danielle Rose²; Karin Nelson³; Susan E. Stockdale⁴. ¹CSHIIP, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ³Medicine, University of Washington, Seattle, WA; ⁴HSR&D Center of Excellence, Greater Los Angeles VA Healthcare System, Sepulveda, CA. (Control ID #4062742)

BACKGROUND: As the Veterans Health Administration (VA) continues to implement virtual care modalities following the COVID-19 pandemic, role tasks and clinic workflows in patient-centered medical home (PCHM) teams will need to adapt to facilitate virtual (video or telephone) consultations delivered by remote primary care providers (PCPs). Because the incorporation of virtual PCPs can result in task-shifting among clinic-based support staff, we sought to investigate how increased use of telework by PCPs may be differentially impacting the experiences of key PCMH team members.

METHODS: From June to October 2021, we conducted 17 semi-structured telephone interviews with PCPs who teleworked one day a week (n=5) and the following frontline staff who worked with them: registered nurses (n=8); licensed vocational nurses (n=2); and clerks (n=2) across three clinics in one VA region. Questions centered on task and role changes or challenges for PCPs working virtually or frontline providers/staff supporting them. Interviews were recorded and notes taken, with a rapid analysis comparing experiences across roles.

RESULTS: PCPs described a high level of satisfaction with the arrangement. Challenges with virtual appointment technology troubleshooting was the most common difficulty discussed among interviewees, but most frequently reported by nurses and LVNs. Sometimes patients lacked equipment, had internet connectivity issues, and did not know how to access the telehealth appointment link or how to email photos. For a few PCPs, troubleshooting video-conferencing technology was noted as disruptive to the workflow and appointment time. Other workflow challenges highlighted by PCPs and nurses included the time-consuming nature of getting digital signatures for paperwork. Clerks noted an increase in workload due to requirements such as scanning all incoming documents from PCPs, encrypting emails, relaying messages between patients and PCPs. Nurses also noted patient struggles pertaining to appointment modality and related notifications. Other changes to tasks or workflow noted by nurses included learning and teaching telehealth and video technology to PCPs, spending more time searching for available PCPs to see walk-ins, and taking over some in-person head-to-toe assessment tasks otherwise handled by the PCP.

CONCLUSIONS: PCPs were largely satisfied with the shift to remote work but nurses and clerks described changes to workflows and increased responsibilities resulting from working with a virtual provider. Effectively integrating virtual clinicians into clinic-based teams may require optimizing guidelines for staff training on telehealth technology troubleshooting, telehealth platform patient education and literacy, improved appointment modality notifications, and streamlining processes for digital documentation. Future research should explore whether remote work task-shifting from virtual providers to clinic-based teams impacts burnout and job satisfaction.

CONTINUITY OF CARE AND EMERGENCY DEPARTMENT UTILIZATION AMONG CHILDREN AND ADULTS WITH COMPLEX CHRONIC CONDITIONS

Mariecel Pilapil¹; Caren Steinway²; Joanna Fishbein⁴; Sophia Jan³. ¹Medicine and Pediatrics, Northwell Health, New Hyde Park, NY; ²Pediatrics, Cohen Children's Medical Center, Queens, NY; ³Pediatrics and Medicine, Northwell Health, New Hyde Park, NY; ⁴Northwell Health, New Hyde Park, NY. (Control ID #4063283)

BACKGROUND: Primary care serves as the foundation of medical care for children and young adults with complex chronic conditions (CCCs). In some populations such as pediatric asthma patients, children with medical complexity, and older adults, higher continuity of care has been shown to reduce Emergency Department (ED) utilization. However, continuity of care (COC) is rarely evaluated across the age spectrum. The objective of this study was to calculate continuity of care in the primary care setting for children and young adults with CCCs and to determine how continuity of care in the outpatient setting affects ED utilization among children and adults with CCCs.

METHODS: A retrospective cohort study was conducted. Data were collected from the electronic health record for all children and young adults (ages 2 to 26 years old) with at least 1 CCC seen across more than 35 primary care practices in a clinically integrated health network from 2015 to 2019. Patients were included if they had 4 or more outpatient primary care visits within a specified 2-year period. The predictor was COC as measured by the Continuity of Care Index (COCI). The COCI values range from 0 to 1 with 0 reflecting the lowest level of continuity, with a different provider seen at every visit and 1 indicating the highest level of continuity where all visits are with the same provider. Demographic information was collected. Logistic regression was used to assess the impact of COCI on ED use after adjusting for age, race/ethnicity, asthma diagnosis, number of visits to any sub-specialist (i.e. cardiologist, etc.) during the 2-yr period, insurance and prior ED use.

RESULTS: A total of 1,856 patients met eligibility criteria. Patients had a mean ± SD age of 14.9 ±5.8 years. Most patients identified as non-Hispanic or Latino (75.9%; n=1,387) and 50.7% were female (n=942). The mean ± SD COCI was 0.45 ± 0.31. Results failed to provide evidence that COC was significantly associated with future ED utilization (p=0.12) after adjusting for potential confounders. However, the odds of having an ED visit were lower for those who identified as non-Hispanic (OR=0.66 (95% CI: 0.44-0.99) or had commercial insurance (OR=0.66 (95% CI: 0.50-0.89) compared to Hispanic or public insurance, respectively. A greater number of sub-specialist visits increased the odds of an ED visit (OR=1.05 (95% CI: 1.02-1.08)).

CONCLUSIONS: In children and young adults with CCCs, we did not find an association between continuity of care and ED utilization. However, in this group, other factors such as ethnicity and insurance status may help identify high-risk populations for ED utilization.

CONTINUOUS GLUCOSE MONITORING FOR TYPE 2 DIABETES IN PRIMARY CARE: NEEDS ASSESSMENT SURVEY OF VA PRIMARY CARE PROVIDERS

Alison J. Leibowitz¹; Jolie B. Wormwood^2,1; Varun Natarajan¹; Shirley Qian^1,5; Bo Kim^6,7; Patricia Underwood^8,9; Paul R. Conlin^4,3; Varsha Vimalananda^1,3. ¹Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA; ²Psychology, University of New Hampshire, Durham, NH; ³Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ⁴Harvard University, Cambridge, MA; ⁵Boston University School of Public Health, Boston, MA; ⁶Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA; ⁷Psychiatry, Harvard Medical School, Boston, MA; ⁸School of Nursing, Boston College, Chestnut Hill, MA; ⁹Endocrinology, VA Boston Healthcare System Jamaica Plain Campus, Boston, MA. (Control ID #4062288)

BACKGROUND: Among patients with type 2 diabetes (T2D), 60% do not meet their targets for glucose control. Continuous glucose monitoring (CGM) is associated with better A1C and reduced hypoglycemia and hospitalizations as compared to fingerstick testing. In July 2023, the Veterans Health Administration (VA) expanded CGM eligibility to ~240,000 Veterans with T2D on basal insulin. Most patients with T2D are managed in primary care rather than endocrine clinic, but CGM management requires knowledge, workflows and resources not historically established in primary care. We aimed to understand primary care providers’ (PCPs) needs for implementing CGM for patients with T2D.

METHODS: In October 2023, we administered an online needs assessment about CGM implementation among 384 PCPs in the VA New England Healthcare System. The response rate was 25% (N=97). Questions addressed each domain of the Consolidated Framework for Implementation Research (CFIR) and asked about Perceived Benefits, Perceived Pressure, Knowledge and Resources, Support: Leadership and Other Services, and Confidence. We also asked about two outcomes: desire to integrate CGM into practice and likelihood of initiating CGM conversations with patients in the next 3 months. Responses were on 5-point Likert scales. We used correlations and multiple regression analyses to identify the CFIR subdomains that were the strongest predictors of each outcome, controlling for demographics. An open-text item was analyzed thematically.

RESULTS: Scores on individual items were highest for perceived benefits for patients (M=4.20, SD=0.81) and clinical practice (M=4.09, SD=0.83), and for patients expressing interest (M=4.15, SD=0.97). Scores were lowest for items about PCP access to (M=2.03, SD=0.98) and familiarity with CGM-related software/cloud-based platforms (M=2.20, SD=1.17), and for team access to professional training on CGM (M=2.22, SD=1.09). Index scores for all CFIR domains were significantly positively correlated with both likelihood of initiating CGM conversations (except Support: Leadership and Other Services) and desire to integrate CGM into practice. In multiple regression models, the CFIR domains together accounted for 60% of the variance in desire to integrate CGM into practice, with the strongest unique predictors being Perceived Benefits (B=0.71, SE=0.13, P<.0001) and Knowledge & Resources (B=0.31, SE=0.14, P=0.03). The CFIR domains together accounted for 30% of the variance in likelihood to initiate CGM discussions, with the strongest predictor being Confidence (B=0.38, SE=0.17, P=0.03). The most common themes for the open-text items were workload concerns, need for PCP and team education, and the role of interdisciplinary coordination.

CONCLUSIONS: VA PCPs and their teams are willing to initiate CGM to benefit patients with T2D, but express concerns about education and supportive workflows and systems to support broader CGM implementation in primary care.

DECODING MISUSE OF MT-SDNA IN CRC SCREENING: TRENDS AND INSIGHTS

Aaron B. Ahn¹; Sajal Kulhari¹; Jasmine Rhee³; Gregory Cooper². ¹School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; ²Gastroenterology, Case Western Reserve University School of Medicine, Cleveland, OH; ³Emory University Woodruff Health Sciences Center, Atlanta, GA. (Control ID #4063956)

BACKGROUND: Colorectal cancer screening is recommended for adults aged 45-75. Indirect screening options include fecal immunochemical tests (FIT) and multitarget stool DNA (mt-sDNA). Mt-sDNA is indicated for asymptomatic individuals between the ages of 45 and 85. Mt-sDNA is not indicated in patients with rectal bleeding, iron deficiency anemia, adenomatous polyps, previous colonoscopy within 10 years, family history of CRC, positive results from CRC screening tests within the past 6 months, or age less than 45 and greater than 85. We studied the prevalence of mt-sDNA use when not indicated and sought to understand the most common reasons why mt-sDNA was not indicated but ordered anyway.

METHODS: 7,345 patients in a Midwestern metropolitan health system’s EMR system underwent mt-sDNA testing between 1/1/2021 to 12/31/2021. Electronic Medical Record Search Engine (EMERSE) was utilized to randomize the sample, from which the first 500 randomized patients were reviewed from an ambulatory electronic health record of an academic health system. Any patient who was ordered and successfully completed mt-sDNA testing within the date range was included. Patients were excluded based on unsuccessful completion of testing, if there was more than one inappropriate reason for testing, or missing EMR information.

Medical records were reviewed to determine whether the tests were ordered appropriately according to the US Preventive Services Task Force criteria released in 2016. Race, sex, insurance type, and the specialty of the ordering provider were recorded as part of demographic data on our selected participants. JASP statistical software was used to conduct chi-square and two-proportion Z-test analyses.

RESULTS: Of 500 patients, (22.2%; n=104) had an inappropriately ordered mt-sDNA test. The most common reason for inappropriate ordering was having a previous colonoscopy done within the past 10 years (51.9%; n=54). The specialties that ordered the most mt-sDNA were family medicine (58.4%; n=292) and internal medicine (34.6%; n=173). White race was most likely to receive inappropriate testing (26.2%; n=72; p <0.001). Internal Medicine providers were most likely to conduct inappropriate testing (28.3%; n=49; p <0.001). No statistically significant difference was found in male versus female rates of inappropriate testing (22.4% vs 19.6%; p= 0.40). Rates of inappropriate testing based on insurance type, Commercial or Government, were not statistically significant (16.8% vs 23.1%; p = 0.07).

CONCLUSIONS: This research underscores a significant incidence of non-indicated mt-sDNA testing within the studied population, primarily driven by recent prior colonoscopies, and varies notably with patient race and the specialty of the ordering provider. These findings highlight the need for targeted educational interventions aimed at healthcare providers, emphasizing adherence to established CRC screening guidelines.

DECREASE IN OPIOID PRESCRIBING AMONG OLDER ADULTS WITH CHRONIC PAIN FOLLOWING IMPLEMENTATION OF THE I-COPE TOOLKIT

Ainur Kagarmanova¹; Wen Wan¹; Nikita Thomas¹; Erin Staab²; Danielle Lazar³; Linda Rosul³; Anne Zhao⁴; Katherine Thompson²; Mim Ari⁵; Neda Laiteerapong⁶. ¹General Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ³Access Community Health Network, Chicago, IL; ⁴Research, Evaluation, and Innovation, Access Community Health Network, Chicago, IL; ⁵Medicine, University of Chicago, Chicago, IL; ⁶Medicine, University of Chicago, Chicago, IL. (Control ID #4064544)

BACKGROUND: Chronic pain management in older adults can be challenging due to their higher risk for drug interactions and adverse events. In particular, opioids may be appropriate for some patients; however, older adults have a higher risk for opioid-related side effects, more emergency department visits, and increases in heroin use and opioid overdose deaths. To develop an effective pain management plan, a thorough understanding of each patient’s goals, preferences, comorbidities is necessary. Improving Chicago Older Adult Opioid and Pain Management through Patient-centered Clinical Decision Support and Project ECHO® (I-COPE) was designed to increase multimodal pain management by collecting patient-reported data on symptoms and preferences, implementing clinical decision support and shared decision-making tools, and providing primary care provider (PCP) education on the full range of chronic pain treatment options based on clinical recommendations from the American Geriatric Society. We aimed to understand whether implementation of I-COPE led to a change in opioid prescribing among older adults with chronic pain, opioid use, and/or opioid use disorder (OUD).

METHODS: I-COPE was a clinic-level intervention piloted at two urban academic primary care practices for one year beginning in June 2021. Patients were included if they were 65 years or older, received primary care at a study site, and had one or more of the following: pain score ≥6, chronic pain diagnosis, current opioid prescription, or OUD diagnosis. We compared quantity of annual opioid prescriptions per patient between pre-intervention (6/1/2020-5/31/2021) and intervention periods (6/1/2021-5/31/2022). Morphine milligram equivalents (MME) was used to standardize opioid dosages across various medications. A linear mixed model was used to determine significance difference between pre- and post-intervention values.

RESULTS: A total of 5,709 and 6,084 patients met eligibility criteria in pre-intervention and intervention periods respectively. Pre-intervention patient population was on average 79 years of age, 73% female, and 75% Black; intervention patient population was 78.6 years of age, 72% female, and 74% Black. 29% (N=1,683) of eligible patients had at least one opioid prescription during the pre-intervention period and 27% (N=1,643) had at least one opioid prescription during the intervention period. Total MME decreased from 844,706 to 683,884 after I-COPE implementation and mean (median) MME decreased from 502 (72) to 416 (50) (p=0.03 by LMM after transformation).

CONCLUSIONS: After implementation of the I-COPE toolkit, there were significant decreases in mean MME. Incorporating tools to collect patient preferences, encourage shared decision-making, and provide clinical decision support may lead to decreases in opioid prescription rates. More research is needed to differentiate the effects of I-COPE on multi-modal pain management.

DELAY IN DIAGNOSIS OF HEART FAILURE WITH PRESERVED EJECTION FRACTION

Yulia Khodneva¹; Larry Hearld²; Pankaj Arora¹; Andrea Cherrington¹. ¹Medicine, University of Alabama Birmingham, Birmingham, AL; ²The University of Alabama at Birmingham, Birmingham, AL. (Control ID #4064377)

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is a complex syndrome with rising prevalence. HFpEF presents a diagnostic challenge in primary care. The aim of this study was to estimate the prevalence and factors associated with the delay of diagnosis in primary care.

METHODS: We used International Classification of Diseases (ICD) diagnostic codes for HFpEF to identify first hospitalizations for HFpEF in University of Alabama in Birmingham (UAB) hospital electronic medical records data between 2017-2022. Delay in HFpEF diagnosis was defined as not having HFpEF among diagnostic codes in any ambulatory encounter within 12 months prior to first HFpEF hospitalization and was investigated in a multivariable-adjusted logistic regression model adjusted for age, sex, race and number of ambulatory visits prior to hospitalization.

RESULTS: 4317 patients with HFpEF who had established primary care in UAB within 12 months prior to first HFpEF hospitalization were included into the study (table) and of them only 425 (9,8%) had HFpEF diagnosed in primary care prior to first hospitalization.

Delay in HFpEF diagnosis was associated with longer length of stay during the first hospitalization for HFpEF. Additionally, older adults with HFpEF and those with more primary care visits were more likely to be diagnosed in primary care prior to hospitalization (adjusted odd ratio (aOR), [95%CI], per 1 year age increase 1.01[1.01-1.02], p=0.01 and per 1 primary care visit increase 1.09 [1.06-1.11], p<.0001, respectively). Compared to women with HFpEF, men with HFpEF were less likely to be diagnosed in primary care, aOR 0.79, 95% CI [0.64-0.98], p=0.03. Compared to African American adults with HFpEF, White adults with HFpEF were less likely to be diagnosed in primary care prior to hospitalization: aOR 0.70, 95%CI, [0.57-0.87], p=0.004.

CONCLUSIONS: Most cases of HFpEF in this study were diagnosed during the hospital admission or in the emergency department. HFpEF is a slowly progressing condition and hospitalization for acute care is usually a result of decompensation of prior underlying HFpEF. Interventions to improve early diagnosis of HFpEF in primary care are warranted

EVALUATING ACCEPTABILITY AND INITIATION OF LONG-ACTING INJECTABLE CABOTEGRAVIR FOR HIV PRE-EXPOSURE PROPHYLAXIS (PREP) IN A DIVERSE SAFETY NET PATIENT POPULATION

Emma J. Hollenberg¹; Dylan M. Baker¹; Alexander Kaplan²; Lauren F. Collins¹; Valeria Cantos¹; Meredith Lora¹. ¹Medicine, Emory University School of Medicine, Atlanta, GA; ²Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4059684)

BACKGROUND: Long-acting injectable cabotegravir (LAI-CAB) is a novel Pre-Exposure Prophylaxis (PrEP) modality for HIV prevention, with superior efficacy to oral PrEP. If equitably implemented, it could help bridge the current racial, ethnic, and geographical HIV incidence inequities, especially in the southern US, where over 50% of all new HIV infections occur and disproportionally impact Black and Latino men who have sex with men. We evaluated LAI-CAB acceptability and initiation at a safety net healthcare PrEP program in the Southern U.S., where LAI-CAB was recently implemented for PrEP.

METHODS: We performed a retrospective chart review of 136 referred patients who completed an LAI-CAB education visit at our safety net hospital PrEP program in the Southern U.S. from 12/2022-10/2023. All referred individuals were considered LAI-CAB eligible unless they had gluteal implants or there were significant LAI-CAB adherence concerns. We collected sociodemographic, insurance status, food insecurity, transportation needs, and housing status data of all eligible individuals. We determined the proportion of eligible patients who agreed to start LAI-CAB (acceptability measure), those for whom medication coverage was authorized either through health insurance or pharmaceutical patient assistance programs, and those who initiated LAI-CAB (received at least one injection). We also described reasons for declining to start LAI-CAB.

RESULTS: 132 patients were eligible for LAI-CAB. Eligible patients had a median age of 35 years, 72% were male sex assigned at birth, and 68% Black. Regarding social determinants of health, 33% were uninsured, 11% had unmet transportation needs, 24% had food insecurity, and 23% had housing insecurity. Of all LAI-CAB eligible individuals, 105 (79.5%) agreed to start LAI-CAB. Of all patients who agreed to start, 83 (79%) received medication authorization and 59 (56%) initiated LAI-CAB. Reasons for declining LAI-CAB included: patient readiness to start (30%), appointment frequency requirement concerns (19%), hesitance to commit to injections (7%), pregnancy intent (15%), and transportation barriers (11%). 93% of uninsured patients who accepted LAI-CAB received medication authorization while only 74% of insured patients received medication authorization.

CONCLUSIONS: In a socially vulnerable population setting, LAI-CAB had high acceptability. However, there was a large drop between patients’ initial agreement to and initiation of LAI-CAB. Implementing innovative strategies to address the increased frequency of visits required, transportation to/from clinic, injection hesitancy, and cumbersome medication authorization processes for insured patients, are needed to improve LAI-CAB initiation at our safety-net institution’s PrEP program.

EXPERIENCES OF PANDEMIC-RELATED ROLE AND TASK SHIFTS AMONG VA’S PATIENT-CENTERED MEDICAL HOME TEAM MEMBERS: A QUALITATIVE ANALYSIS

Alicia Bergman¹; Danielle Rose²; Karin Nelson^5,3; Susan E. Stockdale⁴. ¹CSHIIP, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ³Medicine, University of Washington, Seattle, WA; ⁴HSR&D Center of Excellence, Greater Los Angeles VA Healthcare System, Sepulveda, CA; ⁵General Medical Services, US Department of Veterans Affairs, Seattle, WA. (Control ID #4062918)

BACKGROUND: The COVID-19 pandemic altered the delivery of primary care in the United States, impacting the experiences of providers, staff, and patients. In the Veterans Health Administration (VA), changes such as mask mandates, the establishment of vaccine clinics, and increased use of virtual care modalities (video and telephone consultations) ensured the continuation of patient access to healthcare. Because such changes necessitated adaptations to patient centered medical home team (PCMH) functioning, we sought to understand the extent of pandemic-related changes in role tasks and resulting experiences among PCMH providers and frontline staff.

METHODS: From June to October 2021, we conducted 17 semi-structured telephone interviews with PCPs (n=5) and the following frontline staff: registered nurses [RNs] (n=8); licensed vocational nurses [LVNs] (n=2); and medical support assistants/clerks [MSAs] (n=2) across three clinics in one VA region. Questions centered on task and role changes resulting from the pandemic. Interviews were recorded and notes taken, with a rapid analysis comparing experiences across roles.

RESULTS: PCPs started working from home one day a week, which was described in positive terms by most. PCP task changes included screening all patients for COVID symptoms, adapting to limited availability of specialty care, interfacing remotely with PCMH staff such as clerks, and addressing patient pandemic-related stress and anxiety, which was also noted by some RNs and LVNs. For example, nurses described needing to manage patients’ heightened emotions (e.g., anger over face mask requirements) and resulting blood pressure increases. Some RNs noted increased workloads due to providing regular patient care along with added “COVID duties”, which one described as “overwhelming and frustrating”. RNs attended more staff meetings and spent more time on the telephone with patients while they were also “spread thin” for COVID coverage. Some LPNs conducted virtual appointments from the clinic with patients, began to screen patients prior to appointments (previously handled by clerks), and assisted with the set-up of telehealth equipment. New tasks assigned to MSAs, including checking in patients to vaccination clinics, and converting face-to-face visits to virtual ones or determining appropriate appointment modalities for new visits, increased their workload.

CONCLUSIONS: PCPs embraced the shift to virtual consultations but struggled with specialty care referrals. Role shifts common to PCPs and nurses included managing patient stress and emotions, while nurses and MSAs experienced an increased workload and task and workflow changes. Virtual work arrangements for providers during future national emergencies and pandemics may benefit from careful attention to minimizing excessive increases in frontline workload. PCMH teams may benefit from patient-centric emotional support training to reduce potential staff burnout and increase job satisfaction.

EXPLORING THE ASSOCIATION BETWEEN KNOWLEDGE OF ‘RIGHTS TO INTERPRETATION’ AND HEALTHCARE UTILIZATION AND PATIENT EXPERIENCE AMONG INDIVIDUALS WITH NON-ENGLISH LANGUAGE PREFERENCE IN CALIFORNIA

Miguel Linares¹; Emily Linares²; Shimon Shaykevich³; Lipika Samal³; Jorge A. Rodriguez⁴. ¹Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; ²Romance Languages & Literatures, Harvard University, Cambridge, MA; ³Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ⁴General Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4064447)

BACKGROUND: Individuals with non-English language preferences (NELP) experience suboptimal health outcomes due to language barriers, limited self-advocacy, lower health literacy, and biases. The integration of interpreters has shown mitigating effects, but interpretation is underused in clinical care. While this limited use has been attributed to cumbersome organization and financial constraints, there is scant data on the role of patient self-advocacy for interpreters. This study investigates associations between self-reported knowledge of “rights to interpretation” and health care utilization.

METHODS: We used pooled data from the California Health Interview Survey (CHIS), conducted in 6 languages and offering a representative sample of the noninstitutionalized population, for 2012-2021. Our study population included adults with self-reported NELP who received usual care and responded to the question about awareness of the right to free interpretation. Our primary outcome was health care use and patient experience, proxied by questions about having seen a personal doctor in the previous year, having been to the ER, and having experienced delays for prescriptions or health care. We performed bivariable analysis using weighted chi-squared analysis. For multivariable analysis, we performed weighted logistic regression, controlling for age, race, gender, federal poverty level, insurance status, employment status, health status, survey year and marital status, to explore the association between knowledge of rights and health care utilization/patient experience. SAS v9.4 was used for all statistical analyses.

RESULTS: The study included 14,295 participants (weighted frequency of 2,918,335) with NELP and receiving usual care, 71.12% of whom were aware of “rights to medical interpretation”. These individuals were more likely to be female, married, Latino, and insured. In adjusted analysis, those uninformed of this right had worse health utilization and patient experience in 3 out of 5 outcomes, including having seen a doctor in the past year and having experienced delays in care or prescriptions (Table 1).

CONCLUSIONS: We found that knowledge of interpreter rights was associated with worse healthcare utilization for patients with NELP. This lack of awareness exacerbates disparities in a patient population that is already at risk for suboptimal outcomes. To enhance health equity, health and government institutions should empower patients with the skills to voice their needs, ultimately improving their health and care.

EXPLORING THE IMPACT OF A PRIMARY CARE VALUE-BASED COMPENSATION MODEL IN AN ACADEMIC MEDICAL CENTER

Lindsey Ulin¹; Lisa Rotenstein^1,2; Richard S. Gitomer^1,5; Erin E. Sullivan^3,4. ¹Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²University of California San Francisco Department of Medicine, San Francisco, CA; ³Harvard Medical School, Boston, MA; ⁴Suffolk University, Boston, MA; ⁵MDLIVE Provider Services, Sunrise, FL. (Control ID #4053873)

BACKGROUND: As healthcare systems switch from fee-for-service (FFS) primary care models to value-based care (VBC), out-of-visit work expands, and compensation models adjust accordingly, little is known about how primary care physicians (PCPs) perceive the impacts of these changes. This study aimed to understand how a VBC compensation model, in which variable pay is based on the size and complexity of PCPs’ panels rather than the production of relative value units, has impacted PCPs in an academic medical center.

METHODS: This qualitative semi-structured interview study was conducted virtually from June-September 2023, 2 years after a VBC model began. Participants included 17 physicians from 12 clinics across an academic medical center in New England. Interview transcripts were thematically coded and analyzed inductively.

RESULTS: Respondents had been practicing for an average of 21.8 years since completing clinical training and practiced an average of 4.2 half-day sessions per week. Through qualitative thematic analysis, 5 areas were identified in which physicians perceived differences between the FFS and VBC models: 1) provider experience 2) incentives 3) burnout 4) access to care and 5) systems issues. The findings suggest that the positive impacts of a VBC model include recognition of inter-visit work, removal of perceived pressure tied to FFS models, and concordance of physician values with incentives. Respondents identified negative impacts related to decreased access to care, increased patient portal demands, and systems issues with understaffing and access to specialty care.

CONCLUSIONS: Understanding physician perspectives on VBC models helps to identify ways to improve it to better support patient care and physician engagement. The impacts of and potential for VBC models should be interpreted with consideration of external policy, regulatory, and industry-level changes.

FEASIBILITY OF 20/40 VISIT TYPES IN AN ACADEMIC INTERNAL MEDICINE CLINIC

Michael T. Nguyen. Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX. (Control ID #4062903)

BACKGROUND: Under pressures by the Faculty Group Practice to increase access, RVUs, and collections, the long-standing 30/60 clinic model, of 30 minutes for routine appointments and 60 minutes for new patients to get established, was challenged. Instead, a 20/40 model, aka "accelerated visit model" was proposed and a 6-month pilot project was done. Such 20/40 models have been used historically in the community-based clinics where providers generally do not have learners (ie students, residents, or fellows). The project is to test if this model can work well in an academic clinic

METHODS: Restructured clinic setup in a separate hallway for 1 MA:1 Physician ratio. The front desk as well as disposition staff were also trained on the accelerated model

New schedule templates and appointment times were made. Additionally, patients were called by MA in days prior as appointment reminders

Staff were given more Standing Delegated Orders to be able to perform vaccines, POCT,UAs,and patient education

Staff and patient surveys were given at 3-months (midpoint) and 6-months (end of study)

Data collection included slot utilization, phone encounters, and missed opportunities for scheduling

Over 960 patients were seen

RESULTS: Positive effects on clinic flow included:

Improved efficiency with a dedicated MA:Physician ratio

Improved in-basket management with training of MA to the level of the physician's preferences

MA gets better job satisfaction working with 1 provider instead of many

Some clinic sessions had better access due to more available slots

Negative effects included:

Suboptimal workflow when the trained,dedicated MA is out sick or on break

62% of patients reported feeling rushed and complained about not getting all their health concerns addressed

Due to time constraints, students were often shadowing the physician instead of seeing patients on their own

Patients seen by residents often waited much longer to be staffed due to the tight schedule

Unforeseen increase (approx.35-46%) of extra in-basket messages following the patient's visits due to unaddressed health issues

Physician job satisfaction declined due to more stress, hurried atmosphere, and more "homework"

Clinic often ran 45-60 minutes past the dedicated session affecting MA lunch and/or departure, leading to overtime

CONCLUSIONS: Internal Medicine patients, compared to Family Medicine patients,generally have many more social determinants of health, have more complicated health conditions,often have higher rates of hospitalizations,and require more coordination among specialists and primary care

The accelerated model leads to poorer patient satisfaction,incomplete care,and as a result of such,there is increased in-basket work and more after-the-visit coordination of care

In the academic environment, teaching students and supervising residents is extremely difficult with shorter visit duration times

Shared decision-making becomes much more challenging in a shortened visit

Therefore, IM physicians have more challenges that favor the longer duration 30/60 model.

FREQUENCY OF DIAGNOSTIC ABNORMALITIES IN POTS EVALUATION AT AN ACADEMIC SUBSPECIALTY CLINIC

Allison Angeli¹; Bradley Salonen²; Ravindra Ganesh²; Ryan Hurt²; Ahmed Abdalrhim²; Michael Mueller³; Mary M. Volcheck²; Christopher Aakre². ¹Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ³General Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4027760)

BACKGROUND: Postural Orthostatic Tachycardia Syndrome (POTS) is a heterogenous condition whose diagnostic evaluation is often exhaustive, time-consuming, and costly. Here, we describe our subspecialty clinic’s approach to its diagnostic evaluation.

METHODS: Prospective data was collected via interview and testing on patients seen at an academic medical center's POTS clinic from April 2014-February 2021. Data included demographics, comorbidity screening, head-up-tilt test, serum and urine studies, chest radiograph (CXR), electrocardiogram (ECG), Holter monitor, transthoracic echocardiogram (TTE), cardiopulmonary exercise test (CPET), and overnight oximetry. Additional data was extracted retrospectively by chart review and descriptive statistics were performed using R3.6.3.

RESULTS: Most participants were young (mean age 21.0±5.6), female (89.9%), students (38.5%) or employees (35.0%). Many met criteria for fibromyalgia (50.5% and 59.5% for 1990 and 2010 ACR criteria, respectively) and depression (47.9% with PHQ-9 ≥10). Significant anxiety was uncommon on GAD-7 (26.2% with GAD7 ≥10) or on HAI (mean 16.3±7.4; optimal cut-off < 27). Serum CBC, INR, and CMP fell largely within reference ranges, though TSH was elevated in 11.7%, morning cortisol low in 8.7%, ferritin low in 13.5%, and vitamin D low in 11.4%. Of the positive 24-hour urine screens for alternative etiologies (7.0% hypercortisolemia, 42.4% pheochromocytoma, 3.8% carcinoid syndrome, and 7.1-7.4% mast cell disorder), only 1 patient was diagnosed with carcinoid syndrome. Though abnormalities were noted on ECG at 36.9%, Holter at 79.8%, TTE at 7.5%, and CXR at 13%, these were nearly all clinically insignificant including sinus arrythmia, trivial valve regurgitation, abnormal spinal curvature etc. CPET was abnormal in 75.9%, largely (63.4%) without clear cardiac or pulmonary etiology. Overnight oximetry revealed multiple episodes of tachycardia in 91.5%.

CONCLUSIONS: Based on our findings, some typical screening tests for patients with POTS may be of low-yield and could be driven by clinical suspicion. We recommend the following uniform testing for patients undergoing POTS evaluation: CBC, CMP, vitamin D, ferritin, TSH, morning cortisol, 24-hour Holter, and stand test and/or HUTT. Tests to consider on an individualized basis include urine metanephrines, urine 5-HIAA, urine cortisol, ANA and other autoantibodies, B vitamins, TTE, overnight oximetry, and CPET. While patients may screen positive for anxiety, illness anxiety, and depression, further studies are needed to assess for confounding with current screening tools. Additional comorbid conditions to screen for include fibromyalgia (2010 or 2016 ACR criteria), hypermobility/EDS (Beighton score or 5PQ), and MCAS (AAAAI criteria). Further studies are needed to evaluate the utility of specific testing for POTS in order to develop an efficient, affordable, and standardized diagnostic algorithm.

GENDER DIFFERENCES IN COMPLETION RATE OF BIDIRECTIONAL ENDOSCOPY FOR ADULTS WITH IRON DEFICIENCY ANEMIA

Rachel Porth³; Yordan Penev²; Heather Hardway²; Maelys Amat⁴; Sarah Flier¹; Arvind Ravi²; Joseph D. Feuerstein¹. ¹Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA; ²Halo Solutions, Boston, MA; ³Internal Medicine, Beth Israel Deaconess Medical Center, Somerville, MA; ⁴Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4064763)

BACKGROUND: Iron deficiency anemia is a common diagnosis, impacting approximately 3% of all individuals in North America and 2-7% of adults over the age of 50 in the United States. While there are multiple causes of iron deficiency anemia, gastrointestinal (GI) malignancy is a “can’t miss” diagnosis. Prior studies suggest that 8.9% of patients with iron deficiency anemia are found to have a lower GI malignancy on colonoscopy and 2.0% are found to have an upper GI malignancy on upper endoscopy. Therefore, the American Gastroenterological Association (AGA) guidelines on the evaluation of iron deficiency anemia recommend that all asymptomatic postmenopausal women and men with iron deficiency anemia undergo a bidirectional endoscopy, consisting of both an upper endoscopy and colonoscopy. However, little is known about gender-related differences in completion rates for bidirectional endoscopy in clinical practice. We hypothesized that there would not be a difference in completion rate of bidirectional endoscopy between men and women.

METHODS: Study population consisted of patients diagnosed with iron deficiency anemia between January 2020 and June 2023 at a large academic medical center. Iron deficiency anemia was diagnosed by a ferritin value less than 45, as defined by the 2020 AGA guidelines. Patients below the age of 60 were excluded with the intention of including postmenopausal women and men. Gender was self-identified in the electronic medical record. Two sided Fisher’s exact tests were used to compare completion rate of bidirectional endoscopy by self-identified gender.

RESULTS: 1343 patients were included with a median age of 71. 59.9% were female. There was an average completion rate of 27.8% for upper endoscopy, 31.4% for colonoscopy, and 19.7% for bidirectional endoscopy for all patients within 1 year of iron deficiency anemia diagnosis. Women were less likely than men to complete an upper endoscopy [23.4% vs 34.5% (p < 0.0001)], colonoscopy [27.5% vs 37.3% (p = 0.0002)], or bidirectional endoscopy [16.5% vs 24.4% (p= 0.0006)]. There were no statistically significant differences in baseline ferritin between men and women included in the study.

CONCLUSIONS: Only 20% of patients with iron deficiency anemia above the age of 60 were compliant with AGA guidelines recommending a bidirectional endoscopy to rule out malignancy. Further, postmenopausal female patients had significantly lower completion rates than male patients. This may be because the ferritin lower limit of normal by laboratory assay is typically lower for women than men, which may lead to more missed diagnoses of iron deficiency anemia in women. Quality improvement efforts should, therefore, be targeted to decrease these care gaps.

HOW DOES THE RISK OF DEVELOPING DIABETES PROGRESS FROM YOUNG ADULTHOOD AND BEYOND? GLYCEMIC TRAJECTORIES IN THE CARDIA STUDY

Abigail Arons¹; Lucia Pacca¹; David R. Jacobs³; Anusha M. Vable⁴; Dean Schillinger². ¹Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ³Public Health, University of Minnesota Twin Cities, Minneapolis, MN; ⁴Family and Community Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4059090)

BACKGROUND: A quarter of young adults meet prediabetes criteria, yet prevention efforts are hindered by limited studies on young adults’ risk of progressing to diabetes. The objective of this study was to describe the progression of diabetes risk from young adulthood through middle age by characterizing patterns of long-term glycemic trajectories in a diverse sample.

METHODS: We characterized glycemic trajectory patterns from young adulthood through middle age through a novel application of sequence analysis, using data from the Coronary Artery Risk Development in Young Adults (CARDIA) study. CARDIA follows 5,115 people aged 18-30 at baseline in 1985-1986 with balanced subgroups by race (Black, white), gender, and education level. At 7 timepoints over 30 years, we categorized fasting plasma glucose (FPG) into mutually exclusive categories of normoglycemic, low/high impaired fasting glucose (IFG), diabetes, and other (pregnant, missing, deceased). We used sequence analysis to reduce the individual-level trajectories into a small number of clusters of similar trajectories.

RESULTS: In our sample (n=4624) at exam year 30 (mean age 55), 40% had normoglycemia, 17% had IFG, and 10% had diabetes. Of those with IFG before age 30, 23% had diabetes at exam year 30, compared to 8% of those who had only normoglycemia before age 30. Among the 1068 unique glycemic trajectories observed in the data, we identified 6 trajectory clusters accounting for 74% of the study population (Figure 1). The remaining 26% of the sample had extended periods of missing data or early death.

CONCLUSIONS: This is the first study to characterize glycemic trajectories starting in young adulthood based on FPG for people with normoglycemia or prediabetes at baseline. Common trajectory patterns emerged, suggesting different sub-types of risk of progression to diabetes among young adults. Prediabetes before age 30 tripled the risk of progression to diabetes, but a majority of such individuals did not progress. These trajectories can serve as outcomes in future analyses of individual and environmental influences during young adulthood on diabetes risk, with a goal of informing targeted diabetes prevention strategies for young adults.

HOW MUCH DAA TREATMENT IS ENOUGH? OUTCOMES FROM A LARGE CASE SERIES OF HCV TREATMENT INTERRUPTIONS

Astha Kanani¹; Christopher Bositis¹; Carolyn Chu². ¹Family and Community Medicine, University of California San Francisco, San Francisco, CA; ²Family & Community Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4031233)

BACKGROUND: Simplified treatment with direct-acting antivirals (DAAs) has expanded primary care-based HCV treatment. However, treatment interruptions (TI) are common and few data are available to guide clinical management. This study analyzes a “real world” series of TI and associated sustained virologic response (SVR12) outcomes.

METHODS: Consults involving cases of HCV TI provided to an academically-affiliated program 9/1/22-8/31/23 were retrospectively analyzed using deidentified case data. Details including genotype; prior treatment; fibrosis score; care setting; number/timing of missed doses; DAA interruption management recommendations; and SVR12 outcomes were collected and assessed.

RESULTS: 61 TI cases were identified, 82% from community-based and 11% from tribal health settings. 67% were cis-male, median age was 47 years, 51% were White, and 7% had HIV-coinfection. 50% received glecaprevir/pibrentasvir (G/P) as initial treatment and 34% received sofosbuvir/velpatasvir (SOF/VEL). SVR12 data were available for 28/61 (46%) and pending for 3 (5%). Table 1 describes clinical characteristics and outcomes of the 21 cases involving initial treatment. All 7 individuals who were retreated achieved SVR12: treating clinicians followed AASLD TI recommendations in 3/7; for the other 4, first-line therapy was “recycled”. 30/61 had no available SVR12 information, most (70%) due to lost-to-follow-up.

CONCLUSIONS: Despite a wide range of missed doses in this case series from mostly primary care clinics, 93% of patients with available follow-up data achieved cure. The 7 retreated individuals all achieved SVR12, including 4 where first-line medications were re-used. SVR12 data were not available for 50%, highlighting the importance of early identification of those at risk for, and interventions to prevent, loss to follow-up. Despite this, these results affirm SVR12 occurs even with “imperfect” DAA adherence. More research on the role of “recycling” first-line DAAs are needed.

IMPACT OF A PRIMARY CARE-BASED OBESITY MEDICINE CLINIC ON WEIGHT OUTCOMES

David Turk²; Cathy Chi²; Krithika Kumanan²; Irene Ryan²; Yuliya Thomas¹; Francis G. Wade¹. ¹Internal Medicine, Saint Louis University, Saint Louis, MO; ²School of Medicine, Saint Louis University, Saint Louis, MO. (Control ID #4064246)

BACKGROUND: The USPSTF recommends that patients with obesity are referred to a multicomponent behavioral intervention. Most primary care clinics don’t have access to such an intervention, nor do they have internal options for dedicated obesity treatment. We assessed the impact of a primary care-based, obesity medicine clinic (OMC) on weight outcomes.

METHODS: Between July 1, 2021, and June 30, 2022, a GIM primary care practice referred patients to an internal OMC for nutrition counseling, obesogenic medication management, and selective use of weight loss promoting medications including GLP1 agonists. We compared weight outcomes at one year between GIM patients who had >1 OMC visit versus patients with obesity who were not seen in the OMC.

RESULTS: Of the 76 patients referred by their GIM PCP to the OMC, 46 patients met intervention inclusion criteria: >1 OMC visit with weight data 1 year from initial visit. 524 patients met control group criteria: patient’s PCP entered a visit diagnosis of obesity into the EMR during study period, patient was not seen in the OMC, and weight data was available at 1 year from receiving visit diagnosis of obesity. Patient demographics and weight outcomes are shown (Table 1). In the intervention group, average age was 51.0 (SD 13.0). Average number of OMC visits was 3.0 (SD 0.8). At baseline OMC visit, patients were on an average of 1.5 (SD 1.3) obesogenic medications. 28 patients (60.9%) were started on weight loss promoting medication with 24 patients started on a GLP1 agonist. The average % total body weight loss (%TBWL) was 5.9% (SD 6.1%). 80.4% of patients lost weight with 64.9% of patients experiencing > 5% TBWL. Of the 23 patients who lost weight on a GLP1 agonist, 19 patients (82.6%) experienced >5% TBWL. The intervention versus the control group experienced significantly greater absolute weight loss (16.3lb ± 17.2lb vs 2.3lb ± 23.2, p<.0001) and decrease in BMI (2.5kg/m² ± 2.7 vs. 0.4 kg/m² ± 3.9, <.0001).

CONCLUSIONS: In this pilot study, a primary care-based OMC led to clinically significant weight loss with relatively few clinic visits. Primary care-based OMC’s have potential to improve patient access to dedicated obesity treatment. Future large-scale studies to determine the impact of primary care-based OMC’s on cardiometabolic and population health outcomes are needed.

IMPACT OF DIFFUSION-WEIGHTED WHOLE-BODY IMAGING WITH BACKGROUND SIGNAL SUPPRESSION ON DIAGNOSTIC PERFORMANCE FOR FEVER OR INFLAMMATION OF UNKNOWN ORIGIN

Keishiro Sueda¹; Hiroshi Hori²; Hitoshi Sugawara¹. ¹Division of General Medicine, Jichi Medical University Saitama Medical Center, Saitama, Saitama, Japan; ²Division of Internal Medicine, Minamiuonuma City Hospital, Minamiuonuma-City, Niigata, Japan. (Control ID #4063979)

BACKGROUND: Diffusion-weighted whole-body imaging with background body signal (DWIBS) has recently been applied to the diagnosis of malignant neoplasms, offering critical insights into patient care. As the high signal on diffusion-weighted imaging is not exclusively specific to neoplastic cells and appears in inflammatory lesions, its utility extends beyond oncology. Recent clinical studies have explored the utilization of DWIBS in diagnosing inflammatory or infectious diseases, including giant cell arteritis, IgG4-related disease, and cholecystitis. DWIBS may prove invaluable in localizing inflammation foci via whole-body scanning of patients with fever or inflammation of unknown origin (FUO and IUO, respectively). This study aimed to assess the potential impact of DWIBS on the diagnosis of FUO or IUO.

METHODS: This prospective observational study included patients with an axillary temperature ≥37.5°C or a C-reactive protein level ≥0.4 mg/dL who remained undiagnosed after undergoing a thorough medical examination. Each participant underwent DWIBS, and the results were independently evaluated by two radiologists. In addition to the clinical information, the final diagnosis was made based on DWIBS findings. Patient characteristics were summarized using descriptive statistics, encompassing demographic and clinical information. The final diagnosis and clinical course were described for individuals exhibiting both positive and negative DWIBS results.

RESULTS: Twenty-one patients with FUO or IUO who underwent DWIBS between July 2022 and December 2023 were included in this study. The median patient age was 50 years (interquartile range: 63–75 years), and 66.7% of the study population were male. Fever was present in 71.4% of the patients, inflammation in 81%, and both in 52.4%. DWIBS findings contributed to the diagnosis of five patients with acute focal bacterial nephritis, diffuse fasciitis without eosinophilia, tenosynovial giant cell tumor, IgG4-related disease, or adult-onset Still’s disease. One patient without diagnostic DWIBS results was diagnosed with pure red cell aplasia, and approximately half of the patients experienced spontaneous remission during the follow-up period.

CONCLUSIONS: DWIBS provides additional diagnostic insights into FUO and IUO, especially for patients with autoimmune, infectious, or malignant diseases. It has demonstrated its utility in identifying both systemic and focal diseases. Negative DWIBS results may indicate a favorable prognosis for patients with FUO or IUO. Further studies are needed to confirm these findings regarding the diagnostic effectiveness of DWIBS.

IMPROVING DETECTION OF OSA

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 #4061403)

BACKGROUND: Obstructive sleep apnea (OSA) is a serious medical condition with effects ranging from cardiovascular to neurocognitive; thus, correctly diagnosing and treating OSA is an important undertaking. Many patients are unaware of sleep disturbances, resulting in underdiagnosis. There is also no routine screening. Obesity is a significant risk factor for OSA with data suggesting greater than 70% prevalence of OSA in severely obese patients (BMI of 35 or greater). Baseline data showed 24% of obese patients seen in a resident continuity clinic had an OSA diagnosis. Additionally, no patients had been screened in clinic using the STOP-Bang. This quality improvement project sought to increase OSA screening of obese patients without an OSA diagnosis to 20%.

METHODS: This author pulled data for their team’s primary care patients (1010 total patients assigned to 12 residents) to identify severely obese patients and who had not received polysomnography or sleep medicine referral. If patients did not have any appointments scheduled, this author then reached out to schedulers to schedule these patients for clinic visits with a resident on their care team. Residents utilized the STOP-Bang questionnaire to screen patients and referred positive screens for polysomnography. The study team sent a reminder to screen patients using the STOP-Bangs before the appointments. Outcomes included total number of obese patients screened as well as number of patients referred for polysomnography. Pre and post-intervention data was analyzed using McNemar’s Chi squared test.

RESULTS: From a total of 1010 patients, 288 patients met criteria for severe obesity. 70 patients were excluded as they already had a chart diagnosis of OSA. Of the remaining 218 patients, zero patients had a STOP-Bang documented in the chart. After the intervention, 17 patients (7.8% of eligible patients) had a STOP-Bang performed. The McNemar’s Chi squared test yielded a p-value of 0, indicating a statistically significant increase in OSA screening.

CONCLUSIONS: While falling short of the screening goal, our results indicate a statistically significant increase in OSA screening among obese patients. A high proportion of patients (92.2%) were not screened for various reasons. Scheduling appointments was a factor. Of the 218 patients who met the study criteria, 104 patients scheduled clinic appointments. Clinic attendance was also a factor. Of the 104 patients scheduled, 17 patients showed up to their appointments. However, given that over 1/3 of patients who were screened had a positive STOP-Bang and ended up being referred to sleep medicine, these findings indicate that perhaps STOP-Bangs should be more routinely used in high-risk patients. Future studies could perhaps work on powering the study by getting more patients into clinic and getting screened as well as a longitudinal study to see how many patients get diagnosed with OSA with a polysomnogram. This could provide insight into how much the diagnosis is being missed in this population.

INAPPROPRIATE ANTIBIOTIC PRESCRIBING FOR OUTPATIENTS WITH COMPLEX INFECTIONS AT PRIMARY HEALTHCARE FACILITIES IN CHINA: A NATIONWIDE CROSS-SECTIONAL STUDY

Mengyuan Fu^1,2; Zhiwen Gong¹; Luwen Shi¹; Joseph S. Ross²; Xiaodong Guan¹. ¹Pharmacy Administration and Clinical Pharmacy, Peking University School of Pharmaceutical Sciences, Beijing, Beijing, China; ²Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4055196)

BACKGROUND: Inappropriate antibiotic use at primary healthcare facilities (PHFs) have been described globally. However, previous studies have focused on patients with a single infection, or, among patients with complex infections, focused only on one. In this study, we characterized antibiotic prescribing among primary clinicians caring for patients with complex infections and compared to patients with a single infection.

METHODS: We conducted a national representative survey, collecting outpatient-visit prescriptions from 368 PHFs in 31 cities in six provinces in China between 2017 and 2019. We identified all patients presenting with one of the four most common infections for which routine antibiotic prescribing was not recommended by guidelines, including unspecified upper respiratory tract infection (URTI), acute bronchitis (AB), non-infectious gastroenteritis (NG), and acute pharyngitis (AP). We categorized visits as patients with either single or complex (multiple) infections documented in their diagnoses, and calculated the rates of antibiotic prescribing overall and by diagnostic categories. We then estimated generalized linear models with logit link function to examine the adjusted associations between antibiotic prescribing and single/complex infections, controlling for patient age, gender, place of residence, and intra-cluster correlation in each facility.

RESULTS: Of 239337 eligible outpatient visits, 113743 (47.5%) were associated with an antibiotic prescription. Overall, antibiotic prescribing was 12.6% higher when primary clinicians treated patients with complex as opposed to single infections (single 47.4%, complex 60.0%, p<0.001). Specifically, 46.8% (61815/132210), 57.8% (26405/45688), 34.1% (12462/36597), and 52.6% (11556/21971) of patients with URTI, AB, NG, and AP alone ended with antibiotic prescriptions, while these rates increased to 66.2% (692/458), 33.0% (294/892), 57.1% (508/889), 60.0% (120/200), 61.4% (81/132), and 66.7% (44/66) of patients with URTI-AB, URTI-NG, URTI-AP, AB-NG, AB-AP, and NG-AP.

CONCLUSIONS: Inappropriate antibiotic prescribing for primary outpatients was high in China and associated with complex diagnosed infections, supporting the need for continuously promoting clinicians’ adoption of guidelines, and adding recommendations for complex conditions in the future.

INCREASED HEALTHCARE UTILIZATION IN PATIENTS WITH TINNITUS

Mingee Kim¹; David R. Friedland¹; Jazzmyne A. Adams¹; Masoud Khani²; Jake Luo². ¹Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI; ²Zilber College of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI. (Control ID #4026890)

BACKGROUND: Tinnitus, characterized by a perception of sound in the absence of external stimuli, is a prevalent condition impacting millions of Americans. The National Institute on Deafness and Other Communication Disorders (NICD) estimates that 10% of the United States adult population experiences some form of tinnitus, with 5 million experiencing a chronic form of the disease and 2 million finding it debilitating. Tinnitus exhibits variability in both auditory experiences and associated comorbidities with medical, behavioral health, pharmacological and social contributors to disease severity. This retrospective cohort study builds upon recent international research which revealed that patients with tinnitus had significantly increased healthcare utilization. That study did not control for age, a significant cofactor in health utilization as well as the development of tinnitus. The present study uses a local US adult database and controls for age so as to assess the reproducibility and generalizability of the observed correlation.

METHODS: This retrospective study included 6,236 tinnitus patients, and 6,236 age, sex, and race matched controls, from a mid-west academic health system. The period within one year both prior to and after the initial tinnitus diagnosis was assessed for several parameters such as the total number of clinic visits, number of hospitalizations, medications, and diagnoses for other conditions. Odds ratios with 95% confidence intervals were calculated for categorical analyses and Student t-test used for continuous variables.

RESULTS: Tinnitus and control populations had identical average age (56.7y), proportion of males (47.34%), and proportions of White, Black, and Asian patients (85.74%, 9.36%, 1.19% respectively). In addition, there were no significant differences in BMI (30.56 vs 30.53) or blood pressure: systolic (128.05 vs 126.27 mmHg), diastolic (74.41 vs 75.50 mmHg). Despite this demographic and clinical equivalency, consistent patterns of increased healthcare utilization were seen among individuals with tinnitus. Patients with tinnitus had a mean of 8.57 primary care consultations within the two years surrounding the tinnitus diagnosis compared to 1.04 visits for patients without tinnitus (p<.001). Similarly, tinnitus patients had a mean of 5.34 hospitalizations compared to 0.58 hospitalizations for patients without tinnitus (p<.001). Furthermore, patients experiencing tinnitus had a significant mean difference of 10.58 more new drug prescriptions and 23.02 more diagnoses of other conditions compared to individuals without tinnitus (p<.001).

CONCLUSIONS: Higher health care utilization is noted among a US cohort of patients with a diagnosis of tinnitus when controlling for age, sex and race. Further work is needed to identify whether an increase in medical comorbidities leads to the perception of, and evaluation for, tinnitus; or whether tinnitus heralds impending medical conditions and poorer overall health.

INCREASING "MYCHART" USE BY PATIENTS AND PHYSICIANS IN A RESIDENT CLINIC

Harrison C. McMinn¹; Peter McDonnell²; Natalie Baumann³. ¹Internal Medicine, Washington University in St Louis, Washington University in St Louis, St Louis, MO, US, academic, St Louis, MO; ²Internal Medicine, Washington University in St Louis, St Louis, MO; ³Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #4060368)

BACKGROUND: Electronic medical records are a unique tool within medicine that allow physicians and patients to stay more connected than ever before. Some common services offered with patient portals include direct messaging with your care team, quickly viewing laboratory values, and scheduling appointments. Several studies have shown that increased patient portal (MyChart) use led to increased patient-physician relationship satisfaction and decreased frequency of hospitalizations. As of August 2022, 46% of our patients in a resident-led clinic at Washington University in St Louis had active MyChart accounts. Of our patient population, 24.5% of patients did not have an active MyChart account. 5% refused MyChart activation. 23.5% of patients were pending activation. Our aim is to increase the number of patients with active MyChart accounts. Our theory is that by increasing the number of patients who use MyChart messaging we will decrease the number of calls resident physicians will need to respond to, allow for quicker response to patient queries and in basket requests by resident physicians, and allow for increased continuity of care between patients and physicians.

METHODS: The Plan Do Study Act (PDSA) method of quality improvement was used for this project. Baseline assessment was used to assess the number of patients with active MyChart accounts. The first PDSA cycle looks to increase patient awareness of MyChart by resident physicians including information in patient's checkout material during in person visits. Following two months of this intervention (August 2022 – October 2022) we analyzed the number of patients with active accounts. The first PDSA cycle was completed in October 2022. The final PDSA cycle was completed in March 2023 and included visual reminders of MyChart within patient rooms.

RESULTS: As of August 2022, 46% of our patients had active MyChart accounts. 24.5% of patients did not have an active MyChart account. 5% refused MyChart activation. 23.5% of patients were pending activation. When the study was completed in March 2023, 54% of patients had an active MyChart account, up nearly 9% from the beggining of the study.

CONCLUSIONS: Through our interventions, the number of patients with active MyChart patient portal accounts increased 9% in a 9-month period. Increased patient portal (MyChart) led to increased patient-physician relationships and decreased hospitalizations. Based on the socioeconomic status of our patient population, we believe that the main barrier contributing to decreased MyChart use is the lack of internet access. While we were able to examine the number of patients with active MyChart accounts, we were limited in our ability to determine how often MyChart services (i.e. messaging, viewing laboratory results, scheduling, etc) were specifically utilized. Further expansions of the project should aim to track the number of hospitalizations and the number of phone calls residents were required to respond to with MyChart usage.

KNOW YOUR NUMBERS! UTILIZATION OF TELEHEALTH AND HOME MONITORING FOR MANAGEMENT OF CHRONIC DISEASES IN RESIDENT CLINICS

Sett Naing¹; Sarah Stern¹; Jessica Valente²; Nancy M. Denizard-Thompson³. ¹Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC; ²General Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; ³Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC. (Control ID #4063422)

BACKGROUND: Many under-resourced patients with poorly controlled diabetes mellitus (DM) and hypertension (HTN) follow up in resident primary care clinics. The COVID-19 pandemic exacerbated disparities in both the quality of chronic disease management and the continuity of care provided in our resident clinics. This project aimed to investigate whether integrating telehealth visits and home monitoring could improve the management of diabetes and hypertension for patients in the resident continuity clinic.

METHODS: Patients were identified by their resident PCP if they had an A1C >8% or SBP >150 mmHg. Patients were enrolled prospectively as part of this resident quality improvement effort from 07/2021 to 12/2022. Patients agreeable to participation received home monitoring packages including a blood pressure cuff and glucometer depending on their diagnosis. Patients were then scheduled in residents’ appointment slots as telehealth video visits on a monthly or bi-monthly basis to review home monitoring data and titrate medications as needed. Patients’ A1C and average home SBP were assessed every 3 months to track the outcomes for a total of 6 months. Comparisons were analyzed with paired T-tests for the enrollment and end-of-study (12/2022) changes.

RESULTS: 33 patients with DM and 31 patients with HTN were enrolled for the total of 64 patients from the resident continuity clinic. 8 patients had both DM and HTN. From the diabetes group, the pre-program mean A1C was 11.0% (SD= +/- 1.5%, N=20) and post-program mean A1C was 8.9% (SD= +/- 1.6%, N= 20). The mean A1C difference between pre and post was 2.1% (95% CI= 1.1- 3.2, P= 0.0004). For the hypertensive group, the pre-program mean SBP was 167 mmHg (SD= +/- 18 mmHg, N=19) and post-program mean SBP was 140 mmHg (SD= +/- 21 mmHg, N= 19). The mean SBP difference between pre and post was 26 mmHg (95% CI= 17- 36, P= 0.0001). 13 patients (39%) from the DM group and 12 patients (39%) from the HTN group were lost to follow up.

CONCLUSIONS: Despite a larger than expected number of patients being lost to follow-up during the COVID-19 pandemic, we saw significant decreases in both A1C and SBP for enrolled patients who engaged and followed closely with their resident primary care physician. These results could be due to an improvement in the continuity of care in a resident primary care clinic. Thus, this method of telehealth medicine and home monitoring can be utilized in primary care settings to better manage chronic diseases. Future work includes qualitative interview of the participants to understand the role of telehealth in management of chronic disease from patient’s perspective.

OLDER ADULTS’ GOALS, PREFERENCES, EXPERIENCES, AND SATISFACTION RELATED TO CHRONIC PAIN MANAGEMENT IN PRIMARY CARE

Erin Staab¹; Ainur Kagarmanova¹; Preethi Gopal²; Danielle Lazar³; Anne Zhao³; Linda Rosul³; Katherine Thompson⁴; Mim Ari¹; Neda Laiteerapong¹. ¹General Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²University of Chicago Pritzker School of Medicine, Chicago, IL; ³Access Community Health Network, Chicago, IL; ⁴Geriatrics and Palliative Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4062824)

BACKGROUND: Chronic pain is highly prevalent among older adults and associated with worse psychological and physical outcomes; however, treatment is complicated by comorbidities, risk of adverse events, cognitive and functional impairment, and social needs. Patient-centered decision-making is key when optimal treatment choices are uncertain. Thus, there is a need to understand older adults’ perspectives on chronic pain. This qualitative study explored older adults’ goals, preferences, experiences, and satisfaction related to chronic pain management in primary care.

METHODS: Adults aged 65 or older who had a chronic pain diagnosis, high pain score, and/or opioid prescription and received primary care at an academic medical center or Federally Qualified Health Center network in a large Midwestern city were eligible. Semi-structured interviews were conducted via phone/videoconferencing. Participants were asked about pain management goals, treatment preferences, discussions with clinicians, decision-making processes, and satisfaction. Interviews were analyzed using deductive and inductive thematic analysis. Independent reviewers coded each transcript, identified themes, and discussed to consensus.

RESULTS: 16 interviews were completed (81% female, 75% Black, age range 65-83). Participants described effects of pain on mobility, activities, sleep, relationships, and emotional wellbeing. Goals centered around reducing pain, increasing mobility, decreasing interference with activities, and maintaining independence. Some participants expressed preferences for or against treatments, while others wanted their clinician to choose or guide them. Positive relationships with clinicians facilitated discussion of goals and preferences. Such discussions were less likely when participants thought pain treatment was outside the scope of primary care. About two-thirds of participants said they were satisfied with their pain management. Seven themes linked to satisfaction were identified: 1) adequacy of treatment and effective pain reduction; 2) thorough assessment including physical exam and history; 3) sufficiency of information shared and clarity of explanations; 4) decision-making process and level of patient involvement; 5) quality of patient-clinician relationship and communication; 6) trust and transparency; and 7) patient attitudes and expectations. Participants described contextual factors that impeded pain care, including short visits, limited appointment availability, care discontinuity, insurance/cost issues, racial bias, and opioid-related stigma.

CONCLUSIONS: Helping older adults with chronic pain to identify goals and eliciting information about their preferences could be useful in primary care. Thorough exams, clear explanations, collaborative decisions, effective treatments, good communication, trust, and a sense of hope could facilitate patient satisfaction. Future work should explore strategies to support clinicians in applying these principles while addressing systemic barriers to pain care.

ONE-YEAR WEIGHT LOSS OUTCOMES IN PATIENTS WITH OBESITY WHO RECEIVED SEMAGLUTIDE OR LIRAGLUTIDE

Hamlet Gasoyan¹; Elizabeth R. Pfoh¹; Rebecca Schulte²; Phuc H. Le¹; Michael B. Rothberg¹. ¹Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ²Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH. (Control ID #4060306)

BACKGROUND: Outside of randomized clinical trial settings, limited data is available on weight loss beyond 6 months in patients receiving semaglutide or liraglutide for diabetes or obesity.

METHODS: This retrospective cohort study used data from electronic health records from one health system in Mid-West and Southern regions, including pharmacy dispensation records, from January 1, 2015, to July 28, 2023. We identified adults with body mass index (BMI) ≥30 kg/m² who filled an initial prescription for injectable semaglutide or liraglutide from July 1, 2015, to June 30, 2022, and had weight measured ≥1 year later. Outcome measures included percent weight change and categorical weight loss of ≥10% at 1 year. A multivariable logistic regression model was used to examine the association of GLP-1 RA agent, indication (based on the dosage/brand name of the drug and presence of diabetes diagnosis), and persistence with GLP-1 RAs (defined as a cumulative gap of <90 days over 12 months) with the odds of ≥10% weight loss, controlling for age, sex, race/ethnicity, area deprivation index (ADI) quartile, baseline BMI, Charlson comorbidity index, and previous use of other anti-obesity medications (AOM).

RESULTS: We identified 3614 adults, with a mean baseline BMI of 40 ±8 kg/m² and a median follow-up of 2.6 years (interquartile range, 1.5-4.8); 54% were female, 68% White, 20% Black, and 7% Hispanic; 84% had diabetes. Overall, 1,839 patients received semaglutide dose/brand approved for diabetes, 125 semaglutide dose/brand for obesity, 1,517 liraglutide dose/brand for diabetes, and 133 liraglutide dose/brand for obesity. Overall, 40% were persistent with GLP-1 RAs at 1 year. Mean weight change from baseline to 1 year was -3.5% ±6.7 in the overall cohort; it was -4.5% ±7.2 in patients who received semaglutide vs. -2.3% ±5.9 in those who received liraglutide; -3.0% ±6.2 in patients with diabetes vs. -5.7% ±8.5 without; and -5.2% ±7.0 in those who were persistent with GLP-1 RAs vs. -2.4% ±6.3 who were not. Among those persisting with semaglutide dose/brand as AOM, mean weight change at 1 year was -12.7% ±6.1, with 53% achieving ≥10% and 27% ≥15% weight loss.

In the multivariable model, the odds of achieving ≥10% weight loss at 1 year were higher in patients who received semaglutide (adjusted odds ratio [AOR]=2.01, 95% confidence interval [CI], 1.62-2.50), compared to liraglutide, who were taking it for obesity vs. diabetes (AOR=2.65, 95% CI, 2.03-3.45), and who were persistent with medications vs. not (AOR=2.65, 95% CI, 2.16-3.26). Male sex (AOR=0.56, 95% CI, 0.45-0.69) was associated with lower odds. Age, race/ethnicity, Charlson comorbidity index, ADI quartile, and previous use of other AOMs were not associated with the odds of ≥10% weight loss at year 1.

CONCLUSIONS: In this large cohort of individuals with obesity, weight loss at 1 year significantly varied by the GLP-1 RA agent, indication, and persistence with the medication.

OPTIMIZING FECAL IMMUNOCHEMICAL TESTS (FIT) SCREENING IN A SAFETY-NET HOSPITAL PRIMARY CARE CLINIC

Juan Cerezo¹; Kripali Gautam¹; Briton Lee²; Stan Kogan³; Melinda Katz¹; Karyn Singer⁴; Alianne Brathwaite⁴; Isaac Holmes⁵; Samantha F. Sanders⁴. ¹Internal Medicine, New York University Grossman School of Medicine, New York, NY; ²Gastroenterology, Penn Medicine, Philadelphia, PA; ³Office of Ambulatory Care & Population Health, New York City Health and Hospitals Corporation, New York, NY; ⁴New York City Health and Hospitals Corporation, New York, NY; ⁵Internal Medicine, New York City Health and Hospitals Bellevue, New York, NY. (Control ID #4065019)

BACKGROUND: Colorectal cancer (CRC) screening is critical for early detection. FIT is a modality that is often the primary screening test in settings with limited capacity for colonoscopy. Stool sample collection processes vary by clinic and often require patients to return their sample during business hours. This can be a barrier for completion, especially in safety net populations where FIT return bears many opportunity costs. Thus, we aimed to explore ways to increase CRC screening by implementing pre-prepared, user-friendly FIT kits with option to return by mail.

METHODS: This study was conducted within an adult primary care clinic at a New York City safety net hospital that uses FIT as the primary CRC screening modality. Previously, FIT kits consisted of a collection tube and a biohazard bag that had to be returned in person. In July 2021, pre-packaged, mail-back kits were implemented. The kits were distributed in clinic to patients age 45-75 due for screening. Kits included instructions illustrating how to collect and return a sample. Patients had the option of mailing them directly to the processing lab via a prepaid envelope or dropping them off in clinic.

RESULTS: Our graph shows the trend in the number of FIT tests distributed and resulted. “Distributed” represents FITs that were handed to the patient in clinic. “Returned” represents FITs returned to clinic in person or by mail. The dashed line signifies the implementation of the new kits. There is a near doubling in the volume of FIT tests distributed and resulted since July 2021, from 110 per month to almost 200. The clinic maintained a FIT return rate of 66% within this time frame.

CONCLUSIONS: Our goal was to assess the feasibility of increasing CRC screening by implementing an optimized FIT screening process. Overall, we were able to nearly double our CRC screening rate and maintain an impressive FIT return rate. Our success was likely multifactorial; it may have been due to a streamlined process, which resulted in more kits distributed, as well as our new mail-back option, which made it easier for patients to return kits. Limitations include our inability to assess the specific impact of this option, as we are unable to determine which resulted FITs were returned in person versus by mail. Future investigation is needed to evaluate the rate of return from our mail-back option.

PRIMARY CARE CLINICIAN KNOWLEDGE, PERCEPTIONS AND USE OF INTEGRATIVE TREATMENT OPTIONS FOR CHRONIC PAIN MANAGEMENT

Meera Ronfeldt^1,2; Rachael Maciasz^1,2; Nikhil Navathe³; Kennedy Dubose⁴; Darcy Saffar⁴; Sarah Krein⁴. ¹Primary Care, VA Ann Arbor Healthcare System, Ann Arbor, MI; ²Department of Internal Medicine, University of Michigan, Ann Arbor, MI; ³School of Medicine, Wayne State University, Detroit, MI; ⁴Research, VA Ann Arbor Healthcare System, Ann Arbor, MI. (Control ID #4063929)

BACKGROUND: Access to effective non-pharmacologic treatments for chronic pain, including integrative medicine (IM) approaches, is a Veterans Affairs (VA) priority for reducing opioid use. The VA promotes veteran use of IM but these therapies are under-utilized. Considering the prominent role of primary care clinicians in managing chronic pain, we assessed their knowledge, experiences and use of IM to identify strategies to promote broader utilization.

METHODS: All Primary Care clinicians (N=78) affiliated with a Mid-Western VA healthcare system received 3 invitations to participate in an on-line survey from May to July 2023. The survey assessed clinicians’ knowledge, clinical and personal use, interest, and perceived barriers to providing IM services for the treatment of chronic pain. Data analysis included generating descriptive statistics and graphics.

RESULTS: Twenty-eight clinicians completed the survey yielding a participation rate of 36% with varied sectional response rates (n=23-25).

More than half (55%) reported some prior formal education or training in an IM approach, mostly in nutrition and psychologic (29%, 25%) therapies. Areas of interest for future learning were trigger point injections and cognitive behavioral therapy (CBT) (89%, 86%). Of maximal respondents (n=23), all clinicians recommended the use of CBT. The majority recommended acupuncture and chiropractic (96%, 91%) therapies. Types of IM that clinicians would most like to have available to patients were acupuncture, chiropractic and massage (74%, 70%, 70%). Clinicians’ perceptions of current barriers to offering IM therapies included: access to services and time constraints (96%, 81.5%), lack of evidence and lack of provider familiarity (67%, 63%), and safety/efficacy concerns (33%).

For their personal health, 46% of clinicians indicated having used IM approaches for stress management, physical symptoms (77%, 62%), mental health, and acute injury (39%, 31%). Modalities most frequently used were movement-based and psychologic (62% ea.). Some also used manual, nutrition counseling, and energy/biofield therapies (46%, 41%, 39%). Among clinicians with prior IM use, all reported being comfortable (31% somewhat and 69% extremely) with using such modalities. While most clinicians who had not used IM also reported being comfortable (somewhat 21.5%, very 57%, and extremely 14%), a small portion indicated feeling a little uncomfortable (7%) with personal IM use.

CONCLUSIONS: Incorporating Integrative Modalities is a VA priority for reducing opioid use and ensuring safe and effective chronic pain management. VA primary care clinicians recognize the value of using multiple IM approaches in the care of veterans and for their personal health. Addressing the most common barriers to providing these therapies and developing strategies to explain the evidence and rationale behind the use of IM are key action items to increase the use of non-pharmacologic pain treatment in the VA Healthcare system.

PRIMARY CARE PATIENT CHARACTERISTICS ASSOCIATED WITH WEIGHT LOSS MEDICATION USE IN THE MAINTAIN PRIME RANDOMIZED CLINICAL TRIAL

Molly Conroy¹; Chaorong Wu²; Kayla Jordanova⁶; Maribel Cedillo⁴; Jesell Zepeda⁵; Polina Kukhareva³; Michael Flynn⁷; Rachel Hess^2,1; Kensaku Kawamoto³. ¹General Internal Medicine, University of Utah, Salt Lake , UT; ²Population Sciences, University of Utah, Salt Lake City, UT; ³Biomedical Informatics, University of Utah, Sandy, UT; ⁴General Internal Medicine, University of Utah, Salt Lake, UT; ⁵Department of General Internal Medicine, University of Utah Health, Salt Lake City, UT; ⁶Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT; ⁷Community Physicians Group, University of Utah, Salt Lake City, UT. (Control ID #4064727)

BACKGROUND: With the advent of more effective weight loss medications, especially glucagon-like peptide-1 receptor agonists (GLP-1RA), more primary care patients will request and use such medications. We are conducting a randomized clinical trial (RCT) that enrolled primary care patients with recent, intentional weight loss. In this analysis, we describe weight loss medication use at baseline and patient characteristics associated with use.

METHODS: MAINTAIN PRIME enrolled primary care patients with intentional weight loss of ≥5% in the past 2 years and body mass index (BMI) ≥25 before weight loss. Bariatric surgery in the past 2 years was an exclusion, but the use of weight loss medication was not. Participants were enrolled between September 2021 and April 2023. At baseline, participants were asked if they were using weight loss medication and, if so, to name/list them. Baseline participant characteristics were obtained through surveys (including PROMIS for physical function) and research staff measurements (weight and blood pressure). Maximum percent weight loss was calculated using highest and lowest electronic health record (EHR) weights in the past two years. We conducted t-tests and chi-square tests to compare participant characteristics for those with and without weight loss medication.

RESULTS: We enrolled 268 participants. A minority (n=38; 14%) reported use of weight loss medications at baseline. Among those reporting use of medications, half of them reported GLP-1RA (n=20; 50%), while the other half reported older weight loss medications such as Phentermine (n=20; 50%), with two participants using more than one medication. Those reporting medication use were more likely to be female (76% vs. 65%), have higher BMI before (39.6 vs. 36.1) and after (35.4 vs. 32.8) intentional weight loss, greater maximum percent weight loss (12.7% vs. 10.4%), and lower PROMIS physical function scores (46.9 vs. 50.5) at baseline compared to those not reporting using medication use (all p <0.05). Race/ethnicity, education, blood pressure, and self-reported physical activity levels did not vary by weight loss medication use. History of chronic medical conditions, including diabetes and pre-diabetes, also did not vary by weight loss medication use.

CONCLUSIONS: In our primary care-based weight management trial, we found that participants reporting the use of weight loss medication were more likely to be female, have higher BMI, greater intentional weight loss, and lower physical function at baseline than those who lost weight without a weight loss medication. Since use of weight loss medications will likely increase in primary care settings, we will have a unique opportunity to track the use of weight loss medications in this group and correlate it with weight loss outcomes at the end of our 2-year RCT.

PROVIDER PERSPECTIVES ON STIGMA AND FEAR OF CANCER AS BARRIERS TO LUNG CANCER SCREENING

Molly Ingemi¹; Reva Kleppel²; Renda S. Wiener³; Kobe Haizel²; Peter K. Lindenauer²; Eduardo R. Núñez². ¹Internal Medicine, Baystate Medical Center, Springfield, MA; ²Department of Medicine, Baystate Medical Center, Springfield, MA; ³Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA. (Control ID #4064738)

BACKGROUND: Lung cancer screening (LCS) has been shown to reduce lung cancer-related mortality. However, only 5% of eligible patients have received an initial screen. Patients report smoking-associated stigma and fear of cancer as key barriers. We sought to explore providers’ perspectives on patient-level barriers to LCS engagement.

METHODS: We conducted semi-structured interviews with 22 providers, including 20 primary care providers and 2 pulmonologists, to identify barriers to LCS. We recruited providers who frequently ordered LCS for their patients from two academic centers that serve diverse racial and ethnic populations. Thematic analysis was performed to explore provider perspectives about reasons that patients may not want to undergo screening, including anxiety, fear of cancer, stigma, and fatalism.

RESULTS: Most providers reported that their patients generally perceive LCS to be beneficial and are interested in undergoing screening, but struggled to engage others. Providers often stated that they were unsure of the role, if any, that fear of cancer, anxiety, and smoking-associated stigma had on whether patients engaged in LCS and smoking cessation. Some providers reported they didn’t think patients who smoke experience stigma, whereas other providers suspected underlying guilt related to their tobacco use and fear of cancer as barriers to patients agreeing to LCS.

CONCLUSIONS: Fear of cancer and smoking-associated stigma are key patient barriers that are often under-recognized and poorly understood by providers. Developing patient-centered strategies to address stigma and fear of cancer may enhance engagement and increase utilization of LCS.

REIMBURSEMENT FOR SERVICES PROVIDED BY CLINICAL PHARMACISTS IN PRIMARY CARE: DESCRIPTION OF CHANGES OVER TIME IN AN ACADEMIC PRIMARY CARE NETWORK FOLLOWING THE RECOGNITION OF PHARMACISTS AS PROVIDERS

Cory P. Coffey¹; Kelli D. Barnes³; Neeraj H. Tayal¹; Daniel E. Jonas¹; Stuart J. Beatty². ¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²College of Pharmacy, Ohio Northern University, Ada, OH; ³College of Pharmacy, The Ohio State University, Columbus, OH. (Control ID #4062031)

BACKGROUND: Prior to 2021, billing third-party payers for pharmacist-provided patient care was extremely limited, restricting the ability for complex patients to receive optimal medication management. In January 2021, pharmacists were recognized by Medicaid as providers in a Midwestern state, became eligible to obtain Medicaid Provider ID numbers, and were able to begin billing for services using Evaluation and Management codes 99211-99213 and 99441-99443 for care provided to Medicaid and managed Medicaid Care Plan patients. To date, there is limited information regarding the impact pharmacy provider status legislation has on reimbursement. The objectives of this study were to compare the following outcomes before (2020) and after (2021-2022) pharmacist provider status was implemented in a network of primary care clinics: 1) the percent change in pharmacist provided services that were billed and reimbursed, 2) the percent change in pharmacist provided services that were billed incident-to versus pharmacist as provider, and 3) the percent change in reimbursement per encounter as a result of pharmacist provided services.

METHODS: A retrospective review was conducted of all encounters and administrative claims provided by pharmacists (7.9 FTE) within 7 General Internal Medicine and Med-Peds primary care clinics affiliated with a large academic medical center around a metropolitan area in the Midwest from 2020-2022. The data was compared year-to-year using descriptive statistics to determine the magnitude of change in the percentage of pharmacist provided services that were billed and reimbursed, the percentage of pharmacist provided services that were billed incident-to versus pharmacist as provider, and the reimbursement per encounter for pharmacist provided patient care. This study was reviewed and approved by the institutional review board.

RESULTS: A total of 14,416 encounters were included in the study (1863 in 2020, 4963 in 2021, 7590 in 2022). In 2020, 705/1863 (37.8%) of pharmacist encounters were billed for reimbursement. In 2021, this increased to 1939/4963 (39.1%) encounters and further increased in 2022 to 3725/7590 (49.1%). Differences in the percentage of pharmacist encounters billed incident-to versus pharmacist as provider were also evident with 705/1863 (37.8%) of pharmacist encounters billed incident-to in 2020 as compared to 2796/7590 (36.8%) in 2022. In this same time period, mean reimbursement for pharmacist as provider encounters increased by 189.5% per encounter and the number of pharmacist as provider encounters increased year over year (0/1863 (0%) in 2020, 54/4963 (1.1%) in 2021, 929/7590 (12.2%) in 2022).

CONCLUSIONS: This study found a large increase in the billing and reimbursement attributable to clinical pharmacists in primary care settings after they were recognized as providers by Medicaid payers.

RESETTING ABSOLUTE NEUTROPHIL COUNT RANGE BY DUFFY GENOTYPE

Edgar Asiimwe^1,3; Donglei Hu⁴; Jing Cheng²; Alan Wu⁵; Lawrence H. Kushi⁶; Elad Ziv¹. ¹DGIM, University of California San Francisco, San Francisco, CA; ²Division of Oral Epidemiology & Dental Public Health and Division of Biostatistics., University of California San Francisco, San Francisco, CA; ³National Clinician Scholars Program (NCSP), University of California San Francisco, San Francisco, CA; ⁴University of California San Francisco, San Francisco, CA; ⁵Laboratory Medicine, University of California San Francisco, San Francisco, CA; ⁶Division of Research, Kaiser Permanente, Oakland, CA. (Control ID #4064710)

BACKGROUND: Benign ethnic neutropenia is characterized by mild neutropenia without increased susceptibility to infection and is due to the Duffy null genotype (Fy-/-) in the ACKR1/DARC gene. This trait is common in persons with African ancestry, affecting millions of Americans, and has been associated with early discontinuation of myelosuppressive therapies. We sought to reset the normal range of absolute neutrophil count (ANC) for persons with Fy-/- and evaluate the effect of the new range among persons receiving myelosuppressive therapies.

METHODS: We used UK Biobank (UKB), a cohort of >500,000 United Kingdom participants with genomic and clinical data, to set the normal range of ANC by Fy genotype. We used All of US (AofU), a cohort of >400,000 U.S. participants with genomic and clinical data, to evaluate the effect of drugs on ANC adjusted by Fy genotype. Medications that suppress ANC were identified by literature review and expert opinion. We selected the two most common classes for analyses: common antimetabolites (methotrexate, azathioprine, mycophenolate and hydroxyurea) and anti-seizure medications (carbamazepine, lamotrigine and levetiracetam). Medication start/stop dates were extracted from AoU. Genotypes were extracted from AofU and UKB array datasets. ANC was ascertained from the baseline visit in UKB and from all clinical labs in AoU. We used the baseline ANC in UKB to determine the normal range (2.5^th-97.5^th percentile) for Fy-/- carriers. We applied this new 2.5th%tile threshold to the AoU dataset to classify patients as neutropenic by genotype and compared to a typical threshold <2000 cells/μL (c/μL). Continuous variables were compared using Wilcoxon rank sum test and proportions were compared using chi-squared tests. All analyses were performed in R.

RESULTS: The 2.5^th-97.5^th percentile range of ANC for individuals with Fy-/- in UKB was 1300-5210 c/μL, compared to the range of ~2000-6000 c/μL most labs use. Both antimetabolite and anti-seizure medications were associated with significant drops in ANC regardless of genotype, but there was no significant interaction between Fy-/- and change in ANC. Among Fy-/- carriers on antimetabolite therapies, 15.3% (30/196) dropped to a mean ANC <2000 c/μL which was significantly higher than 6.0% (81/1353) with other genotypes (p<0.001). Similarly, among Fy-/- carriers on anti-seizure medications, 18.2% (40/214) dropped to a mean ANC <2000 c/μL compared to 5.0% (101/2012) of participants with other genotypes (p<0.001). Using an ANC threshold of 1300 c/μL, only 3.0% (6/196) of Fy-/- carriers on antimetabolites and 7.0% (15/214) on antiseizure medications had a mean ANC below that cutoff.

CONCLUSIONS: Re-setting ANC thresholds for Fy-/- reduces the proportion of people who are classified as neutropenic and, if implemented, may decrease the likelihood of early treatment cessation. Future studies should evaluate infection risk by ANC threshold for Fy-/-.

THE ASSOCIATION BETWEEN THE TIMING OF PRIOR NATURAL INFECTION AND VACCINATION AND SUBSEQUENT RISK OF COVID-19-RELATED HOSPITALIZATION AMONG INDIVIDUALS WITH HYBRID IMMUNITY TO SARS-COV-2

Karthik W. Rohatgi¹; Margaret Lind²; Wade Schulz²; Albert I. Ko². ¹Internal Medicine, Yale New Haven Hospital, New Haven, CT; ²School of Public Health, Yale University, New Haven, CT. (Control ID #4064082)

BACKGROUND: Nearly four years into the COVID-19 pandemic, over 80% of the U.S. population has received some form of COVID-19 vaccination and over 70% are estimated to have been infected. Most of the population has therefore acquired hybrid immunity (immunity conferred by vaccination and prior infection), and this proportion will continue to grow. A key knowledge gap is whether hybrid immunity provides prolonged protection (>9 months) after most recent immunity-conferring event. The objective of this study was to estimate the effectiveness of hybrid immunity against COVID-19 associated hospitalization during the Omicron period and examine how effectiveness is modified by (1) whether the most recent event was an infection or a vaccination, and (2) length of time since most recent event.

METHODS: We performed an unmatched, test-negative case-control study of polymerase chain reaction SARS-CoV-2 tests performed on patients immediately before or after their admission to a large New England academic hospital system between December 2021 and May 2023. We included tests performed on patients with hybrid immunity as well as patients with no history of prior infection or vaccination. Logistic regression was used to model the effectiveness of hybrid immunity based on time since most recent immunity-conferring event and type of event (vaccination vs. infection). Models were adjusted for gender, race/ethnicity, insurance status, social vulnerability index, and unweighted Charlson Comorbidity score.

RESULTS: Among 34,838 hospitalization-associated tests conducted during the study period, 9,757 tests were performed on individuals who had evidence of prior hybrid immunity (350 test-positive cases and 9,407 test-negative controls). Among the tests, 57% percent were from female patients, and median patient age was 61 years (IQR: 38-75). Demographic characteristics and comorbidity scores were similar among cases and controls. For tests most recently preceded by infection, hybrid immunity effectiveness decreased from 74% at 4-6 months (95% CI: 61-82%) to 49% at 12+ months (95% CI: 25-65%). For tests most recently preceded by vaccination, effectiveness decreased from 82% (14 days-4 months; 95% CI: 72-88%) to 62% (4-6 months; 95% CI: 41-76%) to 53% (12+ months; 95% CI: 40-63%). In patients with hybrid immunity, booster dose did not confer additional protection compared to those who were fully vaccinated but not boosted.

CONCLUSIONS: Hybrid immunity conferred robust protection against COVID-19 associated hospitalization that decreased over time but was still significant (~50% effectiveness) 12 months after most recent immunity-conferring event. Of note, infection conferred stronger protection than vaccination, though this difference disappeared by 10 months. These findings suggest that as the proportion of the US population that has acquired hybrid immunity continues to grow, vaccination may be effective in providing sustained protection against COVID-19 associated hospitalization until the next annual campaign.

THE LONG-TERM COST-EFFECTIVENESS OF TELEHEALTH INTERVENTIONS FOR PERSONS WITH PERSISTENTLY POORLY CONTROLLED TYPE 2 DIABETES MELLITUS

Ethan D. Borre¹; Matthew Maciejewski^2,8; Matthew J. Crowley^2,3; Phillip E. Tarkington⁷; Hayden B. Bosworth^3,8; David Edelman^3,2; Jennifer Manne-Goehler⁴; Amy S. Jeffreys²; Kenneth A. Freedberg^4,5; Emily P. Hyle^4,5; Pooyan Kazemian⁶. ¹Internal Medicine, Massachusetts General Hospital, Boston, MA; ²HSR&D, Durham VA Medical Center, Durham, NC; ³Medicine, Duke University School of Medicine, Durham, NC; ⁴Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA; ⁵Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA; ⁶Department of Operations, Case Western Reserve University Weatherhead School of Management, Cleveland, OH; ⁷VA Richmond Medical Center, Richmond, VA; ⁸Division of General Internal Medicine, Duke University School of Medicine, Durham, NC. (Control ID #4061144)

BACKGROUND: Telehealth interventions can improve health outcomes among persons with persistently poorly controlled type 2 diabetes mellitus (PPDM). We sought to project the long-term clinical impact and cost-effectiveness of telehealth in persons with PPDM.

METHODS: We used a previously validated decision model of diabetes natural history and treatment (PREDICT-DM) to compare 3 strategies in US Veterans with PPDM: Usual Care, Standard Telehealth (remote patient monitoring and care coordination utilizing the standard Remote Patient Monitoring-Home Telehealth program for 1 year), and Comprehensive Telehealth (Standard Telehealth plus medication management and diet/activity, depression, and self-management support for 1 year). Cohort characteristics included age (mean=58 years), race (76% Black), and 19% had a prior myocardial infarction [MI]. Antidiabetic therapy improved hemoglobin A1c by -0.5-1.5% over 1 year for all patients. Telehealth intervention reductions in A1c (Standard Telehealth, -1.0%, Comprehensive Telehealth, -1.6%), were from a recent randomized trial and in addition to medication therapy. We assumed persons in Usual Care had a 1-year A1c reduction of -0.5%. The simulation projected the lifetime risks of MI, stroke, congestive heart failure (CHF), and associated mortality using risk prediction equations. Costs above Usual Care in 2022 US dollars from the payer perspective included 1-year intervention cost (Standard Telehealth $950, Comprehensive Telehealth $2,470), antidiabetic therapies ($15-890/month), and hospitalization for cardiovascular disease ($11,020-26,900/event). Discounted (3%/year) costs and life-years were used to calculate incremental cost-effectiveness ratios (ICERs).

RESULTS: Compared with Usual Care, Standard Telehealth and Comprehensive Telehealth reduced lifetime MI events by 381 cases/10,000 persons and 485/10,000 pesons, while stroke events were reduced by 217/10,000 and 413/10,000, respectively. Both telehealth interventions increased life-expectancy (0.24y for Standard Telehealth, 0.42y for Comprehensive Telehealth) and were cost-saving over a lifetime compared to Usual Care (Standard Telehealth saved $4,000 and Comprehensive Telehealth $9,000) due to prevention of cardiovascular events and subsequent costs. Even when combining the most influential model inputs in a multi-way sensitivity analysis, we identified a worst-case ICER of $33,300/LY for Comprehensive Telehealth compared with Standard Telehealth.

CONCLUSIONS: Comprehensive Telehealth for persistently poorly controlled DM increases life-expectancy and is cost-saving compared to Standard Telehealth.

THE PROBLEM BASED PRESENTATION: SIGNING OUT THE TRADITIONAL FORMAT FOR AMBULATORY PATIENT PRESENTATIONS

Grant J. Gonzalez, Michael C. Shih, Nicke Worth, Christie Robert, Callie Linden. Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4056477)

BACKGROUND: Traditional patient presentation formats can be difficult to adapt to the primary care setting. The Problem Based Presentation (PBP) was recently introduced to the literature by Steinhilber et al. as a novel presentation format for the academic teaching clinic. Resident interest in primary care continues to decrease in part due to the inefficiencies of resident clinic. In addition to verifying the findings of Steinhilber et al, we sought to evaluate the efficiency and effectiveness of the PBP format as compared to the traditional SOAP model to improve the residency primary care experience.

METHODS: This single center prospective study was conducted at an internal medicine residency program primary care clinic. During the pre-intervention period, medical students and residents gave presentations using the SOAP format. Residents completed pre-intervention surveys regarding their perceptions of the standard presentation format. The intervention was educating students, residents, and faculty on the PBP format and its subsequent implementation. During the transition period, medical students and residents began to practice giving presentations in the PBP format. During the post-intervention period learners continued to use the PBP format. Faculty timed presentations during all three periods.

All continuous and ordinal data did not fit normality via Shapiro-Wilk tests, and thus data were presented as medians. Data were statistically compared via Kruskal-Wallis Tests (post-hoc analyses were completed via Dunn’s Tests with Bonferroni corrections), two-tailed Wilcoxon Signed Rank tests, and Mann-Whitney U tests.

RESULTS: Forty-nine residents completed either the pre-intervention (n=30) or post-intervention survey (n=41). Twenty-two residents completed both surveys. 1,296 presentations were included in the analyses. Due to statistically differing contributions between groups by each of five faculty, data were analyzed for each separately. Two faculty showed a statistically significant reduction in presentation time(p<0.001, p<0.001). Two faculty showed no difference. One faculty showed longer presentations times (p<0.03). Residents noted increased confidence in the expected order of information (p=0.002), efficiency in the sign out process (p=0.0001), and organization (p=0.0004). There was no change in confidence regarding expected content (p=0.08). Residents perceived increased teaching (p=0.02) and more confidence in their care plan (p=0.02). Residents felt more likely to cover the intended and important problems from the patient encounter (p=0.002).

CONCLUSIONS: Our study found that utilization of the PBP format for presentations in the primary care setting leads to increased confidence, efficiency, and effectiveness in the sign out process. Implementation of the PBP format had variable effects on presentation length. While information delivery from learners may be more efficient and concise, increased time spent teaching could explain the lack of uniform decrease in presentation length.

TIME AND TYPE: ASSOCIATION OF INITIAL TRANSITIONS OF CARE APPOINTMENT TIMING AND TYPE FOLLOWING HOSPITAL DISCHARGE AS A RISK FOR EMERGENCY DEPARTMENT PRESENTATIONS AND HOSPITAL READMISSIONS

Jessica Thayer, Jesse Thompson, Shanthi Manivannan. General Internal Medicine, West Virginia University School of Medicine, Morgantown, WV. (Control ID #4063195)

BACKGROUND: Multidisciplinary Transitions of Care Clinics (TCC) are one tool used to help prevent Emergency Department presentations (EDP) and hospital readmissions (HR) following hospital discharge. Retrospective analysis of TCC effectiveness and best practices in terms of appointment type and timing is lacking in literature. Our review aimed to evaluate the optimal time and visit type for initial ambulatory follow-up as a strategy to reduce 30-day EDP and HR.

METHODS: We performed a retrospective analysis of 11,201 appointments scheduled as a TCC visit from January 2021 to September 2023.Visits took place at a Southern academic center and offered to patients without available ambulatory care or complex medical conditions. We used a multi-hospital system electronic health record to collect patient demographics, post-discharge EDP and HR, TCC visit type and visit status. Our primary outcome was time to EDP and HR compared to TCC visit date. Time from discharge to TCC was assigned to several categories: 0—3, 4—7, 8—14, 15—30 days before the visit and 1—7, 8—14, and 15—30 days after a visit. Our secondary outcome was the examination of time to scheduled TCC by visit types and status. Visit types were categorized as in-person, telephone, or video. Visit status included cancelled, completed, or not attended. One-way and two-way ANOVA were used to examine the mean time to TCC visit for the visit type and status and to each other. Post-hoc t-tests and Chi-square tests were used for pair-wise comparisons and the difference between visit type cancellation rates, respectively. Significance was defined as P value <0.05. Analysis was completed using R and RStudio (4.3.2).

RESULTS: Our results show the risk of EDP and HR occur at two time peaks post-hospitalization. The highest EDP and HR was 8—14 days prior to a TCC visit. The second highest period was 1—7 days following a TCC visit. This was consistent regardless of the visit status. Additionally, patients were less likely to cancel a telephone visit compared to an in-person visit (p <0.001) with average times to visit of 10.6 and 9.75 days, respectively.

CONCLUSIONS: These findings suggest that an initial TCC visit within 8 days from hospital discharge is an optimal time period to capture patients before they return to the hospital for acute care. This is in comparison to the current standard of 7—14 days for post-hospitalization ambulatory follow-up. There is also likely a role for additional close ambulatory follow-up given our findings of high EDP and HR 1—7 days after a completed TCC visit. In terms of visit category, telephone visits were less likely to be cancelled than in person visits and less sensitive to later scheduled visits (30.7%, 47.0%). Further studies evaluating the rate of 30-day EDP and HR depending on visit category as well as the implementation of subsequent follow-up TCC visits are needed to continue to improve post-hospitalization care, especially for vulnerable patient populations.

TRENDS IN FUNCTIONAL IMPAIRMENT IN MIDDLE-AGED AMERICANS, 1992-2018

Rebecca T. Brown^1,2; Xi Zuo¹; Kira Ryskina³; Anne Cappola¹; Norma B. Coe¹; Irma T. Elo⁴; Dawei Xie¹. ¹University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²VA Center for Health Equity Research and Promotion, Philadelphia, PA; ³Medicine, University of Pennsylvania, Philadelphia, PA; ⁴University of Pennsylvania, Philadelphia, PA. (Control ID #4063496)

BACKGROUND: Difficulty performing basic activities of daily living (ADLs) such as bathing and dressing affects more than 16% of middle-aged people (i.e., 45-64 years), and this percentage is increasing. While the reasons for this increase are not yet fully understood, it is part of a larger trend of worsening health in this age group, including a rising prevalence of chronic conditions that are risk factors for functional impairment. These findings raise the concern that middle-aged Americans may be experiencing accelerated aging that is causing premature functional decline. However, prior studies measured the prevalence of functional impairment cross-sectionally, and it is unknown how the incidence and trajectories of functional impairment have changed over time.

METHODS: We conducted a retrospective cohort study of 11,166 adults ages 50-56 enrolled from 1992-2010 in the longitudinal nationally representative Health and Retirement Study who were independent in ADLs and instrumental ADLs at baseline. Individuals were followed through 2018 to examine incident functional impairment (i.e., new difficulty performing ≥1 ADLs) and trajectories of total number of ADL difficulties (0 to 6) by age 65. We used Cox regression models to compare incidence across 4 birth cohorts (1931-1941, “pre-war babies”; 1942-1947, “war babies”; 1948-1953, “early baby boomers”; and 1954-1959, “mid baby boomers”). We used linear mixed effects models to compare changes between birth cohorts. In Cox and linear mixed effects models, we adjusted for key risk factors (birth cohort, gender, race/ethnicity, marital status, socioeconomic status, health status, health-related behaviors, physical environment).

RESULTS: Mean age among all participants at baseline was 53.4 years, 52% were women, 10% identified as Black, and 8% as Latinx. Overall, the annual incidence of ADL impairment was 2.3%, and 15% developed ADL impairment by age 65. In unadjusted analyses, the risk of impairment over a maximum of 14.5 years’ follow-up was similar among the war baby and early boomer cohorts compared to the pre-war cohort, but lower among mid baby boomers compared to the pre-war cohort (hazard ratio [HR] 0.81; 95% CI, 0.71-0.93). After multivariable adjustment, the risk of incident ADL impairment was higher in the war baby and early boomer cohorts compared to the pre-war cohort (HR 1.37, 95% CI, 1.18-1.59 and HR 1.19; 95% CI, 1.02-1.39, respectively), but similar between the mid-boomer and pre-war cohorts. In both unadjusted and adjusted linear mixed effects analyses, the rate of change in number of ADL difficulties was similar across all four cohorts (p=.81 and p=.40).

CONCLUSIONS: These findings suggest that developing ADL impairment is less common in mid-boomers compared to earlier birth cohorts, but that trajectories of impairment have not improved over time.

UNDERSTANDING BARRIERS TO CARE FOR TREATMENT OF HEPATITIS C

Ekwevugbe O. Ogbon, Mariam Mehdawi, Kaitlin Liroff. Internal Medicine, Hurley Medical Center, Flint, MI. (Control ID #4064864)

BACKGROUND: Hepatitis C virus (HCV) infection rates have been rising in the community despite the existence of multiple well-tolerated antiviral therapies that can cure infection.1 A greater understanding of the many barriers of factors affecting patients in our community and within our health system is needed to enable interventions and further reduce and eliminate them.

Aim: To identify barriers affecting patients referred for HCV treatment and the proportion that followed up appropriately with visits, treatment, tests, and completion of therapy and its association with socioeconomic factors.

METHODS: A descriptive retrospective analysis of charts and patient surveys was conducted using the outpatient infectious disease clinic (ID) at Hurley Medical Center in Flint, Michigan.

RESULTS: A total of 70 patients were referred to the clinic from both inpatient(28%) and outpatient (72%) settings; 57% male; 43% female; 69% white, 23% Black, 4.3% Hispanic and 4.3% other. 8% had HIV co-diagnosis. Most patients had different insurance policies including private, medicaid and medicare and 5% had no insurance coverage. Mean days from creation of entry to encounter date was 18 days. 53% of patients did not proceed with the appointment. Out of the patients that completed the ID appointment, 76% of patients had medications prescribed following initial visit. This included 73% of white patients compared to 27% of non whites. Medications prescribed included glecaprevir-pibrentasivir (57%), sofusbuvir-velpatasvir-epclusa (35%), and ledipasvir-sofosbuvir-harvoni(9%). Less than half (43%) were confirmed by the pharmacy to have picked up their medications. Only 4% of patients followed up for RNA testing after therapy, out of which 78% were undetectable.

CONCLUSIONS: Barriers to care included insurance coverage, delayed appointment with ID, financial ability and/or insurance coverage to pay for testing and treatment, lack of patient health literacy and awareness with the associated fear of stigma. More active systemic and community-level programs are needed to improve literacy and direct linkage to care for patients with HCV.

VISIT NOTES HAVE LIMITED DOCUMENTATION OF SHARED DECISION MAKING FOR COLORECTAL CANCER SCREENING DECISIONS

Joshua Siar¹; Brittney Mancini²; KD Valentine²; Karen Sepucha²; Leigh Simmons²; Lauren Leavitt². ¹Medicine , Augusta University, Augusta, GA; ²General Internal Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4043651)

BACKGROUND: High-quality shared decision making (SDM) documentation should include discussion of options, pros, cons, and patients’ preferences. SDM is a recommended approach to engaging adults aged 76-85 in colorectal cancer (CRC) screening decisions. However, the quality of SDM documentation in clinical notes for these decisions is not known.

METHODS: Secondary analysis of data from 465 patient participants and 57 primary care physician participants in a multi-site cluster randomized trial focused on promoting SDM in CRC screening decisions for older adults. Intervention arm physicians completed a SDM skills training course and received a reminder to have a SDM conversation with eligible patients prior to an upcoming visit. They also received a toolkit to support patients in the decision and an electronic health record (EHR) SmartPhrase to streamline documentation of CRC screening discussions. Comparator arm physicians received the reminder only. Patients and physicians completed the SDM Process Scale (range 0-4, with higher scores indicating more SDM) after the visit. Two coders independently coded notes from those visits retrieved from the EHR using content analysis to identify SDM elements, including screening options, pros, cons, and patient preferences. Visit notes were assigned a SDM Note score (range 0-4 with higher scores indicating more SDM elements documented in the visit note). Linear multi-level models were used to evaluate differences in SDM Note scores by study arm and the relationship between SDM Note scores and physician- and patient-reported SDM Process scale scores.

RESULTS: Overall, SDM Note scores were low (M=0.80, SD=0.99). Intervention arm SDM Note scores were higher than the comparator arm (Adj. Mean 1.02 (SE=0.1) vs. 0.66, (SE=0.9); p=0.006). Intervention arm notes more frequently documented discussion of stool-based tests (SBT) (52% v. 33%; p=0.02), pros of SBTs (12% v. 5%; p=0.03), and cons of SBTs (16% v. 7%; p=0.04) compared to the comparator arm. Those in the intervention arm were more likely to include cons of colonoscopy in notes compared to the comparator (28% v. 8%; p=0.001). No differences were observed in documentation of patient preferences across study arms (p=0.4). Physician SDM Process scores were consistently higher than SDM Note scores (Adj. b=0.98, p<0.001) and patient SDM Process scores were also higher than SDM Note scores (Adj. b=0.47, p<0.001).

CONCLUSIONS: Documentation of CRC screening discussions with older adults in clinical notes reflects limited accounts of SDM. The intervention group had higher SDM Note scores, suggesting the training intervention improved SDM documentation, specifically with respect to inclusion of alternative options like SBTs, and more discussion of the downsides of colonoscopy. Given limited documentation of SDM even after a training intervention, attention to more robust SDM documentation, including patient preferences and discussion of stopping CRC screening is needed.

WHEN MONEY DOESN’T MATTER: POST-INTERVENTION EVALUATION OF PRESCRIBING PRACTICES, ATTITUDES, AND BARRIERS ON WEIGHT MANAGEMENT IN AN ACADEMIC INTERNAL MEDICINE CLINIC

Stephanie Hannon¹; Morgan Lockhart¹; Andrew M. Wolf²; Rachel H. Kon²; Amber Roberts²; Donna White¹. ¹Pharmacy, UVA Health, Charlottesville, VA; ²University of Virginia School of Medicine, Charlottesville, VA. (Control ID #4060010)

BACKGROUND: At University of Virginia (UVA) Health, low-income patients may apply for financial assistance (FA) which may cover up to 100% of prescription costs. University Medical Associates (UMA) is a large internal medicine resident-faculty clinic, serving over 14,000 patients with 19,000-22,000 patient visits per year. A previous study at UMA investigated weight loss medication prescribing habits showing less than 1% of obese patients with 100% FA were prescribed a weight loss medication. Residents and patients were surveyed to capture prescribing practices and attitudes towards weight loss medications which showed over half the patients would be interested in taking a medication to help them lose weight. Remarkably over half the medical residents felt a lack of training and limited experience were major barriers to prescribing. The purpose of this study was to evaluate changes in prescribing habits one year after completing education on weight loss medication prescribing and assess medication shortage barriers.

METHODS: This study was a retrospective, observational chart review of patients seen at UMA from 10/18/2022 to 10/17/2023. Data were collected from the electronic medical record and UVA data repository. Patients ≥ 18 years old with BMI ≥ 30 kg/m² who had 100% FA were included. Type 2 diabetes, pregnancy, or history of bariatric surgery or current referral were excluded. The primary endpoint was the proportion of obese patients with 100% FA who were prescribed a weight loss medication. Secondary endpoints included class of weight loss medication prescribed, gaps in therapy, and concomitantly prescribed obesogenic medications.

RESULTS: Of patients reviewed, 335 met eligibility. Spanish was the primary language for 81.5% and 67.2% were women. Mean BMI was 34.7 kg/m², mean age was 46 years, and 48% of patients were seen in clinic once while 52% were seen at least twice during the study. Twenty-eight (8.4%) patients were prescribed a weight loss medication. Of these, 26 (7.8%) were prescribed by clinic providers and 2 patients received prescriptions from outside providers. The most common class of weight loss medication prescribed was GLP1 agonists including GLP1/GIP agonist (27 patients). One patient was prescribed phentermine/topiramate then switched to naltrexone/bupropion due to medication availability. Of the 28 patients, 21 (75%) experienced a gap in therapy. Additionally, 44.8% of patients were concomitantly prescribed an obesogenic medication.

CONCLUSIONS: Post-education prescribing increased from less than 1% to over 7% in patients with 100% FA. Identified barriers include patient and inventory factors which may have contributed to prescribing practices. Investigating provider confidence in and attitudes toward prescribing all classes of weight loss medications may provide opportunities for increasing prescribing and navigating barriers such as drug shortages.

“THE DOCTOR WASN’T ALARMED, SO I WASN’T ALARMED”: PERCEPTIONS OF PREDIABETES AND DIABETES PREVENTION AMONG HISPANIC MEN AT A FEDERALLY QUALIFIED HEALTH CENTER

Clarence N. Perez-Mejia¹; Noelia G. Hernandez¹; Cara S. Stephenson-Hunter^2,3; Christopher J. Gonzalez¹. ¹General Internal Medicine, Weill Cornell Medicine, New York, NY; ²Albert Einstein College of Medicine, Bronx, NY; ³Montefiore Medical Center, Bronx, NY. (Control ID #4064383)

BACKGROUND: Hispanic men have a prevalence of diabetes 64% higher than non-Hispanic White men but are relatively underrepresented in evidence-based lifestyle interventions that effectively prevent diabetes. By addressing common misconceptions about diabetes risk, providers can potentially improve Hispanic men’s engagement in interventions that prevent diabetes; however, there is a lack of research exploring Hispanic men’s beliefs regarding diabetes prevention. The objective of this study is to identify perceptions about diabetes prevention among Hispanic men at risk for diabetes.

METHODS: Using purposive sampling at a Federally Qualified Health Center (FQHC) in New York City between 5/2023 and 9/2023, we recruited self-identifying Hispanic men who were: 1) at least 18 years old, 2) a body mass index (BMI) ≥25 kg/m2, and 3) an HbA1c of 5.7%-6.4% within one year. We conducted telephone interviews with a semi-structured guide based on the Health Belief Model, a conceptual model used to understand public and patient engagement in specific health behaviors. Interviews were audio-recorded, transcribed. Two coders performed a thematic analysis, using a hybrid inductive and deductive approach informed by the Health Belief Model, resolving discrepancies through consensus.

RESULTS: In interviews with 15 Hispanic men, five major themes emerged presented here with illustrative quotes. (1) Hispanic men are familiar with and fearful of diabetes, but the implications of prediabetes are less clear: “I know that people even go blind, lose their limbs with diabetes; but I don’t know what prediabetes is.” (2) Dietary recommendations are often scarce, or inconsistent with cultural norms and practices: “I eat a lot of rice and beans, you know the normal Latino stuff. The doctor told me to leave the rice alone, but I’m not gonna stop that.” (3) Despite wanting to engage in physical activity, Hispanic men are often impeded by competing priorities: “I have to pay rent. I have to work. I don’t have time to exercise.” (4) Social support can sometimes motivate them to act, but Hispanic men largely view prediabetes as a personal burden: “I’m the one with prediabetes- I don’t need to discuss it with anybody else.” (5) Resiliency contributes to feelings of self-efficacy: “As a Latino man, I’ve overcome a lot- I can overcome diabetes.”

CONCLUSIONS: Concerns of developing diabetes were prevalent among Hispanic men at risk for diabetes, but understanding of prediabetes was limited. Inadequate guidance and competing priorities further hindered diabetes prevention. While Hispanic men felt prediabetes was a personal burden, they also remained hopeful. Future research should consider developing strategies that assist providers in conveying the implications of prediabetes accurately and effectively, leveraging awareness of diabetes and themes of resiliency, and tailoring prevention recommendations. Addressing these perceptions may be critical to addressing the disproportionately high prevalence of diabetes among Hispanic men.

Scientific Abstract - Career Development, Professionalism, and Wellness

ADVOCACY BEYOND PARENTAL LEAVE: CREATION OF AN INFERTILITY, PREGNANCY, AND POSTPARTUM COMPLICATIONS SUPPORT NETWORK

Agnes Koczo¹; Kathryn Berlacher¹; Annie Im²; Stephanie Maximous³; Jennifer A. Corbelli⁴. ¹Cardiology, UPMC, Pittsburgh, PA; ²Hematology/Oncology, UPMC, Pittsburgh, PA; ³Pulmonary/Critical Care, UPMC, Pittsburgh, PA; ⁴Medicine, University of Pittsburgh Department of Medicine, Pittsburgh, PA. (Control ID #4062013)

BACKGROUND: Background: Physicians are at higher risk to encounter difficulties on the path to family expansion as compared to the general population. There is significant societal stigma around infertility, pregnancy loss and postpartum complications which can isolate individuals and further complicate grieving. Physicians and trainees face additional challenges, including long work hours and training, substantial financial debt, and lack of awareness of infertililty and pregnancy complications during training. Forming a support network among physicians may help to mitigate isolation and destigmatize these experiences.

METHODS: Methods: Physician leadership in the Department of Medicine and its subspecialties constructed a 10-question/5-minute survey to recruit volunteers to form a support network. The survey was iterative and open ended to facilitate expansion of support topics. An Internal Medicine Grand Rounds was held to raise awareness of issues surrounding family expansion and to introduce the support network as a new resource for faculty and trainees. A best practice document was developed for those providing support. A guide was created with personal recommendations by the support network. These were also made available through other physician assistance programs and institutional counseling services.

RESULTS: Results: A total of 43 individuals volunteered, 39 physicians identifying as women and 4 physicians identifying as men. Among these volunteers, a total of 11 support topics were identified: infertility, high risk pregnancy, twin gestation, miscarriage, late pregnancy loss, neonatal illness, adoption, postpartum anxiety and/or depression, unplanned childlessness, breastfeeding difficulties, and egg cryopreservation/donation. Most members felt they were able to support both faculty and trainees as well as both individuals who were physically impacted and partners. A resources guide was also created by the support network. This included licensed psychologists and psychiatrists specializing in pregnancy complications, online support groups as well as doulas, maternal fetal medicine and neonatologists. There was an overwhelmingly positive response to the support network.

CONCLUSIONS: Conclusion: A department-wide physician support network and resource list addressing multiple difficulties surrounding family expansion was successfully created and made readily available. Future steps include expansion of the network to other departments and added inclusions of categories for personal/family difficulty (i.e childhood illness). This low cost, low time investment endeavor is a novel and high impact infrastructure to fulfill major gaps in supporting faculty and trainees across the spectrum of parenthood.

AN ASSESSMENT OF DEPARTMENT OF MEDICINE TRAINEES’ PERSPECTIVES ON PREPAREDNESS TO NAVIGATE THE JOB APPLICATION PROCESS

Sarah Capponi¹; Mili Mehta². ¹Rheumatology, Hospital of the University of Pennsylvania, Philadelphia, PA; ²Cardiology, Tufts Medical Center, Boston, MA. (Control ID #4061380)

BACKGROUND: While most trainee physicians have never gone through a job application process, and it is known to be very stressful, there is surprisingly little research on how to prepare trainees and make this transition smoother. We aimed to better understand the needs and perspectives of residents and fellows at a large academic institution with regards to preparedness for the job search and application process following training.

METHODS: Between April and May 2023, we invited all residents and fellows in the Department of Medicine at a large northeast quaternary care urban academic medical center to complete a voluntary cross-sectional survey. Given a lack of validated survey tools, the authors generated an 18-question survey to explore participants’ perceptions of preparedness for the job application process and curricular training on the subject. Four clinician educators with expertise in survey design reviewed the survey and provided iterative feedback. Questions that targeted those who had completed the job search process and were planning to start a job in the next academic year included level of comfort with various phases of the job search and application process, level of familiarity with different types of job options, and resources utilized. All survey participants were asked if their most recent training program provided dedicated education about the job search process, if a career mentor had been identified, and how to best improve this training.

RESULTS: 146 trainees (40% of invited participants) responded to the survey invitation across multiple post-graduate years and medicine subspecialties. Over 30% of trainee respondents who had recently searched for a job reported feeling unprepared or very unprepared for various steps in the process. 45% of all trainees reported receiving dedicated education around the job application process; 63% of trainees applying for jobs had received dedicated teaching from their training program. Major areas of concern included how to find available positions, the timeline of the application process, types of career options, and practical considerations like contract negotiation and cover letter preparation. The majority of trainees felt unfamiliar with job opportunities outside of academic medical centers and community teaching hospitals. Trainees who had completed the job search process were more likely to identify a career mentor than those who had not (p = 0.006). While 68% of respondents had identified a career mentor, only 23% reported that this career mentor had been assigned by their training program. Participants felt that career navigation training should be repeated during multiple years of training.

CONCLUSIONS: A significant proportion of trainees who completed a job search did not receive education around the procress, and felt unprepared for discrete aspects of the job search process. Future curricula should be repeated in multiple years of training, especially via individualized dedicated career mentorship and small group.

A PRACTICAL AND SYSTEMIC APPROACH TO FORMULATE RANK ORDER LISTS FOR COUPLES MATCH

Xia Wu¹; Yihan Cao². ¹Internal Medicine, Tufts Medical Center, Boston, MA; ²Radiology, Massachusetts General Hospital, Boston, MA. (Control ID #4063776)

BACKGROUND: Living with a partner or family provides residents with both emotional and instrumental support, which is associated with decreased burnout and is critical for residents’ well-being. Since 1984, couples match has offered an opportunity for residency applicants who are applying simultaneously with their partners to coordinate their applications, and thus increase their chance of staying together. However, couples match is an exceedingly complicated process. In particular, finalizing the rank order list (ROL) is very difficult, and can be emotionally taxing. Here we propose a practical and systematic algorithm to make ROLs for couples match.

METHODS: A theorem was proposed and proved, “for two adjacent pairs of programs on a ROL of couples match, if their crossover combination ranks before the two pairs, the matching results will not change when they exchange in position (Figure 1).” Based on the theorem, a common difficult question — how to rank the following combinations: better program for Applicant A and worse program for Applicant B vs. worse program for A and better program for B — can be easily avoided. Subsequently, a useful corollary was proposed, "if two pairs of programs (not necessarily adjacent to each other) can be exchanged in position by repetitively using the above theorem, the matching results will remain the same before and after exchange."

RESULTS: Based on the above methods, we propose the following systematic approach to formulate an ROL: (1) Each partner makes their own ROL separately solely based on their preference, and labels the programs 1, 2, 3, … from top to down. (2) A preliminary couples’ ROL is generated by making the sum of the ranks of the program pair in increasing order. The matching result of the ROL is the same as the partners participate separately in the Match. (3) Adjust the ranking of program pairs that allow the partners to stay together or have other significant implications. In practice, many adjustments of ranking do not require a direct comparison of the adjacent program pairs as above. At other times, head-to-head comparisons are necessitated when the conditions of the theorem are not met.

CONCLUSIONS: Couples match remains a challenge that requires compromises and dynamic communication of the partners. However, the theorem and methods we propose can reduce the difficulty for couples in making their ROLs that best represent their interests and benefits.

ASSESSING ATTENDING PHYSICIAN EXPERIENCE, ATTITUDES AND PERCEPTIONS ON GENERAL MEDICINE INPATIENT TEACHING SERVICES ACROSS AN ACADEMIC LEARNING HEALTH SYSTEM

William C. Lippert¹; Jessica L. McCutcheon²; Greg Russell³; Kenneth Singhel²; Christina Rinaldi¹; Suma Menon¹; Parag Chevli¹; Jacqueline Lippert¹; Edward Ip³; Chi Huang¹. ¹Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; ²Department of Internal Medicine, Atrium Health, Charlotte, NC; ³Wake Forest University School of Medicine, Winston-Salem, NC. (Control ID #4026585)

BACKGROUND: Current studies continue to find high rates of reported burnout worldwide among attending physicians. However, many of the studies have been limited in assessing attendings well-being across multiple sites. Within our health enterprise, we have a diverse group of attendings who rotate on the inpatient general medicine teaching services. This group is comprised of hospitalists and general internists, who rotate on the inpatient teaching services for various durations at our tertiary medical centers and community hospitals. The purpose of our study was to evaluate the attending’s experience, attitude and perceptions on the inpatient general medicine teaching services at Atrium Health Carolinas Medical Center (AHCMC) and Atrium Health Wake Forest Baptist (AHWFB).

METHODS: After IRB approval was secured, all attending physicians supervising the inpatient general medicine teaching services at three institutions across our enterprise from July 1, 2022 - June 30, 2023, were invited to participate in the study. A 28-question survey was distributed via RedCap with up to 3 reminders over a 6-week period. All survey responses were anonymous and confidential. The survey results were also analyzed by a neutral third party using descriptive analysis with Fisher’s Exact tests utilized to assess differences in group responses.

RESULTS: 30 out of 54 attending physicians completed the survey (response rate: 56%). 12 (40%) of the attendings were based at AHCMC and 18 (60%) of the attendings were based at AHWFB. Attendings who were the primary caregiver to a family member/friend were more likely to experience feelings of depersonalization (p=0.031). Attendings who had <10 years of experience at their current institution were more likely to report having feelings of emotional exhaustion (p=0.041). Attendings with >10 weeks of inpatient service were more likely to report feelings of emotional exhaustion (p=0.041) and depersonalization (p=0.012). Attendings with protected administrative time had reduced feelings of emotional exhaustion (p=0.054), but they felt that non-patient care obligations (e.g., meetings) affected their ability to effectively teach the learners on the team (p=0.020). No statistical differences in feelings of emotional exhaustion, depersonalization, or reduced personal achievement were observed across the sites.

CONCLUSIONS: To the best of our knowledge, this is the first study to assess attending physician experience, attitude and perceptions across an academic learning health system. Symptoms of burnout were identified in those attendings who were the primary caregiver to a family member or friend, had less experience at their current institution (<10 years), and had more inpatient service (>10 weeks). Also, those with protective administrative time felt that non-patient care obligations affected their ability to effectively teach the learners on the team. Attention to these particular groups may be warranted to help improve attending well-being and professional fulfillment.

BURDEN OF EMOTIONAL EXHAUSTION AND ASSOCIATION WITH ATTRITION INTENT AMONG A NATIONAL SAMPLE OF FEMALE PHYSICIAN TRAINEES

Lila Steinberg¹; Ami N. Shah⁴; Maria A. Woodward⁵; Adrienne W. Mann^1,3; Tyra Fainstad². ¹Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ³Medicine, Veterans' Health Administration, Eastern CO Health Care System, Aurora, CO; ⁴Surgery, Rush University Medical Center, Chicago, IL; ⁵Perspectives Coaching Analytics LLC, Birmingham, MI. (Control ID #4062643)

BACKGROUND: Physician burnout disproportionately affects females and worsens during training. Physician attrition is a costly problem that is linked to burnout. Attrition intent is evident in training but its association with burnout is not well defined.

METHODS: This is a descriptive analysis of a baseline survey of female physician trainees at 26 GME institutions who enrolled in a digital coaching program in August 2022. Baseline data included attrition intent and burnout, as described by the Maslach Burnout Inventory (MBI) and its 3 subscales: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). We used established thresholds of EE ≥27 (range 0-54) and DP ≥10 to define the presence of burnout. Attrition intent was assessed in four domains: 1) intent to leave specialty within two years, 2) likelihood to leave program before graduation, 3) intent to stay at current institution if offered a job and 4) likelihood to recommend program to a medical student. Responses were recorded on a five-point Likert scale. Associations with attrition intent and EE were assessed using univariable linear regression.

RESULTS: 1,017 trainees responded to the survey and 781 completed the full MBI. The average age was 30.8 years, 959 self-identified as a woman, 843 as heterosexual and 540 as White. 207 were in post graduate year (PGY) 1, 198 in PGY-2 and 595 in PGY-3 or beyond. 186 were surgical trainees. 570 (73.0%) met criteria for burnout, with 788 experiencing EE and 810 DP. There was a significant association with overall burnout and EE, DP and PA. 267 had intent to leave their specialty within 2 years, 175 had intent to leave their program before graduation, 105 had no intent to stay at their current institution if offered a job and 38 would definitely not recommend their training program to a medical student. There was a positive association between all reported levels of attrition intent and EE.

CONCLUSIONS: This study demonstrates a strong association between attrition intent and burnout. It underscores the opportunity for training programs and health systems to measure and address burnout early in training, potentially impacting retention of early career women physicians.

BURNOUT AND THE BARRIERS AND FACILITATORS OF HELP-SEEKING IN INTERNAL MEDICINE RESIDENTS

Lauren G. Navitsky, Dylan Yang, Brielle Spataro. Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #4064867)

BACKGROUND: Burnout, a psychological syndrome characterized by emotional exhaustion, depersonalization, and a sense of low personal achievement, is becoming increasingly more prevalent among physicians. Burnout negatively impacts patient care, health care costs, and physician health. Although burnout appears to be highest among resident physicians, trainees have generally been low users of interventions that aim to minimize burnout, including those that promote help-seeking. Prior research has shown that time, access, cost, concerns about confidentiality, and a preference for self-management are some of the most cited reasons for why resident physicians do not seek help when experiencing emotional distress. Furthermore, prior data suggest that resident physicians experiencing burnout face even greater perceived barriers than those who are not. This study aims to use qualitative methods to describe the systematic and cultural barriers and facilitators of help-seeking in internal medicine residents.

METHODS: Study participants were recruited from a single academic medical center. Participants completed a survey that included the Maslach Burnout Inventory (MBI) and basic demographic information. Using an approach previously described in the literature, MBI scores were used to sort residents into one of two interview groups: residents experiencing burnout and residents not experiencing burnout. Participants from each group were invited to complete 30-minute semi-structured interviews. The interviews explored residents’ experiences with burnout and help-seeking as well as the systematic and cultural factors that facilitated or prevented help-seeking. Interviews were conducted by a trained interviewer and transcribed verbatim. A codebook was developed using an inductive approach, and after coding, a thematic analysis was performed.

RESULTS: Forty-nine residents completed the survey with most respondents (73.5%) scoring positive for burnout. Twenty residents (10 experiencing burnout and 10 not experiencing burnout) completed interviews. Qualitative interviews describe variability in burnout and help-seeking experiences. Factors that promote help-seeking include schedules that incorporate built-in personal time and cultures where help-seeking is openly discussed and normalized. Factors that prevent help-seeking include schedules that do not allow for autonomy and flexibility and well-being resources that require a high degree of activation energy to access.

CONCLUSIONS: This study expands upon existing knowledge about help-seeking in residents, and to our knowledge, it is the first study to explore the systematic and cultural factors that promote and prevent help-seeking using qualitative methods. Though burnout and help-seeking experiences are unique to individuals, the factors that promote and prevent help-seeking are actionable and could be used to guide system-level changes to improve trainee well-being in the future.

CRYING IN THE STAIRWELL: A NEEDS ASSESSMENT ON HOW AND WHERE INTERNAL MEDICINE RESIDENTS PROCESS GRIEF

Lauren Phinney, Alyssa Perez. Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4064140)

BACKGROUND: Grief is a response to bereavement and is a complex process characterized by symptoms that ebb and flow over time. Medical trainees encounter patient deaths commonly and often feel personal bereavement in relation to patient deaths. During the Covid-19 pandemic, medical providers experienced increased burnout in relation to grief, and many structured programs for resident support around grief and death were postponed. This study aims to evaluate how Internal Medicine residents process work-related grief to subsequently identify interventions to support trainees.

METHODS: A gap analysis was conducted using a survey and focus groups. Internal Medicine residents at a large training program completed a needs assessment survey with Likert scale and free response items. Survey development was rooted in prior feedback from residents and focused on frequency of and reaction to grief-inciting events in the clinical environment. Respondents were then invited to participate in focus groups with semi-structured interviews which were guided by survey data. Survey data were analyzed with descriptive statistics. Qualitative content analysis from focus groups interviews provided further insights on resident grief processing and resident suggestions.

RESULTS: Sixty-six respondents completed the survey. Eighty nine percent experience a grief-inciting event in the clinical environment at least monthly. Respondents cited events of challenging patient cases, loss of patients, burnout as contributor, and larger systemic issues. Fifty percent felt somewhat supported at work, and thirty-one percent felt minimally or unsupported. Ten residents subsequently participated in four focus groups. Qualitative data analysis revealed barriers to grief processing such as lack of time or physical space due to ongoing clinical duties, insufficient training in supporting junior team members, compilation of frequent traumatic events and hierarchy-dependent culture determining extent of grief-processing. Residents reported experiencing guilt, shame, numbness, and anger in relation to incomplete processing of grief. Respondents offered suggestions for improved support to prevent burnout secondary to grieving: embedded time and space for processing after traumatic events, formal grief training, peer support programs and culture shifts to promote time for bereavement.

CONCLUSIONS: Grief experienced in the clinical environment is a common occurrence for residents and is often inadequately processed. This study identifies resident-perceived barriers to grief processing and potential factors that may address these deficiencies and improve overall resident wellbeing. Next steps involve implementation of Kern’s steps for curriculum development in standardizing grief processing practices and addressing culture around bereavement in the clinical environment.

DOUBLE THE BENEFITS: OUTCOMES OF A PEER-BASED COACHING AND MENTORING PROGRAM

Andrea Sikon¹; Jordan Alpert²; Elaine E. Schulte³. ¹Dept. of Internal Medicine & Geriatrics, Cleveland Clinic, Cleveland, OH; ²Center for Value-Based Care Research, Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; ³Pediatrics, Children's Hospital at Montefiore, New York, NY. (Control ID #4063967)

BACKGROUND: In 2009, a large non-profit academic health center developed a peer-based coaching and mentoring program for physicians and research scientists. A prerequisite 8-hour training for all potential program enrollees clarified role definitions and provided skill based interactive training with observation and feedback. Training participants were then invited to join the program as a coach, mentor, and/or coachee/mentee. Coachees were matched with a peer coach and could also match with multiple mentors in different domains according to need.

METHODS: A survey assessed the impact of the program for participants across roles. Respondents were asked to rank how their participation influenced three domains: engagement, resilience, and job fulfillment. A 5-point Likert scale was utilized, ranging from “not at all” to “substantially.” Survey questions were aligned with Press Ganey® survey question language. Univariate descriptive statistics were calculated and the non-parametric Wilcoxon signed-rank test determined differences among categories.

RESULTS: 177 responded to a 2020 periodic survey (32% among coachees/mentees-CE/ME and 27% response rate amongst coaches/mentors- C/M). 47.5% were coached, 40% were mentored, and 12.5% received both coaching and mentoring. 41.9% were coaches, 16.1% mentors, and 47.9% served as both a coach and mentor. 77.1% CE/ME and 87.5% C/M were involved in the program for at least two years. Participants reported that the program strengthened engagement, resilience, and fulfillment. Engagement: 89.8% program increased their sense of value as a member of the organization; 88.1% expanded relationships with colleagues; 84.2% found meaning in their work. Resilience: 85.69% program increased their dealing with conflict; enhanced their sense of empowerment (84.5%); increased use of utilize asset-based thinking (84.8%). Fulfillment: 84.7% felt more in control when dealing with difficult problems; work was meaningful (83.6%); and worthwhile at work (81.9%). Participants reported using coaching skills with colleagues (CE/ME 90.3%; C/M: 80.9%), patients (CE/ME 81.3%; C/M 73.7%) and in their personal lives (CE/ME 86.5%; C/M 78.5%). The program contributed to the decision of nearly two-thirds (CE/ME 62.7%; C/M 61.9%) to stay at the organization.

No significant difference existed based on race for all the variables except for CE/MEs utilizing skills with colleagues (white: 92%, non-white: 87%; p<0.05). No significant differences existed between coaches/mentors and those being coached/mentored among all the variables.

CONCLUSIONS: A peer coaching and mentoring program enhanced participants’ engagement, resilience, and fulfillment for all, regardless of role or race. Such programs are valuable for improving retention and making individuals feel important within the organization. As both those on he receiving end as well as peer coaches and mentors gain the same benefits from participation, this can in essence double the benefits for the organization.

EARLY DRIVERS OF PRIMARY CARE WORKFORCE SHORTAGES: BURNOUT MEASURES ASSOCIATION WITH LONGITUDINAL VERSUS ACUTE CARE SPECIALTY CHOICE IN US MEDICAL STUDENTS

Rachel H. Kon²; Soham Ali²; James R. Martindale¹; Tabor E. Flickinger². ¹Medical Education, University of Virginia, Charlottesville, VA; ²Medicine, University of Virginia School of Medicine, Charlottesville, VA. (Control ID #4063466)

BACKGROUND: The United States faces a shortage of psychiatry and primary care physicians that care for patients longitudinally. Research into recent shifts away from primary care careers among US MDs suggests associations with burnout, among other factors. Burnout includes emotional exhaustion (EE) and depersonalization (DP) (characterized by cynicism, resentment, and disconnection), which may lead to avoiding longitudinal patient relationships. Burnout measures are high in medical students during clerkship year when they are making specialty choice decisions. We hypothesized that higher EE and DP during clerkship are associated with choosing specialties with minimal longitudinal care.

METHODS: All medical students at a large US academic center were sent an annual wellbeing survey in 2015-2021 that included the 22-item Maslach Burnout Inventory (MBI). Data was collected at orientation, end of pre-clerkship, during late clerkship, and just before match day. The IRB approved following students with unique identifiers which were linked to a database of educational outcomes including NMRP Match results. Match specialties were categorized into acute and longitudinal care specialties similar to past studies. Cross-sectional 1^st through 4^th year student burnout EE and DP differences by specialty choice were analyzed using Hotelling’s multivariate t with the Wilks’ Lambda statistic for p value determination and partial eta squared for effect size.

RESULTS: Specialty choice was available for 96% of students who completed the MBI (mean response rate 45%). EE and DP levels were analyzed for 205 1st-year, 258 2nd-year, 316 3rd-year, and 313 4th-year students pooled from 6 academic years of survey administration. EE mean scores (SD) were 18.57 (10.82), 24.33 (10.38), 25.65 (11.13), and 18.57 (9.67) for 1st, 2nd, 3rd, and 4th-years respectively. DP mean scores (SD) were 3.86 (4.40), 5.52 (5.06), 9.06 (6.06), and 8.04 (5.70) for 1st, 2nd, 3rd, and 4th-years respectively. Students who chose acute care specialties had higher levels of EE [25.7 (11.8) vs. 25.5 (10.3)] and higher levels of DP [9.6 (6.3) vs. 8.4 (5.7)] during their third year of medical school than those who chose longitudinal care specialties. These differences did not reach statistical significance.

CONCLUSIONS: Burnout levels seen were similar to national studies showing that late clerkship is a time of high emotional exhaustion and depersonalization for medical students. Those students who chose acute care rather than longitudinal care specialties had higher levels of depersonalization, but this did not reach statistical significance. Larger studies of burnout across multiple institutions may see a further trend. The categorization of specialties is limited by match data for internal medicine, family medicine, and pediatrics that does not tell us if physicians end up practicing longitudinal care or hospital-based medicine specialties. While likely only one of multiple factors influencing specialty choice, burnout is potentially modifiable.

EVERYONE WINS: PROFESSIONAL AND PERSONAL BENEFITS OF A PEER-BASED COACHING PROGRAM FOR FACULTY

Andrea Sikon¹; Jordan Alpert²; Elaine E. Schulte³. ¹Dept. of Internal Medicine & Geriatrics, Cleveland Clinic, Cleveland, OH; ²Center for Value-Based Care Research, Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; ³Pediatrics, Montefiore Health System, Bronx, NY. (Control ID #4060162)

BACKGROUND: Faculty at a large, non-profit academic medical center participated in a peer coaching program to facilitate career and leadership development. After 32 hours of coaching skills training, peer coaches matched with coachees to identify career goals, reflect strengths, align goals with values and develop an action plan with accountability.

METHODS: A survey assessed the impact of the peer-based coaching on professional and personal development for both coachees and coaches. Using a mixed-method design, univariate descriptive statistics were calculated and the non-parametric Wilcoxon signed-rank test determined differences among categories. A free response question was analyzed qualitatively using an inductive, thematic approach.

RESULTS: 105 participants completed a survey (47% response rate amongst coaches; 37% among coaches). Coaches identified as 82% white, 16% non-white, 7% Hispanic, and 83% matched with an average of 2 coachee colleagues. Coachees identified as 68% white, 32% non-white, 6% Hispanic, and 60% were in a coaching relationship for <1 year.

Professionally, coaches helped coachees identify meeting objectives (96%), link goals and actions to values (95%), feel worthwhile at work (93%), enhance their sense of meaning at work (93%), and improve happiness at work (93%). 67% of coachees reported that coaching impacted grant acceptance, promotions, and publications. Personally, coachees learned to express empathy (97%), see things from a new perspective (97%), clarify goals, motivations, and values (95%). Coaches were able to create a safe relationship (97%), build confidence (95%), and help coachees reflect and reframe (95%). 67% of coachees agreed that the coaching program impacted their decision to stay at the organization.

Coachees’ qualitative responses about the program’s impact included two themes. Theme 1: Relationship centeredness. Participation fostered trusted and close relationships; 1a) Safe space: coachees felt comfortable expressing concerns; 1b) Emotional support: coachees benefited from discussing problematic issues; 1c) Confidence: improving self-worth. Theme 2: Shape career trajectory. Coachees felt successful in leadership roles 2a) Alignment: merging personal and professional goals; 2b) Improved communication: interacting with supervisors effectively.

Coaches also achieved positive outcomes. Coaches felt valued by the organization (100%), were able to find meaning at work (98%), and used coaching skills with colleagues (100%), patients (98%) and in their personal lives (100 %). Qualitatively, coaches 1) became better listeners, 2) found purpose by helping others, and 3) formed meaningful relationships. 68% of coaches agreed that the program impacted their decision to stay at the organization. No significant differences were found based on race or between coaches or coachees.

CONCLUSIONS: A peer-based coaching program fostered relationship-centeredness and impacted coachees’ career trajectory. Similar benefits were experienced by both coachees and coaches.

IDENTIFYING INDIVIDUAL FACULTY DEVELOPMENT PROFILES OF ACADEMIC GENERAL INTERNISTS IN ORDER TO BETTER TAILOR ACADEMIC ADVANCEMENT RESOURCES

Rachel Havyer¹; Meredith DeZutter²; Shelby Gathje³; Sagar Dugani¹. ¹Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Kern Center for Science of Health Care Delivery, Mayo Clinic Minnesota, Rochester, MN; ³Mayo Clinic Minnesota, Rochester, MN. (Control ID #4064829)

BACKGROUND: A disparity exists in the academic promotion of academic general internists compared with subspecialty internists in our academic institution. We sought to better understand the individual and structural factors contributing to this promotion disparity in order to guide institutional and divisional strategies to help promote academic advancement among general internists.

METHODS: Using human-centered design approaches, interviews were conducted from June to September 2022 by an experienced designer with 6 senior and 14 junior academic internists across our institution’s 3 general medicine divisions (community internal medicine/geriatrics/palliative care, general internal medicine, and hospital internal medicine). Faculty development journey maps were created by the designer based on the experiences of the interviewed faculty with iterative discussions by the team to discover themes, identify profiles and ideate on system solutions.

RESULTS: Along the journey maps of faculty development, three types of internist profiles were identified: hesitators (slower start in research with lack of experience/mentoring), explorers (open to increasing scholarly activity with need for further support in skills and mentoring) and drivers (clear goals, research experience and established network). Three common themes emerged as opportunities to help promote academic advancement: 1) identifying a research focus, 2) nurturing peer and mentor collaborative relationships, and 3) supporting skill building and mentoring in research scholarship.

CONCLUSIONS: Academic internists are diverse in their skills, experience and motivations for academic advancement. Helping to identify the individual profile of junior faculty may provide better tailored faculty development interventions to help value faculty diversity and support earlier academic advancement. Further work is needed on tool development for identifying profiles and connecting faculty to tailored resources according to need.

INITIATIVES TO SUPPORT HOME-LIFE OF WOMEN IN MEDICINE: A SCOPING REVIEW

Christina J. Kelly¹; Stephanie Abbuhl²; Barbara J. Turner¹. ¹Medicine, Keck Hospital of USC, Los Angeles, CA; ²Emergency Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4063675)

BACKGROUND: Numerous initiatives and programs address job-related inequities for women versus men in medicine but far less is known about initiatives to support women’s greater home-life responsibilities. We undertook a pilot scoping review of interventions and recommendations from professional and other physician groups to support home-life of women in medicine.

METHODS: We conducted a PubMed search with a librarian to find 2010-2023 publications on interventions or potential solutions to home-life demands of women in medicine, using terms such as female physician, childcare, work hours, maternity leave, lactation, and eldercare. Eligible studies in English or French included: 1) intervention studies or 2) recommendations from professional society, physician survey, or literature synthesis. Excluded studies focused on: work-related efficiency; career advancement; work satisfaction; barriers to home-life support; or commentaries. One author (CK) reviewed all titles and 2 authors (CK and BJT) examined abstracts and full text publications as well as references for eligible studies. One author (SA) resolved disagreements. We adapted Joanna Briggs Institute Manual for scoping reviews to classify studies by population, study type, intervention, or recommendation(s), and context (community vs academic).

RESULTS: Removal of duplicates yielded 850 titles meeting search criteria. We identified 51 potentially relevant abstracts and references from studies. Abstract review excluded 26 studies followed by full text review of 25 papers. This scoping review included 19 publications. Three were empiric studies with women physicians. One retrospective pre-post Turkish study of 109 women physicians examined changes after a law to reduce pre- and post-delivery working hours, resulting in increased breastfeeding after the law. One case control (no N) study of a new lactation room reported that women returned to work sooner. One case-control study of 60 faculty offered credits from work activities for home services or research support and increased professional satisfaction. Of 16 papers with recommendations to support home-life, 2 were literature syntheses and 14 offered recommendations from multi-institutional surveys or interviews of: 3 medical professional groups; 6 academic settings; 1 rural setting; and 4 academic/rural settings. Recommendations focused on: 1) childbearing (e.g. maternity leave, modified job role), childrearing (e.g. onsite childcare, lactation support); 2) work flexibility (e.g. reduced hours, job sharing; staffing to cover); 3) eldercare; and 4) fostering household support (e.g. partner, family, community).

CONCLUSIONS: Although women physicians serve a vital role in healthcare, this scoping review identified few studies of interventions addressing home-life support while academic and community groups have offered recommendations about opportunities. This evidence gap must be addressed to promote sustainable, satisfying careers and home lives of women in medicine.

KNOWLEDGE, ATTITUDES, AND PRACTICE OF TRAUMA-INFORMED CARE AND CHILDHOOD POSITIVE AND ADVERSE EXPERIENCES AMONG MEDICAL STUDENTS AND CLINICAL INSTRUCTORS AT UNC SCHOOL OF MEDICINE

Angelica R. Lackey¹; Alexandra Stanford¹; Jason Hu²; Erin Malloy³; Amy Weil⁴. ¹The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ²Department of Statistics and Operations Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC; ³Department of Psychiatry, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ⁴Department of Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC. (Control ID #4063405)

BACKGROUND: Trauma is ubiquitous with earlier experiences particularly impacting health and wellbeing. Studies have shown medical students have adverse childhood experiences (ACEs) similar to the general population, increasing the risk of burnout, depression, and professional lapses. Medical education curricula and learning environments also pose risks of vicarious traumas, instilling new distress or retraumatizing learners. Institutions are responsible for anticipating these needs in a trauma-informed manner. Yet, prior to implementing appropriate training, it is prudent to characterize communal needs and understand existing knowledge, attitudes, and practice of trauma-informed care (KAP-TIC) to ascertain preparedness for safe, effective teaching and learning. Accordingly, the study explored students’ and preceptors’ KAP-TIC and the relation to childhood experiences. We hypothesized that those in medicine have positive experiences to buffer early adversities and that those exposed to higher adversity would have higher KAP-TIC scores.

METHODS: A 52-item survey was offered to all UNC School of Medicine medical students (n = 757) and clinical instructors (n = 150). The assessment included three validated tools: knowledge, attitudes, and practice of trauma-informed care (KAP-TIC) (21 item 5-point Likert scale); expanded ACEs (21 items, assessing discrimination, safety, bullying, foster care, and conventional ACEs); and benevolent childhood experiences (BCEs) (10 items).

RESULTS: A total of 133 participants completed the survey (89 medical students and 44 clinical instructors) with a response of 14.7%. Sixty-seven percent (n = 89) reported at least one conventional ACE, and 18% (n = 24) reported four or more. Almost half (47%) grew up with a parent or caregiver who had mental illness. Forty-two percent (n = 56) reported at least one of the five expanded ACEs, and 17.3% reported two or more. The mean BCE score was 9.0 out of 10 (SD 1.5). For assessment of KAP-TIC, 83% strongly agreed trauma affects well-being. However, responses showed greater variance about trauma prevalence, with only 43% strongly agreeing trauma is common. Additionally, while 66% (n = 88) strongly agreed that TIC is essential for clinical work, only 23% endorsed comprehensive TIC understanding. Overall, participants with ≥4 total ACEs had 2.24 times the odds of being in stronger agreement across all KAP-TIC measures (95% CI 0.92-5.43).

CONCLUSIONS: Students and instructors had childhood experiences comparable with the general population, with a high proportion of positive experiences even among those with higher ACEs. Still, almost half (47%) grew up with a caregiver with mental illness; higher than NC and US adults (15.2% and 17.3%), which bears further study. The findings also underscored educational gaps by the strongly endorsed importance of TIC with a coinciding lack of understanding. The study will continue data collection, analyzing relations of childhood experiences and KAP-TIC between groups and by clinical exposure.

LEADERSHIP AND GENDER-DISPARITIES IN BURNOUT: CAN LEADERSHIP AFFECT THE GAP?

Rachel Hannum²; Scott D. Rothenberger³; Yihao Zheng¹; Jon Arnold¹; Jennifer Berliner⁴; Jane Liebschutz¹; Andrew J. Klein¹. ¹Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²The Ohio State University, Columbus, OH; ³Medicine, University of Pittsburgh, Pittsburgh, PA; ⁴UPMC, Pittsburgh, PA. (Control ID #4064318)

BACKGROUND: Using the validated Leadership Quality Index, more highly rated leaders have been associated with reduced rates of burnout among their physician teams. At the same time, burnout has been shown to disproportionately affects female physicians more than male. We examined whether more highly rated leaders can close gender disparities in physician burnout.

METHODS: We analyzed results of the Healthcare Professional Well-being Consortium survey of physicians at a large academic health system in 2018 and 2020. Professional Fulfillment Index (PFI) measured individual burnout (0-10 scale) and professional fulfillment (0-10 scale) with higher scores indicating more burnout or fulfillment, respectively. Respondents rated their direct supervisors’ leadership using the Leadership Quality Index (LQI) (0-4 scale): a higher score indicates better leadership. We modeled the association of LQI and physician gender with burnout and fulfillment in regression models adjusted for demographics (age, years practicing, and specialty). We a priori identified additional variables as potential confounders (% clinical time, partner’s employment status, parenting status, EHR experience, control over schedule, support for family needs, relationship status, caring for elderly or dependent parents, and pregnant or young children) and used backward elimination with a criterion of p<0.20 to arrive at our final model for each year. In our final model, we included an interaction term between gender and leadership quality to assess for moderation. The primary outcome was the moderating effect of leadership on the association between gender and burnout in 2018 and 2020.

RESULTS: We analyzed 2576 responses (66%) from 2018 and 2457 responses (51%) in 2020. A minority of respondents identified as female (40.0% and 41.2% in 2018 and 2020, respectively). Mean burnout score was 3.10 (SD 2.04) in 2018 and 2.78 (SD 1.96) in 2020. The mean overall leadership quality was similar both years, 2.60 (SD 1.01) in 2018 and 2.77 (SD 0.98) in 2020 (p=0.17), with a higher score associated with lower overall physician burnout in both years (p<0.01). Male and females scored similarly on the burnout scale in 2018 (p=0.41). Males scored 0.24 points lower on burnout scales in 2020 than females (p<0.01). Leadership significantly moderated the association between gender and burnout in 2018 (B=-0.15; p=0.04) with higher LQI leading to lower burnout scores for males than females. No moderation was seen in 2020 (p=0.23).

CONCLUSIONS: We found higher leadership ratings moderated the effect of gender on burnout in 2018, with higher leadership scores associated with reduced physician burnout more among men than women. This moderation disappeared in our 2020 data. These results suggest that local leadership can have an important impact on disparities in physician burnout between men and women. Further analysis is needed to better understand this relationship and impact of the global COVID19 pandemic.

MENTORING THE ACADEMIC INTERNAL MEDICINE HOSPITALIST

Kimberly Bloom-Feshbach¹; Maria Klimenko²; Kimberly Fluet³; Valerie J. Lang⁴. ¹Medicine, Weill Cornell Medicine, New York, NY; ²Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ³Center for Professional Development and Education Reform, University of Rochester Warner School of Education, Rochester, NY; ⁴Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY. (Control ID #4063601)

BACKGROUND: Burnout and attrition are common in hospital medicine,¹ especially among women and underrepresented minority (URM) faculty,² and lead to increased patient mortality and healthcare spending.^3-5 Mentoring is one solution to enhance faculty self-efficacy, vitality, and retention.^6,7 As part of a study of academic hospitalists, we explored the mechanisms of impact of mentoring on professional identity formation (PIF).

METHODS: We used a social-constructivist paradigm in this qualitative^8-11 research and engaged in thematic analysis¹² informed by theoretical frameworks of identity development, including communities of practice, in medical education^13-16. We conducted ten 1-hour long virtual focus groups with a total of 31 hospitalists from 3 academic medical centers. A question was asked specifically pertaining to mentoring: “How have mentors impacted your career?” Four qualitative researchers developed codes, categories and themes, through an iterative thematic analysis process.^17-19 Each transcript was coded by multiple investigators, who engaged in reflexivity²⁰ and memoing of their process and codes generated. Codes were compared across focus group transcripts by the study team to resolve discrepancies in code or category.

RESULTS: The hospitalists had a mean of 7.7 years of hospitalist experience (range: 1 to >20). Participants identified as white (74.2%) or Asian (29.0%); the majority were female (64.5%). Distinct models of mentoring across institutions contributed to academic hospitalist PIF including: dyadic mentoring, peer mentoring, organic mentoring, and mentoring teams, each with benefits and limitations. Across mentoring models, nine key mentoring actions impacted PIF and influenced hospitalists’ careers and location of self: role modeling, guiding, shaping perspectives, supporting, challenging, sponsoring, empowering, maintaining accessibility, and navigating uncertainty. Several limitations and barriers to effective mentoring of hospitalists emerged including lack of mentoring awareness, lack of access to experienced mentors, poor quality mentoring, lack of time, and lack of mentor-mentee alignment. In addition, some aspects of hospitalists’ professional identity posed barriers to mentoring, including the breadth of academic interests and avoidance of mentoring related to variability and ambivalence around academic identity.

CONCLUSIONS: Mentoring plays a pivotal role in the PIF of academic hospitalists. However, access to effective mentoring remains lacking due to few senior mentors in the relatively new field of hospital medicine, low quality mentoring, and variability and reticence in academic identity. The sample lacked representation of URM hospitalists, and research is needed to explore their mentoring needs. Our work should prompt consideration of mentoring training for hospitalist mentors and mentees, and integration of mentoring into institutional culture and promotions criteria.

PREVALENCE AND PREDICTORS OF PRIMARY CARE PHYSICIAN REDUCTIONS IN CLINICAL EFFORT: A NATIONWIDE ANALYSIS

Lisa Rotenstein^1,2; Gabriel Weinreb³; Nate Apathy⁴; A Jay Holmgren²; Bruce E. Landon⁵. ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²University of California San Francisco, San Francisco, CA; ³Harvard Business School, Boston, MA; ⁴MedStar Health, Columbia, MD; ⁵Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #4064148)

BACKGROUND: Primary care physicians (PCPs) in the United States face diverse and expanding demands, resulting in burnout and workforce attrition. While PCPs reducing their clinical effort to enhance the perceived manageability of the job is often discussed, the true prevalence of changes in PCPs’ clinical effort has not been well characterized.

METHODS: We used May 2019 to April 2022 data from the national Epic Signal database, which includes appointment and electronic health record (EHR) use information from >400 institutions across the US. Our analysis focused on PCPs present in the dataset at the start of the study period.

We quantified the distribution of quarter-to-quarter changes in PCPs’ mean weekly appointment volume (excluding Q1 of 2020 COVID appointment volume changes) and the percent of days with scheduled appointments per week. We subsequently identified the percent of PCPs who had a quarter-to-quarter decrease or increase of ≥10% in weekly appointment volume or percent of weekly days worked that was sustained for an additional two quarters. Finally, we estimated multivariate logistic regression models to identify factors associated with sustained reductions or increases in PCPs’ appointment volume.

RESULTS: The sample included a median of 37,621 PCPs each quarter, 85% of whom worked in an organization with both hospital and clinic facilities and 31% of whom worked in an academic health system. Across the sample, PCPs completed a median of 43.6 appointments per week across a median of 3.5 days per week with appointments.

A median (IQR) of 8.0% (6.8%, 11.9%) of PCPs had a decrease of ≥10% in weekly appointment volume and sustained this reduction over two additional quarters and 6.0% (5.6%, 8.8%) had a sustained reduction of ≥10% in weekly days with appointments. Meanwhile, a median of 12.4% (11.1%, 13.1%) and 11.6% (9.0%, 13.5%) of PCPs had a sustained increase of ≥10% in weekly appointment volume and weekly days with appointments, respectively.

In a multivariate logistic regression model, working in an academic medical center (OR: 1.07 (95% CI: 1.04, 1.09)) or a safety net hospital (OR: 1.18 (95% CI: 1.15, 1.21) was associated with greater odds of a ≥10% reduction in weekly appointment volume sustained over two quarters. On the other hand, working in a Catholic hospital (OR: 1.05 (95% CI: 1.01, 1.08)) was associated with greater odds of a ≥10% increase in weekly appointment volume sustained over two quarters. PCPs in the North and West (versus the South) were more likely to have sustained reductions in weekly appointments.

CONCLUSIONS: In this nationwide, longitudinal analysis, we characterize trends in PCPs’ clinical effort from 2019 to 2022. Reductions in clinical effort were more likely to occur in academic medical centers, safety net hospitals, and specific geographic regions, while sustained increases in appointment volume were more likely to occur in Catholic hospitals. These findings shed novel light on PCPs’ work patterns and the factors that influence them.

PROFESSIONAL IDENTITY ESSAYS DEMONSTRATE HOW THE COVID-19 PANDEMIC ENRICHED ENTERING MEDICAL STUDENTS’ PROFESSIONAL IDENTITY FORMATION

Lisa Mayevsky¹; Stephanie Zhang¹; Elizabeth L. Wargo¹; Matthew Kijowski¹; David Garcia¹; Lisa Altshuler²; Lynn Buckvar-Keltz². ¹Program for Medical Education Innovations and Research, NYU Langone Health, New York, NY; ²Medicine, NYU Langone Health, New York, NY. (Control ID #4056584)

BACKGROUND: We explored the impact of the pandemic on entering medical students’ reflections on their professional identity, based on a reflective writing exercise (Professional Identity Essay – PIE) completed by all entering students at academic medical center.

METHODS: The PIE consists of nine free-response prompts designed to elicit students’ beliefs around expectations from themselves, the profession, and society as well as any potential challenges in meeting these expectations. We examined the PIEs of 93 students entering in 2019 and 94 students entering in 2022. Two readers conducted a thematic analysis of the 2019 PIEs, and four raters conducted the same analysis of the 2022 PIEs. For the 2022 PIEs, the codes derived from the 2019 PIEs were used as a base, with one new parent code (“COVID”) and various child codes added in the process. We compared findings from both datasets to identify any impact the pandemic may have had on incoming medical students’ understanding of professional identity.

RESULTS: Three themes emerged, 1) awareness of negative perceptions of physicians, 2) moral aspirations of the profession, and 3) concerns about failing to meet goals. Compared to students entering in 2019 (average age 28, range 24-36), students entering medical school in 2022 (average age 24, range 22-31) exhibited a greater awareness of negative perceptions largely noting the loss of societal trust and unrealistic expectations. One student noted, the “explosion of misinformation and subsequent distrust of science that has plagued our society in recent times is something we must continually fight against”. These students strongly viewed the importance of impacting healthcare policy and systems, one noting the “archetypal physician is not only able to operate within the boundaries of [social and geopolitical influences], but to play a central role amidst these influences in shaping the landscape of healthcare”. More students expressed a greater desire to be a leader, address issues of justice, and contribute to advancing medicine through policy. Moreover, they exhibited a more sophisticated understanding of physicians as both individuals and collectives. As one student noted, the pandemic “helped me realize that being a professional isn’t an exclusive identity” and how “other identities and unique experiences give us more insight into our careers”. A third of 2022 learners explicitly mentioned the pandemic, mostly in terms of loss of trust, physician sacrifice, and personal growth.

CONCLUSIONS: Students in the later class have a deeper understanding of the physician’s role within society and the medical community, yet perhaps paradoxically also attach greater significance to individuality within the profession. These students exhibit more gratitude and humility surrounding the profession but also struggle more with societal and self-imposed expectations, suggesting the experience of the pandemic has brought heightened social consciousness and personal pressure to meet wide-reaching expectations.

SEX DIFFERENCES IN AGE OF PHYSICIAN WORKFORCE ATTRITION ACROSS SPECIALTIES: A NATIONWIDE, LONGITUDINAL ANALYSIS

Lisa Rotenstein^1,3; Zili He²; Edward Melnick²; Cameron Gettel². ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Yale School of Medicine, New Haven, CT; ³University of California San Francisco, San Francisco, CA. (Control ID #4064077)

BACKGROUND: Compounding multiple workforce pressures facing the US healthcare system, a physician shortage is projected by 2034. Prior work has demonstrated that female physicians are more likely to reduce their clinical load or leave the workforce. However, the relative timing of workforce attrition for female versus male physicians, as well as how these measures vary by specialty and geographic setting, have not been well characterized.

METHODS: Physicians and their demographic characteristics were identified via the Centers for Medicare and Medicaid Services 2013 to 2020 Provider Utilization and Payment data, with specialties aggregated into 6 standardized groups. Physicians were included in the analysis if they received reimbursement for at least 50 Evaluation and Management services as per Medicare Part B claims in any study year. Physicians were defined as entering the workforce in a particular year if they were not identified in any preceding year dataset. Attrition was defined as clinicians leaving permanently during the study timeframe.

Using linked information about physician age, we identified mean ages of workforce exit and compared these values by sex using Wilcoxon Rank Sum Tests. We then built multivariable linear regression models with an outcome of age of attrition, adjusting for physician sex, physician specialty, and rural versus urban practice location. Bonferroni corrections were used to adjust for multiple comparisons.

RESULTS: The study sample consisted of a total of 738,205 physicians. Primary care (27.8%) and hospital-based specialty physicians (28.6%) were most represented in the sample.

In unadjusted analyses, female and male physicians exited the workforce at a mean (SD) age of 48.9 (11.8) and 57.7 (13.2) years, respectively. In adjusted analyses, female physicians had significantly lower mean ages at attrition than male physicians across specialty groupings: -7.5 years (95% CI: -8.8, -6.1; p<0.001) in primary care, -4.3 years (95% CI: -5.81, -2.80; p<0.001) in hospital-based specialties, -6.6 years (95% CI: -8.4, -4.8; p<0.001) in medical specialties, -9.9 years (95% CI: -13.8, -5.9; p<0.001) in obstetrics/gynecology, -4.8 years (95% CI: -8.4, -1.2; p<0.001) in psychiatry, and -6.9 years (95% CI: -9.4, -4.4; p<0.001) in surgical specialties. When controlling for specialty, female as compared to male physicians had significantly lower ages at attrition in both rural and urban settings.

CONCLUSIONS: In this national, longitudinal analysis, we demonstrate that across specialties, female physicians leave the workforce significantly earlier than male counterparts. Notably, the greatest disparities in attrition age were present in primary care and gynecology, which have the greatest representation of female physicians. Our findings suggest the need for concerted attention to the structures and biases that drive earlier attrition for female physicians.

STORIES THAT BRIDGE US: A MIXED METHODS STUDY TO UNDERSTAND THE IMPACT OF A HOSPITAL-WIDE STORYTELLING EVENT

Maria F. Nardell^1,2; Malini M. Gandhi³; Barbara Sarnoff Lee⁴; Amy Wasserman⁵. ¹Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Brigham and Women's Hospital, Boston, MA; ³Harvard Medical School, Boston, MA; ⁴Social Work and Patient Family Engagement, Beth Israel Deaconess Medical Center, Boston, MA; ⁵Organizational Development, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4062022)

BACKGROUND: Oral storytelling events for healthcare professionals are gaining in popularity, yet evaluation of these initiatives is scarce. We designed a hospital-wide storytelling event at an academic medical center in New England and assessed the impact of the event for attendees and storytellers.

METHODS: This study was grounded in social constructivism, which posits that our understanding of the world is formed through interactions with others and shared language. The event was planned by an interdisciplinary Steering Committee, with representation from medicine, organizational development, social work, nursing, and others. Stories were solicited from all hospital staff on the theme of “defining moments: the stories that shape us.” Six selected storytellers were paired with storytelling coaches. The hybrid in-person/virtual event was held in December 2021. Attendees were invited to complete a post-event survey with Likert-based responses; they could also provide in-depth reflections through an interview or written responses. Storytellers were invited to reflect via a post-event focus group or written responses. Qualitative semi-structured guides used open-ended questions to explore respondents’ experiences of the event. Written and transcribed qualitative data were coded by two team members using an inductive content analytic approach. We used descriptive statistics to analyze survey data.

RESULTS: The storytellers included two attending physicians, a resident physician, a nurse, an infrastructure project manager, and an administrator. Story topics ranged from professional experiences in healthcare to personal experiences related to illness or in childhood. The 155 attendees included 25 in-person and 130 via Zoom. Thirty attendees completed the post-event survey, and nine gave in-depth qualitative reflections, six by writing and three through oral interviews. Two storytellers participated in a focus group, and one gave written reflections. For both attendees and storytellers, qualitative data revealed that the event evoked a process of individual and collective meaning-making. Sharing personal stories with others fostered interpersonal connection and a sense of common humanity that was enhanced by the storytellers’ vulnerability, courage, and diversity. Storytellers highly valued coaches’ support and creative guidance. Lastly, the event was felt to strengthen the hospital community. Respondents called for more initiatives to promote a broader culture of storytelling within the hospital. These themes were echoed in the quantitative data, with >75% of respondents indicating that the event helped them to feel a sense of connection to others, understand others’ perspectives, reflect on their values, and connect to a sense of purpose. 93% said they were quite or extremely likely to attend in the future.

CONCLUSIONS: Oral storytelling events can be a valuable tool in promoting reflection and connection among healthcare professionals and can foster a sense of institutional belonging.

THE ASSOCIATION OF SITE AND HEALTHCARE WORKFORCE CHARACTERISTICS ON WELL-BEING OUTCOMES AND ORGANIZATIONAL RATINGS AMONG A NETWORK OF UNIVERSITY-AFFILIATED OUTPATIENT PRIMARY AND SPECIALTY CARE CLINICS

Henry J. Michtalik^1,2; Christine Weston¹; Amanda Cullison^1,3; Gayane Yenokyan^1,4; Cheryl Connors⁴; Jane Miller²; Martina Penalosa¹; Kristina Weeks²; Tanvi Bafna¹; Mansoor Malik⁴; Albert W. Wu^1,4. ¹Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; ²Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD; ³Johns Hopkins Community Physicians, Baltimore, MD; ⁴The Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #4063666)

BACKGROUND: Identifying site or individual healthcare worker characteristics associated with poorer staff-reported well-being outcomes and organizational ratings can allow for tailored improvement interventions.

METHODS: We surveyed 45 university-affiliated outpatient primary care and specialty clinics in the Maryland/Virginia/D.C. area in 2022. Healthcare workforce characteristics included demographics, position, years in the organization, peer or program support, and site (urbanity, state, size, types of services). Outcomes included burnout, anxiety, low resiliency, job satisfaction, supervisor or coworker support, management trust, and organizational commitment to well-being. Peer (listening, empathizing, processing, emotional support, and resiliency) and program (program, access, whom to contact) support items were collapsed into summary scores. Multivariate logistic regression was used to estimate the odds of low well-being outcomes and organizational ratings.

RESULTS: Of the 538 workforce members surveyed, 366 (68%) responded. Most were between 30-44 years old (43%) or older (43%), female (87%), White (43%), with 29% Black and 12% Latino ethnicity. Individuals were primarily clinician/provider (56%), receptionist/assistant (26%) or leadership/administration (12%), with largest proportion with the organization over 10 years (28%). Low peer and program support ratings ranged from 58-65% and 66-71% respectively. The majority of practices were in suburban setting (63%), Maryland (90%), and 60% primary care (Family and/or Internal Medicine or Pediatrics) with a median of 20 employees. Overall burnout, anxiety, and low resiliency frequencies were 39%, 35%, and 15% respectively. The majority reported low job satisfaction (63%), organizational commitment to well-being (63%), and trust in management (63%). After statistical adjustment, mid-age range (30-44 years old) compared to older (45+) were more likely to report low job satisfaction (OR 2.46; p<0.01) and commitment to well-being (OR 1.94; p<0.05). Males reported more low job satisfaction (OR 2.64; p<0.05). Low resilience was less in other races compared to Whites (OR 0.14; p<0.01). Leadership role individuals reported less low management trust (OR 0.36; p<0.01). Higher peer and program support were associated with lower reports of low supervisor support (OR 0.69; p<0.01) and low management trust (OR 0.73; p<0.05). Anxiety was higher in larger practices (OR 1.84; p<0.05) while lower supervisor support was more likely in primary care clinics (OR 2.09; p<0.01). No significant differences were found for ethnicity or site location.

CONCLUSIONS: Well-being outcomes and organizational ratings are similar for both primary and specialty care outpatient clinics. Healthcare workers of age 30-44 and males were more likely to report lower organizational ratings. Less anxiety was reported in smaller clinics. Research should further explore the workforce challenges for these demographic groups and consider targeted organizational improvement strategies.

THE EFFICACY OF RESILIENCE TRAINING IN RESIDENCY: A SYSTEMATIC REVIEW

Ayesha Zaidi¹; Shaista Guyara²; Patrick Wood³; Denis Harkin³. ¹Internal Medicine, Baystate Medical Center, Springfield, MA; ²RCSI Bahrain, Buseiteen, Bahrain; ³Royal College of Surgeons in Ireland, Dublin, Dublin, Ireland. (Control ID #4064863)

BACKGROUND: Personal resilience can be defined as an individual’s capacity to manage encountered stresses and challenges. Surgeons encounter high-stress decision-making with escalating burnout and are in need of effective strategies for maintaining resilience. While resilience has been proven to be protective against burnout, it is yet unclear whether educational interventions can improve resilience. This systematic review aims to evaluate the impact of resilience training programs on surgeons, specifically in terms of quality of life, self-efficacy, resilience, and coping.

METHODS: We conducted a systematic literature review, screening multiple databases (MEDLINE, CINAHIL, EMBASE, PsycINFO, Web of Science and the Cochrane Library, Scopus) for studies from 2012-2022. All studies with formal psychological resilience training programs in surgeons/surgical trainees were included. The primary outcome sought was changes in resilience as measured by a validated scale. Secondary outcomes included changes in validated scales measuring perceived stress.

RESULTS: Out of 6381 screened studies, 161 peer-reviewed articles were reviewed, and only eight studies met the inclusion criteria. Methodological quality assessment of included studies was conducted with the Mixed Methods Appraisal Tool (MMAT) to assess the risk of bias. Five out of the eight studies assessed changes in stress scores after receiving psychological resilience training. Three studies showed an improvement in post-test validated resilience scores.

CONCLUSIONS: This systematic review showed a wide range of interventions, with a minority indicating an improvement in validated resilience scores. The observed heterogeneity suggests a current lack of evidence in the most effective approaches for enhancing resilience in surgeons. Further research is necessary in order to potentially avert a burnout related workforce crisis in residency.

THE IMPACT OF COACHING ON TRAINEE BURNOUT, PROFESSIONAL FULFILLMENT AND ERRORS: A RANDOMIZED CONTROLLED TRIAL

Ritika S. Parris¹; Zhiyong Dong¹; Alicia Clark¹; Margaret M. Hayes¹; Amy Sullivan⁴; Carrie Tibbles²; Kerri Palamara³. ¹Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ³Medicine, Massachusetts General Hospital, Boston, MA; ⁴Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4059368)

BACKGROUND: There is a known relationship between trainee burnout and medical errors, but evidence-based interventions to jointly impact these factors are limited. We studied the effects of a novel coaching program on well-being and medical errors in graduate medical education trainees.

METHODS: We performed a randomized controlled trial of a coaching intervention for trainees using trained volunteer faculty as coaches. Trainees randomized to coaching (“coachees”) were offered 4 sessions of coaching and pre and post quantitative surveys were obtained; outcomes included medical errors, burnout, professional fulfillment, self-valuation, resilience, and post traumatic growth. Analysis included paired survey responses from 83 trainees, (43 intervention; 40 control).

Categorical data were analyzed using Chi-squared tests; continuous outcome variables with paired T test and Wilcoxon signed rank sum tests. Difference-in-Difference (DID) regression model examined the effect of coaching, controlling for PGY level and gender.

RESULTS: 183 trainees from nine departments were recruited; 94 trainees were randomized to coaching.

When asked if they were involved in a medical error, fewer trainees from both groups answered “yes” at the end of the study period, with coachees more likely to shift from “yes” to “no,” while control trainees more likely to change from “yes” to “unsure.” Post-intervention, coachees had 2.18 times the odds of answering “no” to medical error involvement, versus answering “unsure or yes”, compared to control trainees, though this did not reach significance (p=0.09). Coachees had significantly improved burnout (1.38 pre vs 1.25 post, p<0.001; burnout cutoff is 1.33) and professional fulfillment scores (2.33 vs 2.75, p=0.004) after the intervention; a change not seen in control trainees. A dose-response effect with number of coaching meetings was observed for burnout (p=0.01) and self-valuation (p=0.05). Improved coachee burnout scores persisted six months after the end of coaching, at which time coachees had lower burnout compared to control trainees (1.18 vs 1.58, p=0.01). At the end of the intervention, coachees also had better coping confidence based on their perceived ability to choose the best response in difficult situations (p=0.04) and ability to have emotionally balanced thoughts in negative times (p=0.01). DID modelling showed improved burnout (p=0.01) and professional fulfillment (p=0.004) in coachees as compared to control trainees.

CONCLUSIONS: Coaching significantly impacted burnout, professional fulfillment, and coping confidence in trainees involved in an interdepartmental coaching program, with burnout reductions persisting 6 months post-intervention. Medical errors may also be impacted by coaching and further research is needed.

THE ROLE OF CONFIDENTIAL MEDICAL STUDENT CAREER ADVISORS: IMPLICATIONS FOR ADVISORS AND STUDENTS

Hannah Archibald²; Karen E. Hauer¹. ¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Internal Medicine, California Pacific Medical Center, San Francisco, CA. (Control ID #4064626)

BACKGROUND: Choosing a specialty and applying to residency are important, high stakes tasks during medical students’ development toward their physician careers. This career decision-making is complex, and students typically seek advisors to help. It is not clear how interactions with advisors contribute to career decisions, and many advisors may be perceived by students as controlling access to the field through roles in residency selection. In our school, confidential career advisors bypass this concern about conflict of interest as they are not involved in the residency selection process. A useful framework to understand career decision-making is Social Cognitive Career Theory (SCCT), which posits that self-efficacy, outcome expectations, and goals interact and are influenced by contextual factors to shape career decisions. This framework can be used to understand how confidential advising relationships contribute to students’ career decisions. The aim of this study was to explore how confidential advising interactions influence medical students as they decide about specialty and apply to residency.

METHODS: We conducted semi-structured interviews with confidential career advisors and fourth-year medical students at University of California, San Francisco November 2022 through October 2023. Interviews questions explored the content of the meetings between advisors and students, expectations and understanding of the role of the confidential advisors, and participants' reflections on the impact of the meetings. Interviews were recorded, transcribed, and analyzed using thematic analysis.

RESULTS: Twelve medical students and ten advisors participated. After partial analysis of the interviews to date, we identified three themes. First, values identification: students placed high importance on advisors helping them identify their values, which in turn helped with decision-making regarding specialty choice to achieve values congruence. Second, relationship strength: Several aspects of the relationship allowed advisors to more successfully help students identify their values and make decisions, including creating a personal connection, the presence of similarities (gender, race, sexuality, etc) between advisor and advisee, and the confidential nature of the relationship. Third: imagined career: the advisor’s ability to provide information about the specialty helped students gauge their anticipated “fit” in a specialty.

CONCLUSIONS: Our initial findings suggest that identifying values is important for decision-making, the nature of the personal relationship between advisor and student affected their ability to do so, and advisors help students imagine their future career. These findings suggest that the advising process affects career decisions through influencing students’ outcome expectations as advisors share information about a specialty and discuss a students’ “fit” and through helping students to refine their goals through exploration of values and preferences.

THE THRIVING PHYSICIAN - A QUALITATIVE STUDY

Benjamin R. Doolittle¹; David Vermette²; Katherine Gielissen³. ¹Internal Medicine, Yale School of Medicine, New Haven, CT; ²Internal Medicine, Washington University in St Louis, St Louis, MO; ³Internal Medicine, Emory University, Atlanta, GA. (Control ID #4063766)

BACKGROUND: Burnout is characterized by emotional exhaustion, depersonalization of the other, and lack of accomplishment. Much is known about the demographic associations among burned out physicians. However, very little is known about those physicians who are thriving. What makes a physician happy in their role?

METHODS: Physicians were identified by snowball sampling and were asked to complete validated instruments to identify job/life satisfaction. Semi-structured interviews were conducted, focused on aspects of participants' career and life which contributed to their thriving.

RESULTS: Several groups of physicians participated: primary care physicians (32), emergency physicians (23), physicians in Pakistan (24), palliative caregivers in South Africa (29). Several themes emerged.First, thriving physicians placed a high value on their relationships with their patients. Second, they were intrinsically motivated to provide high-quality care. Several expressed little value on income or social status. Third, they expressed a value in maintaining autonomy and flexibility in their schedule.Fourth, many expressed a strong social network of friends and family upon whom they could rely for social support. Fifth, these physicians cited several challenges that threatened their sense of satisfaction.They identified administrative burdens, financial obligations to staff, and the electronic medical record as the three main areas that led to stress.

CONCLUSIONS: While much is known about the prevalence and demographics of burnout, very little is known about the factors that describe a thriving physician. There are several implications to this project. First, can these behaviors be taught? Can physicians be trained to place a high value on relationships and quality care? Second, are there systemic issues that merit attention, such as administrative burdens? Fostering an environment to minimize negative attributes and optimize the positives shows promise towards a replicable model for physician thriving.

UNPLUGGED OR PLUGGED IN? PHYSICIAN TIME IN THE ELECTRONIC HEALTH RECORD (EHR) DURING PAID TIME OFF (PTO)

Corey Obermiller¹; Richa Bundy¹; Lauren Witek¹; Adam Moses¹; Lindsey E. Carlasare²; Gary Rosenthal¹; Christine Sinsky²; Ajay Dharod¹. ¹Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; ²Professional Satisfaction, American Medical Association, Chicago, IL. (Control ID #4025108)

BACKGROUND: Individual working habits while taking paid time off (PTO) may hold implications for overall well-being and job satisfaction.1 While existing research has explored Electronic Health Record (EHR) use during working days,2-6 understanding how physicians spend their PTO on EHR-related duties is foundational for measuring individual capacity for work-life integration. By examining these patterns, we intend to shed light on work-life integration for primary care physicians and provide a framework for analyzing EHR time during PTO.

METHODS: We collected PTO data from 57 primary care physicians between January 1, 2022, and June 31, 2023. We ascertained PTO dates for 24 academic physicians working at least 0.5 “full time equivalent” (FTE) hours from a Human Resources database, whereas PTO dates for the remaining 33 full-time community-based primary care physicians were inferred based on unscheduled workdays. Next, we developed a method for analyzing EHR use during PTO by aggregating consecutive PTO dates into unique units called “PTO blocks.” Within each block, we calculated several metrics including average time in the EHR, time in notes, time in the in-basket, and PTO length in days. We used descriptive statistics to summarize these metrics and developed an ordinal logistic regression model assessing associations between level of EHR use and physicians’ characteristics.

RESULTS: Among the 1,314 total PTO blocks, the average block was 3.83 days and had a mean daily EHR time of 32.7 minutes (Table 1). On average, 56.9% of days within a block had at least some EHR use. Additionally, 37.4% of total EHR time was spent on in-basket activities, 15.6% in notes, and 47.0% on other activities. Longer PTO Blocks and those which included a national holiday were associated with decreased EHR use. No significant associations were detected between EHR use and provider demographics or provider panel complexity.

CONCLUSIONS: We defined a methodology for assessing physician time in the EHR during PTO and found that over half of PTO days per block are spent with at least some time in the EHR. These findings suggest physicians dedicate a considerable proportion of their PTO towards EHR-related activities. This study contributes to the overall body of work for physician Work on Vacation (WoV). Additional WoV studies are vital to both replicate our findings and assess whether engagement with the EHR during PTO is associated with provider dissatisfaction, burnout, or differences in work-life integration.

UPTAKE AND UTILIZATION OF A VIRTUAL ADMINISTRATOR PROGRAM TO IMPROVE PHYSICIAN WELLNESS

Emily P. Hyle¹; Susanne S. Hoeppner²; Aleena Banerji^3,4; Yao Tong⁵; Jodi M. Kurtz⁵; Jacqueline T. Chu¹; Ana D. Fernandes³; Edward R. Xiong⁶; Anna R. Wolfson³; Ruanne V. Barnabas¹; Camille N. Kotton¹; Kerri Palamara⁷. ¹Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA; ²Department of Psychiatry, Massachusetts General Hospital, Boston, MA; ³Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital Department of Medicine, Boston, MA; ⁴Harvard Medical School, Boston, MA; ⁵Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA; ⁶Massachusetts General Hospital, Boston, MA; ⁷Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4063708)

BACKGROUND: Administrative burden is rising for physicians with negative effects on well-being. We developed the Virtual Administrator Program (VAP), a novel approach for physicians at an academic medical center (AMC) to request 10-12 hours of administrative services (e.g., document formatting, literature searches, presentation preparation) provided by AMC staff interested in additional paid hours. We measured uptake of VAP services in a prospective, individual, randomized cross-over trial.

METHODS: Physicians were invited to participate in April 2023. Participants were randomly assigned to 6 weeks of VAP vs usual support after which participants crossed over to the opposite group for 6 weeks. We compared demographics and baseline metrics for workplace environment, burnout, and self-valuation among physicians who completed pre-randomization surveys (those who participated vs not) and among participants (those who made VAP requests vs not), using logistic regression.

RESULTS: Of 99 eligible physicians, 72 completed pre-randomization surveys, 59 participated, and 34 submitted VAP requests. Univariate logistic regression models identified 4 predictors for participation: 1 standard deviation (SD) increases in work exhaustion and interpersonal disengagement were each associated with greater odds of participation (OR [95%CI], 2.24 [1.07,4.70], p=0.03 and 2.61 [1.23,5.55], p=0.01, respectively); 1 SD increases in feeling valued by the organization and quality of life were each associated with lower odds of participation (0.49 [0.25,0.95], p=0.04 and 0.34 [0.12,0.97], p=0.04, respectively). For participants who made VAP requests, a stepwise regression model retained 3 significant predictors: 1) women were more likely to make VAP requests than men (22.8 [3.66, 142.31], p<0.001); 2) 1 SD increase in work stress stability was associated with a greater likelihood for VAP requests (2.77 [1.08, 7.11], p=0.03); and 3) 1 SD increase in degree of efficient teamwork was associated with a lower likelihood of making VAP requests (0.32 [0.12, 0.85], p=0.02).

CONCLUSIONS: A Virtual Administrator Program was utilized by physicians, particularly women, at increased risk for burnout and offers a novel approach to improve physician well-being.

WELL-BEING CHAMPIONS ASSOCIATED WITH IMPROVED FACULTY MENTAL HEALTH AND WELLNESS-RELATED IMPROVEMENTS IN AN URBAN MEDICAL CENTER

Celestine He²; Eleonore De Guillebon²; Christie Mulholland¹; Robert Pietrzak²; Jonathan Ripp²; Lauren Peccoralo². ¹Internal Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; ²Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4060174)

BACKGROUND: Well-being champions have been adopted in a variety of organizational settings as ‘agents of change’ to help promote healthy lifestyle behaviors and improve mental health. Employees at organizations that have started wellness champion programs have reported increased awareness of wellness opportunities and rated their perceived wellness higher. This novel study investigated the effects of faculty well-being champions (FWC) on faculty well-being and mental health outcomes in a large, urban hospital system.

METHODS: A cross-sectional, anonymous survey was sent out to all faculty members across a large urban hospital system in Spring 2022. Demographic and occupational characteristics, psychosocial factors, symptoms of depression, anxiety, and burnout, and the presence/absence of FWC in one’s department were assessed. Descriptive statistics were computed, and chi-square tests were conducted to examine associations between having an FWC and measures of mental health and well-being-related improvements in one’s department. A logistic regression analysis was then conducted to examine the relationship between FWC and mental health outcome variables.

RESULTS: Of 1,534 faculty member respondents, 821 (53.5%) responded to the question regarding FWCs and were included in this analysis. A total of 670 (81.6%) faculty members reported having an FWC, representing over 30 hospital departments/divisions. Faculty members who had an FWC in their department were less likely than those who did not to screen positive for anxiety (8.1% vs. 15.2%, p=0.006) and depression (2.8% vs. 9.9%, p<0.001), but did not differ with respect to burnout symptoms (35.2% vs. 29.8%, p=0.205). Faculty with an FWC were also more likely to agree that there were enhanced faculty appreciation efforts (20.9% vs. 9.9%; p=0.002); improved diversity and inclusion in the workplace (41.5% vs. 31.8%, p<0.028); increased access to leadership development training (14.3% vs. 7.9%, p<0.036); and enhanced access to mentorship (11.8% vs. 6.0%; p<0.036). Results of a logistic regression analysis revealed that faculty members with an FWC had 55% lower odds of screening positive for at least one mental health outcome (OR=0.45, 95% CI=0.27-0.75, p=0.002).

CONCLUSIONS: Faculty members with an FWC at an urban medical center reported lower rates of mental health symptoms, as well as improvements in wellness-related resources. This may be due to increased support and awareness of wellness resources, such as leadership development trainings, mentorship resources, and appreciation efforts led by or advertised by FWCs. While the study is limited by moderate response rate and cross-sectional design, results suggest that well-being champions may help promote faculty mental health and increase wellbeing-related efforts in an urban medical center.

WHAT MAKES FOR SUCCESS: EXPLORING CAREER TRANSITIONS IN ACADEMIC CLINICIAN EDUCATORS

Felicia Hui¹; Meera Sheffrin¹; Karl Lorenz¹; Cati Brown-Johnson². ¹Medicine, Stanford University School of Medicine, Stanford, CA; ²Evaluation Sciences Unit, Stanford School of Medicine, Stanford, CA. (Control ID #4063836)

BACKGROUND: Career transitions are features in every clinician-educator’s (CE) journey in academic medicine. However, there is a lack of research on the individual CE experience during these transitions. Such experiences are critical to create more diverse and equitable systems to support faculty during these vulnerable periods. We sought to explore the lived experience of career transitions to assess opportunities and challenges faced by CEs undergoing career transitions in academic medicine, and determine factors that influence the perceived success or failure of a transition.

METHODS: Participants were clinician-educators in primary care, geriatrics, or palliative care who self-identified as having experienced a career transition in the last 12 months, recruited through snowball sampling and mailing list recruitment. During 30-minute semi-structured interviews, participants were asked about their career transition, factors that prompted the transition, and barriers and facilitators to success. Interviews were audio-recorded with subsequent deidentified verbatim transcription. Card sorting developed the coding structure by which all interviews were coded and analyzed. Multiple meetings were held to resolve any disagreements to ensure interrater reliability. Three coders then performed qualitative thematic analysis to identify emergent themes.

RESULTS: Overall, 19 physicians from 12 academic institutions participated in interviews. Participants were predominantly women (58%), had a mean age of 40.4 years, and included five (26%) primary care, two (11%) geriatrics, and 12 (63%) palliative care physicians. Four major themes emerged including work-life integration, mentors and support, professional development, and research and funding. Markers of success included feeling comfortable in a role, having no regrets about transitions, and being able to adapt to the role. Conversely, feeling unprepared or ill-equipped, unproductive, or isolated contributed to a perceived failed transition.

CONCLUSIONS: Academic CE careers are intimately affected by success and failures of transitions within them. Our findings inform critical factors influencing career transitions and have potential to abet improving structure and support for CE faculty.

“I NEED TO CARE MORE ABOUT THEIR SUCCESS THAN MINE”: PERSPECTIVES ON SPONSORSHIP AND EQUITY IN ACADEMIC MEDICINE

Rachel Schwartz¹; Mia F. Williams²; Mitchell D. Feldman². ¹Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA; ²Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4063680)

BACKGROUND: Sponsorship may play a pivotal role in advancing individuals' careers in academic medicine (AM). However, recent studies report inequities in sponsorship and suggest the need for institution-level sponsorship interventions to promote equity in career advancement opportunities. This study sought to understand leaders’ perceptions of individual responsibility to provide sponsorship as well as existing barriers to, and strategies for, creating an equitable culture of sponsorship in AM.

METHODS: Semi-structured interviews with 15 leaders (8 female) across Schools of Medicine, Nursing, Dentistry, and Pharmacy at an academic medical center. Leaders included division chiefs, department chairs, and deans. Data were analyzed using an inductive thematic analysis approach.

RESULTS: Leaders varied in perceptions of sponsorship responsibility: Those who did not feel it was their responsibility cited concern about authentic connection in the sponsorship pairing, noting it occurred on a case-by-case basis. Others felt proactively sponsoring faculty was critical, especially for women, those underrepresented in AM, and those who had fewer opportunities.

Leaders proposed systems-level sponsorship interventions:

Education – Leaders suggested creating didactics for talking to faculty about sponsorship, guidance for sponsees on sponsorship etiquette, developing repositories of “sponsorship best practices” and content menus of sponsorship behaviors. Others proposed videos featuring faculty sharing how sponsorship impacted their career, and training for junior male faculty on their roles in creating an equitable culture of sponsorship.

Infrastructure – Leaders suggested integrating sponsorship education in onboarding of new leaders, normalizing vocabulary for sponsorship, and having explicit conversations with faculty on sponsorship. They advocated for greater transparency in sharing career opportunities to increase equity. They proposed sponsorship conversations could take place in annual review meetings. Some suggested that sponsorship awards would increase visibility and role modeling of sponsorship.

Assessing sponsorship– Potential metrics leaders proposed for assessing sponsorship included examining whether a sponsorship intervention increased the diversity of applicants for leadership positions, adding sponsorship activities to the CV sections used for promotion, and establishing a link between sponsorship behaviors and accelerated promotions.

CONCLUSIONS: Leaders acknowledged the importance of sponsorship, yet exhibited varying perspectives on their individual roles and responsibilities. Improving sponsorship equity may require proactive systems-level interventions; targeting training initiatives for leaders, sponsors, and sponsees; developing metrics for tracking sponsorship; and introducing routine discussion of sponsorship into existing institutional infrastructure. Areas of divergence among leaders reflected the complex and nuanced nature of discussions surrounding sponsorship equity.

“LEARNING FROM THOSE WHO KNOW THE SYSTEM INSIDE AND OUT:” EXPERIENCES OF PHYSICIAN-MOTHERS WHO ARE INFORMAL CAREGIVERS

Wagahta Semere¹; Andrea N. Ponce²; Eleni Linos³; Reshma Jagsi⁴; Christina Mangurian⁵; Meghan Halley⁶. ¹Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ²Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; ³Dermatology, Program for Clinical Research and Technology, Stanford University School of Medicine, Stanford, CA; ⁴Radiation Oncology, Emory University School of Medicine, Atlanta, GA; ⁵Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California San Francisco School of Medicine, San Francisco, CA; ⁶Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA. (Control ID #4059209)

BACKGROUND: For physicians, the added responsibility of being an informal caregiver (IC, providing regular care for seriously ill loved ones) can create challenges such as increased rates of burnout that have received little attention. Understanding the perspectives of physician ICs is key to mitigating increased risk for physician burnout, achieving gender equity, and may improve patient and family experiences accessing healthcare. In this study, we explored physician-mothers’ informal caregiving experiences and probed their perspectives on how health systems can better support their needs.

METHODS: From 9/14/2021 to 10/31/2021, we distributed an online survey to a national sample of 196 physician-mothers who self-identified as ICs. The survey included standardized measures characterizing informal caregiving (e.g., caregiver and care recipient characteristics; caregiving responsibilities) and open-ended questions that explored respondent perspectives on workplace changes needed to support ICs. Two coders (WS, MH) reviewed all open-ended responses independently and generated thematic codes, which were then reviewed and integrated through consensus by all study authors.

RESULTS: Among 196 physician-mothers who received the survey, 55 responded (28%); 32 respondents (58%) self-identified as a current IC, 23 (72%) of whom completed the survey. Of the 23 IC respondents, 26% reporting spending an average of 40 hours per week caregiving and 44% were ICs for five years or more. Approximately half (48%) of respondents were caregivers for a child, and 74% co-resided with their care recipient. Main caregiving responsibilities included communicating with healthcare providers (91%) and managing and/or attending medical appointments (70%). Three central themes, named using exemplary quotes, emerged from open-ended questions: (1) “It’s an exhausting and unrecognized burden,” reflects challenges participants experience being both ICs and physicians, (2) “Our healthcare system is difficult to navigate, even for physicians,” reflects the barriers participants experience in trying to navigate the healthcare system despite their insider status as physicians, and (3) “Flexible work schedules, no penalties,” references the participants’ expressed need for flexibility in their work arrangements without concern for professional penalties such as reduced work hours or salary.

CONCLUSIONS: One-quarter of physician-mother ICs were working while providing the equivalent of full-time care for their loved one. Physician-mother ICs fill critical, demanding roles as healthcare leaders and caregivers at home. Balancing these dual roles presents significant challenges that can have adverse effects, leaving physician-mother ICs vulnerable to burnout and attrition. Targeted support strategies including flexible staffing models, expanded telehealth, and paid informal caregiving leave may improve experiences for physician ICs more generally.

Scientific Abstract - Clinical Informatics and Health Information Technology

ASSESSMENT OF SATISFACTION WITH TELEMEDICINE AMONG US PHYSICIANS: RESULTS FROM THE 2021 NATIONAL ELECTRONIC HEALTH RECORDS SURVEY

Dang Nguyen¹; Oliver T. Nguyen^2,3; Anthony Zhong⁴; Simar S. Bajaj⁵; Yusuf Qureshi⁶; Lisa Rotenstein^7,8. ¹Massachusetts General Hospital, Corrigan Minehan Heart Center, Harvard Medical School, Boston, MA; ²Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; ³Department of Industrial and Systems Engineering, University of Wisconsin at Madison, Madison, WI; ⁴Department of Medicine, Harvard Medical School, Boston, MA; ⁵History of Science, Harvard University, Cambridge, MA; ⁶Judy Genshaft Honors College, University of South Florida, Tampa, FL; ⁷University of California at San Francisco, San Francisco, CA; ⁸Department of Medicine, Brigham and Women’s Hospital, Boston, MA. (Control ID #4064630)

BACKGROUND: During the COVID-19 pandemic, telemedicine became increasingly important. Given the continued prevalence of telemedicine-based care delivery, it is crucial to understand how this change affects the experience of healthcare workers. This study sought to identify factors associated with satisfaction with telemedicine among physicians using nationally representative data.

METHODS: We analyzed the 2021 National Electronic Health Records Survey, which includes questions about the use of telemedicine technology among physicians in the United States. The sample was restricted to respondents who reported using telemedicine for their patient visits since March 2020. A multivariable ordinal regression model was used to assess whether the use of telemedicine technology was independently associated with the level of satisfaction among physicians. We controlled for potential confounders that may influence the experience of physicians, including sociodemographic characteristics related to physicians, practices, and telemedicine platforms. A significance level of P<0.05 was used.

RESULTS: The unweighted sample consisted of 1,540 respondents, representing 331,686 physicians. Most respondents were male (66.5%), over 50 years old (66.2%), and primarily specialized in primary care (48.2%). Among surveyed physicians, 61.6% reported satisfaction with telemedicine. In multivariable regression, physicians who conducted over 75% of their patient visits via telemedicine had greater odds of reporting higher satisfaction compared to those only using >0-25% (OR = 5.59, 95% CI 3.10–10.06, p < 0.001). The use of telephone audio visits also resulted in higher satisfaction (OR = 1.54, 95% CI 1.11–2.14, p = 0.01) among physicians. Male physicians were less likely to be satisfied with telemedicine technology (OR = 0.66, 95% CI 0.45–0.94, p = 0.02) than female physicians. Lower odds of satisfaction were also observed if the telemedicine platform was not easy to use or did not meet the physicians' needs (OR = 0.34, 95% CI 0.23–0.51, p < 0.001), was not suitable for their specialty or patient type (OR = 0.19, 95% CI 0.14–0.27, p < 0.001), or if patients faced limitations in accessing the technology (OR = 0.70, 95% CI 0.50–0.97, p = 0.034).

CONCLUSIONS: This study shows that frequent telemedicine use and audio-only visits may be associated with greater physician satisfaction with telemedicine. However, satisfaction may decrease when physicians encounter technical challenges with their patients or when telemedicine platforms do not align with specific medical specialties or patient needs. These findings emphasize the importance of ensuring user-friendly telemedicine options and developing tailored digital health solutions for diverse physician and patient populations.

AUTOMATED VERTEBRAL COLUMN SEGMENTATION FROM EOS FULL-BODY IMAGING USING ARTIFICIAL INTELLIGENCE: APPLICATION IN QUANTIFICATION OF SPINAL PATHOLOGY

Yash Lahoti, Bashar Zaidat, Samuel K. Cho, Jun S. Kim. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4061996)

BACKGROUND: Advancements in EOS imaging, a low-dose, weight-bearing X-ray technology, enable safer, longitudinal imaging modalities for patients with adult degenerative scoliosis (ADS). Curvature estimation is an insightful index to quantify the severity of ADS and plan surgical intervention. However, manual annotation of the vertebral column is labor-intensive, requires domain expertise, and introduces a significant degree of interobserver and intraobserver variability. Deep learning tools have the potential to introduce standardization and rapid analysis of alignment changes thoughout disease progression.

METHODS: This study consisted of 54 patients with full length EOS X-ray images in both the AP and LAT orientation. The image dataset was crafted to include ADS positive and negative samples. For each orientation, 44 images were used to train a model, and 10 radiographs were withheld for model performance evaluation. Our algorithm comprises two stages to preserve image quality and improve interpretability. Stage 1 identified the region of interest (ROI) on the X-ray image, which includes the whole spine, including cervical, thoracic, and lumbar vertebrae. Stage 2 used the output ROI to generate a segmentation mask that can identify the curvature of the gross vertebral column. This approach was applied to train separate models for the AP and LAT radiographs. A 10th order polynomial function was fit to each mask to model the curvature of the spine.

RESULTS: We utilized the Dice similarity coefficient (DSC), a spatial overlap index, to evaluate the quality of the generated segmentation mask. The average DSC calculated across the 10 test patients was 0.92 in the AP view and 0.96 in the LAT view, indicating a high degree of accuracy in the mask (with 1 being identical overlap).

CONCLUSIONS: Automated segmentation and curvature modeling provides a standardized approach to quantifying ADS pathology. This framework serves as a precursor to generating more labor intensive metrics, such as Cobb-Angle and Lenke Classification.

CLINICIAN PERSPECTIVES ON REAL-TIME PRESCRIPTION BENEFIT TOOLS TO IMPROVE OUT-OF-POCKET PRICE TRANSPARENCY AT THE POINT OF PRESCRIBING: A QUALITATIVE STUDY

Jeremy Schwartz¹; Arian Schulze¹; Christopher Laurie¹; Nitu Kashyap^4,1; Jing Liu⁴; Erika Smith²; Bradley H. Crotty²; Muhammad Ali³; Harold Lehmann³; Jiangxia Wang⁵; Fasika Woreta³. ¹Internal Medicine, Yale University School of Medicine, New Haven, CT; ²Froedtert Hospital, Milwaukee, WI; ³Johns Hopkins Medicine, Baltimore, MD; ⁴Yale New Haven Health System, New Haven, CT; ⁵Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4064359)

BACKGROUND: The point of prescribing represents an opportune moment for clinicians and patients to discuss out-of-pocket (OOP) medication cost and for clinicians to modify prescriptions accordingly. However, a lack of price transparency limits that potential. Real-Time Prescription Benefit tools (RTPB) display patient-specific OOP cost data and suggest lower OOP cost alternatives using data directly populated by pharmacy benefit managers. Centers for Medicare and Medicaid Services mandates that RTPB be integrated into electronic health records. The evidence supporting RTPB implementation is limited and we are not aware of any studies that have examined clinicians’ perspectives. The objective of this study is to explore clinicians’ perspectives on RTPB to inform continued adaptations to their implementation.

METHODS: The present abstract focuses on the qualitative arm of an explanatory sequential mixed methods study we conducted across three large academic health systems represented by investigators in our RTPB research group - Yale New Haven Health, Froedert & Medical College of Wisconsin, and Johns Hopkins Medicine. All sites use the same electronic health record but RTPB implementation has varied between sites. Using a deviance approach, we first categorized clinicians by relative RTPB utilization rate. We then used purposive sampling to recruit participants for qualitative interviews and focus groups. A distinct qualitative interview guide was used to guide non-user and user interviews. Interviews – all conducted virtually by one interviewer- explored clinician comfort in discussing medication cost and approaches to OOP cost containment, experience with and exposure to RTPB, and opportunities to improve the tools and their implementation.

RESULTS: We interviewed 43 clinicians (27 female, 16 male)- physicians, nurse practitioners, physician assistants, and a clinical pharmacist- from diverse specialties. Thirty were classified as RTPB non-users and 13 as users. Preliminary findings reveal four emergent themes: 1. Clinicians, especially those with high prescribing rates, feel hampered in their ability to provide the best quality care because of patients’ high OOP cost burden; 2. Clinicians and their staff have developed labor intensive, informal systems to generate price checking and cost mitigation strategies; 3. Barriers to RTPB utilization include perceived time burden, lack of awareness and training, and that the tools do not comprehensively display OOP cost for all of a patient’s prescribed medications; and 4. Accuracy and reliability of the displayed OOP cost data are critical facilitators to clinician adoption.

CONCLUSIONS: RTPB have the potential to promote clinician-patient OOP cost conversations at the point of prescribing and action toward lowering these costs. However, health systems must offer relevant training and the cost data presented by RTPB must be accurate and reliable if they are to be trusted and used by clinicians.

COMPARATIVE DIAGNOSTIC ACCURACY BETWEEN CHATGPT-4 WITH VERSUS WITHOUT VISION IN COMPLEX CLINICAL CASES

Takanobu Hirosawa¹; Yukinori Harada¹; Kazuki Tokumasu²; Takahiro Ito³; Tomoharu Suzuki⁴; Taro Shimizu¹. ¹Department of Diagnostic and Generalist Medicine, Dokkyo Ika Daigaku, Shimotsuga-gun, Tochigi, Japan; ²Department of General Medicine, Okayama Daigaku, Okayama, Okayama, Japan; ³Satsuki home clinic, Utsunomiya, Tochigi, Japan; ⁴Department of Hospital Medicine, Urasoe Sogo Byoin, Urasoe, Okinawa, Japan. (Control ID #4054274)

BACKGROUND: Achieving diagnostic excellence in complex cases requires a multifaceted approach, including effective collaboration with clinical decision support systems. Multimodal generative artificial intelligence (AI) systems, like ChatGPT-4 with vision (ChatGPT-4Vision or ChatGPT-4V), have the potential to enhance diagnostic accuracy by integrating text and image data. However, the full impact of multimodal AI systems on diagnostic accuracy has not been explored.

METHODS: This study utilized case descriptions and final diagnoses from the American Journal of Case Reports, from 2022 to 2023, focusing on cases of adults and adolescents with image data and a definitive diagnosis. From 557 case reports, 130, 35, and 29 were excluded due to non-diagnosis, patients under the age of 10, and the absence of image data, respectively. We evaluated the diagnostic accuracy of ChatGPT-4 with and without vision capabilities. ChatGPT-4 with vision analyzed both case descriptions and image data from these cases to generate the top 10 differential-diagnosis lists, compared to lists generated by ChatGPT-4 without vision using only case descriptions. The inclusion of the final diagnosis within the differential-diagnosis lists were independently evaluated by physicians.

RESULTS: A total of 363 case descriptions were included. The rate of final diagnoses included in the top 10 differential-diagnosis lists by ChatGPT-4 with vision was 85.1% (309/363), compared to 87.9% (319/363) by ChatGPT-4 without vision (P=.33). The rate of final diagnoses as the top diagnosis generated by ChatGPT-4 without vision was 55.9% (203/363), superior to 44.4% (161/363) by ChatGPT-4 with vision (P=.002).

CONCLUSIONS: The study demonstrates a comparative analysis of diagnostic accuracy between ChatGPT-4 with and without vision capabilities using case descriptions. The rates of final diagnoses within the differential-diagnosis lists generated by ChatGPT-4 with vision were not improved compared to those without vision. The rate of final diagnoses as the top diagnosis generated by ChatGPT-4 without vision was superior to that with vision. This could be partly because image data might distract from the final diagnosis in the current multimodal generative AI system. Therefore, ChatGPT-4 with vision mainly relies on text data, even though it accepts image data for generating differential diagnoses. Multimodal generative AI systems should be further developed to improve diagnostic performance through better integration of clinical data before being utilized in medicine.

DIFFERENCES IN PATIENT PORTAL MESSAGE VOLUME ACCORDING TO PRIMARY CARE PROVIDER CLINICAL FULL TIME EQUIVALENT

Laura Macke²; Lauren A. Drake¹. ¹Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²General Internal Medicine, University of Colorado, Denver, CO. (Control ID #4062474)

BACKGROUND: Time in the electronic health record (EHR) and high volumes of inbasket messages are associated with higher levels of provider burnout (Adler-Milstein 2020, Hilliard 2020). Studies have demonstrated differences in EHR use by clinician gender. Female PCPs spend substantially more time in the EHR inbasket and receive significantly more staff and patient messages than their male counterparts (Rittenberg 2022, Rule 2023).

It is likely that other clinician differences also impact EHR inbasket volume. We hypothesized that clinicians with lower clinical full time equivalent (cFTE) may perform disproportionally more work in the EHR inbasket than higher cFTE colleagues. In this analysis, we aimed to determine how PCP cFTE correlated with EHR patient message volume in our academic general internal medicine (GIM) practice.

METHODS: We conducted a retrospective analysis of 6-months of EHR inbasket data from 4 academic GIM practices in metro Denver (3/1/22-8/31/22). Data was aggregated by clinician for 54 Physicians (MD/DO) and 6 Advanced Practice Providers (NP/PA) who carried a patient panel. Resident physicians were excluded. Clinical FTE excluded precepting resident clinic and urgent care hours. One physician outlier was excluded as their cFTE value was invalid. Data from 59 clinicians (31% male, 69% female) were analyzed.

The primary outcome was the total number of EHR inbasket messages sent to and received by patients, adjusted for cFTE to normalize distribution. The secondary outcome was the number of EHR messages sent by the clinician directly to patients, adjusted for cFTE to normalize distribution.

Descriptive statistics were calculated using SPSS version 29 to characterize the sample and variables. Spearman’s rank-order correlation was computed to determine the strength and direction of a linear relationship between clinician cFTE and the primary and secondary outcomes.

RESULTS: - A moderate negative relationship was found between cFTE and normalized total EHR inbasket message volume (ρ = -0.42, p=.001).

- A moderate negative relationship was found between cFTE and normalized EHR messages sent directly by the clinician to patients (ρ = -0.41, p=.001).

- For both female and male PCPs, the volume of EHR inbasket messages adjusted for cFTE increased as cFTE decreased.

- Clinician gender influenced the relationship between cFTE and EHR inbasket volume.

CONCLUSIONS: Given the association of EHR inbasket burden with burnout, understanding all factors that influence inbasket volume is essential to clinician wellness. This analysis demonstrated internal medicine PCPs in our system with lower cFTE managed a higher volume of inbasket messages per clinical hour than their higher cFTE colleagues. Findings support previous studies which showed a gender difference in EHR inbasket volume. Further analysis is needed to determine what drives the observed impact of clinical FTE on EHR inbasket volume and any impacts this may have on patient care and clinician wellness.

EFFECT OF EMR-CONNECTED HOME BLOOD PRESSURE MONITORING ON HYPERTENSION CONTROL

Asim Viqar²; Fallon Way¹; Lauren Eberly¹; Neel Chokshi¹. ¹Hospital of the University of Pennsylvania, Philadelphia, PA; ²UPMC, Pittsburgh, PA. (Control ID #4064999)

BACKGROUND: Home blood pressure monitoring (HBPM) strategies improve hypertension (HTN) control and resource utilization. Secure transmission of patient BP data and integration into clinical workflows is complex, but advances have enabled data sharing via the Electronic Medical Record (EMR) to facilitate timely titration of medications. We present results from a real world remote HTN management pilot program implemented via the Epic EMR to understand feasibility and clinical implications.

METHODS: Patients (pts) with suboptimal HTN control during cardiology office visits at an academic center were referred by clinicians from October 2020 to March 2022. Pts were educated on BP self-assessment and transmission of BPs via the Epic EMR patient portal via mobile or web based app. Pts were asked to submit at least 12 BP measurements over a two-week duration with follow up by video visit or telephone. HBPM data was populated in the EMR for clinician review and medication adjustments were performed at clinician discretion. A retrospective chart review was performed at 6 months post enrollment to assess BP values, medication changes and number of patient encounters.

RESULTS: Of 57 pts referred to the program, 20 pts (35%) participated and transmitted sufficient data for clinical assessment. The cohort was 30% female, 30% Black, with a mean age of 58 years (±13.5). Baseline comorbidities included CAD (45%), arrhythmia (45%) and stroke (10%). The mean office BP in the participating cohort was 138/82 mm Hg at baseline with post intervention mean HBPM of 129/78 mm Hg. The mean number of anti-HTN meds prescribed at baseline was 1.5 and increased to 1.7 post intervention (p=0.007). The mean number of encounters related to HTN over the study duration was 3.3 in the participating group compared to 1.3 in those referred but not participating in the intervention.

CONCLUSIONS: The study demonstrates the feasibility and potential benefits of a remotely implemented HTN management program in a high-risk population with use of commonly available EMR tools. Larger scale investigations with control subjects are warranted to evaluate clinical impact as well costs of such innovative programs.

EFFECTS OF SPRAY CRYOTHERAPY ON COUGH RECEPTORS AND AIRWAY MICROENVIRONMENT IN A CANINE MODEL OF CHRONIC BRONCHITIS

Long Liang. Department of Respiratory Medicine, Peking University Third Hospital, Beijing, China. (Control ID #4024955)

BACKGROUND: Currently, the treatment of chronic bronchitis is mainly pharmacological and has limited efficacy. Spray cryotherapy (SCT) as a new physical therapy is expected to improve the patient's symptoms.

METHODS: We examined the expression of transient receptor potential vanilloid 1/4 (TRPV1/4) and the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) at the gene and protein levels before and after SCT. In addition, we explored whether TRPV1/4 could regulate inflammatory factors via mediator adenosine triphosphate (ATP). The levels of ATP and cytokines in alveolar lavage fluid and cell supernatant were measured using ELISA.

RESULTS: SCT effectively downregulated the expression of TRPV1/4 and SP/CGRP in canine airway tissues with chronic bronchitis and reduced the levels of inflammatory mediators and cytokines that affect cough receptor sensitivity, achieving cough relief. TRPV1/4 - ATP - inflammatory cytokines axis has been demonstrated at the cellular level, which in turn modulate the milieu of the airways and promote the formation of a cough feedback loop.

CONCLUSIONS: Our study has fully revealed the specific mechanism of SCT in treating cough in a canine model of chronic bronchitis, providing a solid theoretical basis for future clinical treatment.

ESTIMATING OUT-OF-POCKET MEDICATION COSTS DURING CLINIC VISITS: A QUALITATIVE STUDY OF THE PRIMARY CARE EXPERIENCE

Caroline Sloan^1,2; Heather King^1,4; Laura Macke⁶; Widline Senatus³; Davina Le⁵; Joseph K. Davis³; Virginia Wang^3,4. ¹Department of Medicine, Duke University School of Medicine, Durham, NC; ²Duke Margolis Center for Health Policy, Washington, DC; ³Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; ⁴Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC; ⁵Duke University, Durham, NC; ⁶General Internal Medicine, University of Colorado, Denver, CO. (Control ID #4064989)

BACKGROUND: Real-time benefit tools (RTBT) are clinician-facing applications embedded in the electronic health record (EHR) that display the out-of-pocket costs of medications being prescribed as well as any lower-cost alternatives, if available. Since 2021, Medicare Part D plans have been required to make cost information available to RTBTs. Prior studies have shown that RTBT use leads to reduced out-of-pocket costs and higher medication fill rates, but that very few primary care providers (PCP) actively use them. Little is known about PCPs’ attitudes toward and experiences with RTBTs.

METHODS: We conducted a qualitative study of PCPs practicing at clinics affiliated with one academic health system in Oct-Nov 2023. All PCPs used one instance of the Epic EHR (Madison, WI). Semi-structured interview guides were informed by the Organizational Theory of Innovation Implementation Effectiveness framework and the Unified Theory of Acceptance and Use of Technology model. We asked PCPs to describe their attitudes toward out-of-pocket cost transparency, their experiences using RTBTs, major barriers to use, and suggestions for design modifications that could make RTBTs more relevant to their practice. We analyzed transcripts using thematic analysis.

RESULTS: We interviewed 17 PCPs (12 physicians, 5 advance practice providers). Seven practiced at clinics in lower-income census tracts and 7 had <10 years’ experience. Participants felt it was important to try and estimate out-of-pocket costs during visits and were open to using an RTBT. They found that the RTBT was intuitive, was useful for making cost-informed medical decisions, and did not substantially lengthen visit time. Many even described reductions in administrative burden and delays in care (“It's going to save you time on the back end -- they don't come back 3 months later, and they haven't gotten their medicine and their A1C's super high”). Barriers to use included lack of knowledge about RTBTs (“I didn't realize that if you clicked on that it pulled up all that information”), clinically inappropriate lower-cost alternatives (“It was making me write metformin. Her creatinine is 1.8. I do not want to give you metformin!”), distrust in the RTBT’s accuracy (“I just got frustrated…it wasn't worth looking”), and fear of losing autonomy (“I don't want it to deter me from using something that is beneficial to the patient”). Suggested modifications included showing the costs of all of a patient’s medications (not just those being prescribed that day), displaying insurance step therapy protocols, linking to coupons, and presenting costs during medication selection rather than upon signing. PCPs also recommended training pharmacists and nurses to use RTBTs.

CONCLUSIONS: While most PCPs viewed RTBTs favorably, they identified a number of technical and logistical barriers to optimal use. EHR developers should harness clinicians’ early experiences with RTBTs to redesign them with the goal of improving patient care while minimizing administrative burden.

FINANCIAL TOXICITY IN MUSCULOSKELETAL DISEASES

Amber K. Brown Keebler¹; Sofia Pedro²; Kaleb Michaud¹; Ted Mikuls¹. ¹Internal Medicine, University of Nebraska Medical Center, Omaha, NE; ²FORWARD Registry, Wichita, KS. (Control ID #4063822)

BACKGROUND: Often not evaluated in clinical visits, financial distress associated with medical costs, known as financial toxicity, has emerged as an important factor affecting health due to reduced adherence, stress, and other negative impacts. The FACIT-COST questionnaire provides a quantitative measure of financial toxicity validated in chronic diseases such as cancer, diabetes and cardiovascular disease. Financial toxicity has never been described in musculoskeletal (MSK) diseases (MSKD), which collectively are among the leading cause for primary care encounters. We aimed to quantify financial toxicity and identify associated factors in participants with rheumatoid arthritis (RA) versus non-inflammatory MSKD (NI-MSKD).

METHODS: Adult participants were enrolled in a national disease-based registry, had RA or NI-MSKD, and completed the FACIT-COST in 2023. Comprehensive health and sociodemographic information were collected. In this cross-sectional study, the FACIT-COST score was analyzed as a continuous variable (higher score indicates less financial toxicity) and as a binary variable with a cutoff: low toxicity (≥ 26) vs high (< 26). LASSO was applied to linear regression and logistic regression to select the best multivariable models evaluating association between financial toxicity and other covariates.

RESULTS: There were 1918 participants with RA and 1241 with NI-MSKD. RA patients had a mean (SD) FACIT-COST score of 32.6 (9.3) vs. 33.6 (8.6) for NI-MSKD. High toxicity was more frequent in RA than NI-MSKD (28.3% vs. 17.7%), though the difference was not statistically significant. Irrespective of disease group, characteristics associated with high financial toxicity included age, sex, household income, education, being retired, and Medicaid insurance. Significant associations were also observed between financial toxicity and comorbidities, specifically cancer, diabetes, and depression. Patient global assessment score was also associated with worse financial toxicity. For RA only, DMARD use was not associated with financial toxicity while oral corticosteroid use was associated with financial toxicity in all models and diseases.

CONCLUSIONS: This is the first analysis of financial toxicity in MSKD. These results show that financial toxicity is prevalent in patients suffering from these conditions and appears to be compounded in the context of comorbidities frequently encountered in the primary care setting. Further studies are necessary to examine the clinical utility of including the assessment of financial toxicity in primary care healthcare models. In addition, future prospective studies will be needed to examine causal directionality and better understand whether future interventions aimed at these comorbid conditions might result in clinical benefit.

HOW TEAMS IMPACT PRIMARY CARE PHYSICIANS’ ELECTRONIC HEALTH RECORD TIME

Estelle Martin¹; Erin E. Sullivan⁴; Christine Iannaccone²; Lance Rachelefsky²; John Lewis³; Richard S. Gitomer³; Lisa Rotenstein^1,2. ¹Department of Medicine, University of California San Francisco, San Francisco, CA; ²General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ³Internal Medicine, Brigham Health, Boston, MA; ⁴Center for Primary Care, Harvard Medical School, Boston, MA. (Control ID #4064451)

BACKGROUND: Primary care physicians (PCPs) spend the most time on the EHR of any specialty and PCPs’ work on the electronic health record (EHR), particularly after-hours, is associated with burnout. Importantly, increased EHR time is also associated with higher quality ambulatory care. These two realities suggest the need to optimize the time that PCPs spend on the EHR.

METHODS: We used Epic Signal data to quantify variation in total EHR time, pajama time (5:30 PM to 7 AM) and electronic inbox time across a Northeast healthcare system's 14 primary care clinics. We then conducted a survey of medical directors, practice managers, and nursing directors at each clinic. The survey queried respondents on team structure (i.e. set, rotating, ad-hoc), membership on clinical teams, and who helps physicians with key tasks, including documentation, in each clinic. We summarized survey results and then examined how distributions of EHR time differed between clinics with differing team and support structures.

RESULTS: We found significant variation in EHR time across clinics, with total EHR time per appointment ranging from a median of 45.9 minutes at one clinic to 27.4 minutes at another. Median pajama time per visit and electronic inbox time per visit ranged from 13.1 minutes to 3.5 minutes and 10.6 minutes to 4.7 minutes across clinics, respectively. Survey results also demonstrated variability in team structure across the clinics. Respondents from 6/14 (24.9%) of clinics reported a set clinical team, while the remaining 8 had a more flexible team composition. PCPS in 11/14 (78.6%) clinics reported consistently working with a medical assistant, while only PCPs in 5/14 clinics consistently worked with a licensed practical nurse. In 7/14 (50.0%) clinics, PCPs received no assistance with clinical documentation from their team. PCPs in 3/14 (21.4%) had documentation help from scribes, while 4/14 (28.6%) received documentation assistance from other members of the care team. Clinics with a set team structure had a higher median total EHR time (3.8 minutes), pajama time (1.3 minutes), and electronic inbox time (1.5 minutes) per visit than those with an ad-hoc team structure. Meanwhile, clinic that had scribes to assist PCPs with documentation had a lower median total EHR time (7.5 minutes), pajama time (2.0 minutes), and inbox time (2.3 minutes) compared to clinics lacking this service

CONCLUSIONS: Our findings highlight significant variation in EHR time and clinical team structure across 14 PCP practices in a large academic health system. They underscore the need to better characterize how team structure variation may influence PCPs’ EHR time.

IMPLEMENTATION OF A SCALABLE ONLINE WEIGHT MANAGEMENT PROGRAM IN CLINICAL SETTINGS: ENROLLMENT AND EARLY ENGAGEMENT DATA

Ryan Dunk²; JoAnn Cho²; Sarah Noonan²; Richard Fay²; Caroline M. Apovian¹; Ashley C. McCarthy¹; Alexander J. Blood⁶; Lipika Samal²; Naomi D. Fisher⁴; Endel J. Orav²; Jorge Plutzky⁶; Jason P. Block²; David W. Bates²; Ronen Rozenblum²; Michela Tucci³; Marian McPartlin⁶; William J. Gordon²; Katherine D. McManus¹; Cheryl Morrison-Deutsch⁵; Benjamin M. Scirica⁶; Heather J. Baer². ¹Center for Weight Management and Wellness (CWMW), Brigham and Women's Hospital, Boston, MA; ²Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ³Clinical Transformation, Brigham and Women's Hospital, Boston, MA; ⁴Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA; ⁵Healthfleet Inc., Needham, MA; ⁶Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4055522)

BACKGROUND: There is an urgent need for scalable strategies for treatment of overweight and obesity. PROPS 2.0 (Partnerships for Reducing Overweight and Obesity with Patient-Centered Strategies 2.0) aims to implement an online weight management program, plus additional support from health coaches, in a broad population of patients.

METHODS: PROPS 2.0 is being implemented across primary care and specialty clinics in an academic medical center in New England, with an enrollment goal of 5000 patients. To be eligible, patients must be ≥ 20 years old, speak English or Spanish, and have a body mass index (BMI) of > 30 kg/m2 or a BMI of 25-29.9 kg/m2 plus another cardiovascular risk factor or obesity-related condition. Patients were recruited through provider referral, self-referral, and electronic health record (EHR) identification. After enrolling, patients register for RestoreHealth (HealthFleet, Inc.), a 12-month digital health program that pairs an online program/app with live coaching. Through RestoreHealth, patients can view brief lessons on nutrition, sleep, exercise, and stress, and they can also log meals and get feedback from a coach. RestoreHealth utilizes data from connected devices, including digital scales, allowing for real-time data to be uploaded. Weight change at 12 months (assessed through routine clinical care or at home via digital scales) is the primary outcome; other clinical outcomes data will be extracted from the EHR, and engagement will be assessed via RestoreHealth. A sample of patients are sent a brief electronic survey after registration to assess weight loss practices, diet, physical activity, and other patient-reported outcomes; a follow-up survey will be sent at 12 months to assess changes in these outcomes and program satisfaction.

RESULTS: Recruitment and enrollment for PROPS 2.0 occurred from November 2022 through October 2023. During this time, 8155 patients were referred by providers (78.4%), 732 patients self-referred (7.0%), and 1512 patients were identified through EHR (14.5%). A total of 5061 were eligible and enrolled (48.7%), 299 of whom were Spanish-speaking (5.9%), and 4508 registered for RestoreHealth (89.1% of enrolled). At enrollment, patients’ mean age was 51.1 years, mean weight was 221.1 pounds, and mean BMI was 36.1 kg/m2; 77.6% of patients were female, 69.9% were non-Hispanic white, 9.9% were non-Hispanic black, and 14.0% were Hispanic. Of the 946 patients who completed the post-registration survey (54.0% response rate), 11.7% were participating in other weight loss programs besides PROPS 2.0, and 12.3% were taking prescription weight loss medications. During the first three months, 94% of patients were actively engaged with RestoreHealth, with 85% having communicated with their coach via text message.

CONCLUSIONS: An online weight management program, combined with support from health coaches, can be successfully implemented in clinical settings, reaching a broad and diverse patient population.

IMPLEMENTING HIGH-VALUE CARE WITH AMBULATORY COSTS TRANSPARENCY (ACT): IMPROVING PROVIDER AWARENESS OF ORDERS EXPENSES

Matthew Ellis, Nyree K. Thorne, Sean Hernandez, Lauren Witek, Richa Bundy, Adam Moses, Corey Obermiller, Ajay Dharod, Nancy M. Denizard-Thompson. Internal Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC. (Control ID #4064701)

BACKGROUND: High-value care is characterized by the delivery of optimal patient care that produces the best results within the given circumstances, all while maintaining cost-effectiveness. In the realm of clinical practice, achieving high-value care involves meticulous medical decision-making, where the potential benefits and drawbacks of interventions are carefully weighed against one another, taking into account the economic considerations. Despite the conceptual clarity of this approach, the United States grapples with soaring healthcare costs and suboptimal health outcomes, presenting formidable challenges for physicians and residents embracing this methodology. One effective strategy to surmount these challenges involves furnishing physicians and trainees with direct information about the cost of care, encompassing elements like laboratory tests and procedures. This proactive measure aims to discourage the unnecessary ordering of low-value tests and encourages the prescription of cost-effective medications. Our hypothesis posits that this supplemental information will prompt providers to engage in more judicious high-value care practices, limiting orders to what is truly essential during a patient's visit. Furthermore, we anticipate a consequential reduction in the average cost per clinical visit, contributing to an overall decrease in healthcare expenditure.

METHODS: We implemented a cost transparency tool into our EHR to provide transparency of lab and procedure cost to providers. An interventional study was completed on provider lab ordering practices a medically and socially complex internal medicine clinic that serves an under-resourced and under-insured population. We compared the top 15 labs ordered at the clinic for chronic disease management during the pre and post periods (March-October of 2022 and 2023) and evaluated their ordering at the 3- and 6-month marks. Insurance was separated into five categories; Commercial, Medicare, Medicaid, Other, and No Insurance Listed. Poisson tests were completed to analyze the difference in ordering rates between insurance categories and across the pre and post study groups.

RESULTS: When comparing lab ordering rates between the pre and post period, ‘Other’ and ‘No Insurance’ types showed a decrease. However, the difference was not significant at the 3-month (p-value: 0.24 and 0.49) or 6-month (p-value: 0.06 and 0.12) evaluation period, despite showing downward trends. Medicare and Medicaid increased in ordering in both the 3- and 6-month evaluations with Medicaid being a significant difference throughout both (p-value <0.001).

CONCLUSIONS: We will continually evaluate the lab ordering rates at 3-month intervals to determine the ongoing effect of the cost transparency tool on ordering practices. We anticipate a continued decrease in the rates of labs ordered in the ‘Other’ and ‘No Insurance’ groups.

INPATIENT USE OF PATIENT PORTAL MESSAGING TO COMMUNICATE WITH OUTPATIENT PROVIDERS

Kevin A. Menjivar¹; David W. Bates¹; Jorge A. Rodriguez². ¹General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA; ²General Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4064729)

BACKGROUND: Communication between patients and their inpatient and outpatient clinicians is critical during admissions. Patient portals are the primary patient-facing tool for patient-provider communication. Prior work has focused on secure messaging by outpatients, but there is little data on secure messaging by admitted patients to their outpatient teams. Our objectives were to determine the prevalence of messaging by admitted patients and categorize the content of the messages.

METHODS: We evaluated adult, primary care patients who were admitted in 2022 to an academic medical center and had an active portal account. We categorized message content using the taxonomy of consumer health information communication types. The categories and subcategories are: informational needs or communications (problems, management, tests, and interventions), medical needs or communications (appointments/scheduling, medical equipment, prescriptions, and tests), logistical needs or communications (insurance/billing, personal documentation, and facility/policy), social needs or communications (acknowledgment, complaints, and emotional need or expression), and other. We used chi squared analysis to compare the characteristics of patients who did and did not send a message. All analyses were performed in R (4.3.2).

RESULTS: Our study included 869 patients across 1,142 inpatient medicine admissions. A total of 175 (20.1%) patients across 211 encounters (18.5%) sent at least one message for a total of 551 messages. Compared to patients who did not send a message, patient who messaged tended to be younger, English-speaking, White, non-Hispanic, and had longer lengths of stay. After categorizing the messages, 36% were about medical needs or communications, 35% were about informational needs or communications, 14% were about social needs or communication, 11% were associated with logistical needs or communications, and 4% were categorized as other. The most common subcategories were problems, appointment/scheduling, and prescriptions (Figure).

CONCLUSIONS: We found that about a fifth of admitted patients sent messages to their outpatient teams. Most messages addressed patient’s informational or medical needs. Our findings highlight an opportunity for patient-centric coordination between clinical teams.

INTEGRATING A HIGH BLOOD PRESSURE ADVISORY ACROSS A PRIMARY CARE NETWORK: A QUASI-EXPERIMENTAL TRIAL TO EVALUATE EFFECTIVENESS AND IMPLEMENTATION

Anuradha Phadke¹; Yingjie Weng¹; Cati Brown-Johnson²; Marcelle Winget²; Manisha Desai¹; Jonathan Shaw¹. ¹Medicine, Stanford University School if Medicine, Palo Alto , CA; ²Evaluation Sciences Unit, Stanford School of Medicine, Stanford, CA. (Control ID #4064646)

BACKGROUND: Leveraging technology to prompt team-based care may improve ambulatory hypertension care.

We sought to assess whether an electronic medical record (EMR) high blood pressure (BP) advisory improves hypertension control (primary objective) and diagnosis (secondary objective) and explore integration barriers and facilitators (secondary objective).

METHODS: We conducted a mixed-methods study where a quasi-experimental design assessed hypertension control pre- and post- intervention and concurrent care team observations and interviews assessed implementation. The study followed patients presenting for primary care office visits at 28 primary care clinics in a single academic health system. 8/28 clinics contributed data toward the primary objective while 6-28 contributed data toward the secondary objectives.

The intervention was an EMR high BP advisory combined with team training and audit & feedback. BP ≥ 140 systolic or ≥ 90 diastolic triggered the advisory. Initial EMR entry of elevated BP prompted a medical assistant-focused interruptive recheck advisory. Persistently elevated BP prompted a second clinician-focused interruptive advisory and order set.

The primary outcome was an in-clinic blood pressure of <140 systolic and <90 diastolic during a follow-up office visit within 6 months of an initial primary care visit. Secondary outcomes included the presence of BP recheck after an initial elevated value and new hypertension diagnosis within 1 month following a primary care office visit. Qualitative outcomes included clinical team experience and feasibility.

RESULTS: The odds of hypertension control increased by an average of 18% per month (p<0.001) in the post vs. pre intervention cohort. Modeled rates of hypertension control over 6 months went from 85.6% to 88.6% for the post intervention cohort vs 78.9% to 78.1% for the pre intervention cohort. The odds of having a new hypertension diagnosis increased significantly (p < 0.001) and the odds of BP recheck in primary care visits with an initially elevated BP recording increased approximately 5-fold. In interviews of 34 individuals (clinicians, medical assistants, and managers) from 6 clinics, implementation barriers included competing priorities and time for BP rechecks, order set complexity, and mixed clinician engagement; facilitators included intervention visibility, EMR integration, and team-based approach.

CONCLUSIONS: We found that an intervention that emphasized team-based care and EMR-integration significantly improved primary care hypertension control and diagnosis. Improvement opportunities identified included implementation timing and simplifying order sets. Interventions explicitly emphasizing human and technology interplay will continue to prove essential for population health across primary care networks and warrant robust evaluation of both effectiveness and implementation.

INTERPRETING ARTERIAL BLOOD GASES USING ANTHROPIC’S CLAUDE V2, A LARGE LANGUAGE MODEL

Praveen N. Meka. Medical Oncology, Harvard University, Cambridge, MA. (Control ID #4064222)

BACKGROUND: Large language models (LLMs) have demonstrated exceptional proficiency in various specialized tasks, yet their effectiveness in clinical decision support has not been thoroughly investigated. Although they achieve remarkable accuracy in other domains such as coding, a true assessment of their potential in medicine requires a comprehensive evaluation. Models like Flan-PaLM have set new accuracy records(1). However, they still do not measure up to human clinicians, underscoring need for further testing and development. This study seeks to evaluate the LLM Claude v2's ability to analyze Arterial Blood Gases (ABG), a common clinical task. It will then explore the implementation of Retrieval-Augmented Generation (RAG), prompt engineering and a mathematical scratchpad to determine if these enhancements improve accuracy.

METHODS: We began by creating a comprehensive bank of Arterial Blood Gases (ABGs) covering a range of clinical scenarios, each featuring a simple primary and a secondary abnormality. The target sample size was calculated to be 50 samples to achieve a statistical power of 90%, assuming effect size >30%. The first step was to use the ABG database directly to gauge accuracy of Claude v2 LLM. Subsequently we incorporated the decision architecture to assess the accuracy rate. Prompt engineering entails designing input prompts to direct the LLM's stepwise analysis. Retrieval Augmented Generation (RAG) assists in synthesizing information from various documents to provide context. The LLM’s struggle with mathematical analyses, hence we introduce Python based math scratchpad.

In this study we plan is to test and compare the accuracy rate on the same dataset of ABGs using none versus implementing prompt engineering, RAG architecture and a Math scratchpad.

RESULTS: Initial results with the Claude Large Language Model (LLM) showed less than 50% accuracy in interpreting arterial blood gases (ABGs). However, incorporating the decision architecture with Recursive Aggregation architecture, refining prompts and adding math scratchpad led to an improvement. The decision architecture increased accuracy to over 85%.

CONCLUSIONS: As a hospitalist, ABG interpretation has remained a crucial skill that I use regularly. Mixed acid-base disturbances can be particularly challenging. With the advent of LLMs like Claude v2, I see opportunity to evaluate their accuracy in interpreting diagnosing acid-base disorders.

In this study I compare the LLM to evaluate a database of ABG’s with and without using decision architecture. The LLM used is Claude v2. I found the accuracy of LLM’s to interpret ABGs was <50%. I then, implemented a decision architecture to improve the LLM's proficiency that includes prompt engineering, implementing RAG, and providing a math scratchpad. With the decision architecture implemented I found accuracy to improve to >80%. More research and evaluation would be needed before LLM’s could be applied to supporting clinical decision making.

IS CHATGPT A COMPLEMENT OR SUBSTITUTE FOR PRIMARY CARE? RESULTS FROM A NATIONAL SURVEY

Richard L. Kravitz¹; Oluwatobiloba Ayo-Ajibola²; Ryan Davis²; Matthew E. Lin²; Jeffrey Riddell². ¹General Medicine, UC Davis, Sacramento, CA; ²University of Southern California Keck School of Medicine, Los Angeles, CA. (Control ID #4047153)

BACKGROUND: For at least a decade, 2/3 of US adults have reported using the internet as their initial source of healthcare information. The landscape is shifting rapidly with the advent of generative artificial intelligence models such as ChatGPT. However, patients with a usual source of primary care (USPC) may have more continuous access to trusted human advisors and therefore engage differently with online health information (OHI). We undertook this study to investigate if OHI-seeking differs between patients with and without a USPC.

METHODS: From June through August 2023, we invited 21499 members of a disease-neutral recruitment registry (ResearchMatch) to participate in an internet-based survey. The survey included questions about demographics, single-item health status, types and frequency of OHI use, and whether respondents had a usual source of primary care (doctor’s office, clinic, or VA) as opposed to episodic care (emergency room, urgent care, retail clinic, or “none”). We analyzed the unweighted data in Stata 15.1 using descriptive statistics, chi-square tests, t-tests, and logistic regression.

RESULTS: Among 2406 respondents (response rate, 11.2%), 99% used some form of OHI, with 89% reporting use of passive OHI (e.g., Google, Wikipedia, WebMD), 53% interactive OHI (e.g., online forums, Q&A sites like Quora, ChatGPT), and 22% ChatGPT specifically. Compared to patients receiving episodic care (n=1061, 44%), those with a USPC (n=1345, 56%) were more likely to use passive OHI (94% vs 82%, p<0.001), somewhat less likely to use interactive OHI (52% vs 56%, p=0.049), and substantially less likely to use ChatGPT (18% vs 25%, p<0.001); the same patterns held in logistic regressions adjusted for age, education, income, and single-item health. Among ever-users of ChatGPT, there were no differences between patients with and without a USPC in terms of frequency or duration of use (p>0.20). ChatGPT users with a USPC were less likely than those without a USPC to have suspected “that the information provided by ChatGPT was inaccurate” (63% vs. 72%, p=0.04) but more likely to bring any doubts about accuracy to the attention of a physician or other health professional (73% vs. 63%, p=0.013).

CONCLUSIONS: In this diverse non-probability sample from a medical research recruitment registry, patients with a USPC exhibited different patterns of OHI use than patients reliant on episodic care. Despite more avid use of OHI overall, USPC patients were less likely to engage with interactive OHI and specifically with ChatGPT. We speculate that having a USPC both diminishes the need for interactive OHI and complements passive OHI by helping patients assess the credibility and relevance of the information. In contrast, patients without a USPC may be turning to ChatGPT as a silicon-based substitute for a doctor who knows them. More research is needed to confirm these results and test interventions that enhance OHI complementarity in primary care and beyond.

LARGE LANGUAGE MODEL BASED ASSESSMENT OF RESIDENT CLINICAL REASONING DOCUMENTATION

Verity Schaye¹; David J. DiTullio²; Benedict Guzman³; Ilan Reinstein³; Danielle Weber⁴; Sally Santen⁴; Abbie Goodman⁴; Larry Gruppen⁵; Danny Wu⁴; Jesse Burk Rafel³. ¹Division of General Internal Medicine, NYU School of Medicine, New York, NY; ²Medicine, NYU Langone Health, New York, NY; ³New York University, New York, NY; ⁴University of Cincinnati, Cincinnati, OH; ⁵University of Michigan, Ann Arbor, MI. (Control ID #4053303)

BACKGROUND: Improvements in clinical reasoning documentation quality can lead to improvements in diagnostic accuracy, yet feedback can be lacking owing to barriers including time and lack of expertise. Advances in artificial intelligence (AI), such as large language models (LLMs), can help overcome these barriers. Previously, we used non-LLM AI models to create a binary model for low- or high-quality resident clinical reasoning documentation quality. Here, we describe the development of an LLM-based assessment that predicts the quality of residents’ clinical reasoning documentation in real clinical notes.

METHODS: Hospital admission notes from the Electronic Health Record (n = 691) written between July 2020-June 2021 by internal medicine residents at one academic center were rated by clinicians using a validated rubric on two scores: Differential diagnosis prioritization “D score” (scored 0 [fewer than 2 unique diagnoses], 1 [intermediate], or 2 [2 unique diagnoses and explicit prioritization]) and Explanation of reasoning “E score” (scored 0 [no supporting data points], 1 [intermediate], or 2 [2 diagnoses with supporting data points]). Cohen’s k was calculated on a note subset (n = 76) with multiple raters. Models were trained by fine-tuning a local LLM pre-trained on 7.25 million clinical notes to calculate D and E scores. Training was performed on 80% of the rated notes; performance was assessed on the unseen 20% of notes using area under receiver operating characteristic curve (AUROC) and average precision (i.e., positive predictive value) to classify each of the three levels of the two score domains (six total models).

RESULTS: Human interrater agreement was moderate-to-high (Cohen’s k: D score 0.68, E score 0.76). AUROC and average precision were as follows for each of the six models: D score 0 (0.91, 0.72), D score 1 (0.57, 0.33), D score 2 (0.80, 0.87), E score 0 (0.75, 0.34), E score 1 (0.79, 0.75), E score 2 (0.80, 0.86).

CONCLUSIONS: Using advanced AI technologies, including LLMs, we have developed models that predict clinical reasoning documentation quality that can be used to provide specific, automated feedback on clinical reasoning documentation in clinical notes across wide ranging diagnoses. These results indicate excellent performance across four of six score classes (D scores 0 and 2, E scores 1 and 2). Notably, poor model performance was seen in D score of 1, which are notes with intermediate quality differential diagnoses that represent a complex rating task. Ongoing work will seek to combine the multi-class scores into a unified model, further improve performance across all score categories (including experimentation with other LLMs), and deploy the model in a formative feedback intervention to improve trainee clinical reasoning documentation behaviors. This tool can be used to increase the frequency of trainee feedback on their clinical reasoning documentation, ideally driving improved clinical reasoning documentation and thus diagnostic accuracy.

MYCHART BILLING: STRIKING A BALANCE BETWEEN PROTECTING PROVIDER TIME AND OFFERING ACCESSIBLE CARE

Suryaa Gupta¹; Sara Alturky¹; Andrea Smeraglio²; Jeff Gold². ¹NA, Oregon Health & Science University, Portland, OR; ²Internal medicine, Oregon Health & Science University, Portland, OR. (Control ID #4023873)

BACKGROUND: Amidst the COVID-19 pandemic, physicians turned to technology to conduct virtual visits and increased communication with patients via MyChart messaging. This improved accessibility but providers were mostly not compensated for time spent responding to patient messages. In 2022, Oregon Health & Science University began a rollout of billing for MyChart messages in order to protect and compensate provider time. While this is an important step for physician time management, there is little data on patient impact. We aimed to determine if initiating billing for Mychart messages disproportionately impacts MyChat use amongst vulnerable populations such as patients > 65 years of age and those in racial minority groups.

METHODS: An alert was sent to all OHSU MyChart patients on 2/27/2023 announcing initiation of bills for MyChart messages. Data regarding MyChart message frequency and billing status pre and post this announcement were sorted by various demographics (e.g., age, race, ethnicity, RUCA status, etc.). Utilizing an XmR (individual and moving range) control chart template, analysis was completed to demonstrate stability and variability across various data points, illustrating trends over time, pre- and post-billing implementation.

RESULTS: The announcement that billing would occur did not change patient behavior. Rates of patient MyChart messaging remained unchanged. Before the billing rollout, 23% of the senior population utilized MyChart messaging, which insignificantly rose to 26% following. Interestingly, providers also issued very few bills despite having this option, with less than 0.3% of MyChart messages being billed monthly.

CONCLUSIONS: Despite the implementation of a MyChart billing system, vulnerable patients were not dissuaded from utilizing the service. While this is encouraging news that billing for MyChart does not change accessibility, further studies should investigate if receipt of a bill changes patient behavior or creates disproportionate barriers to the vulnerable.

NATIONAL TRENDS IN PATIENT-INITIATED MEDICAL ADVICE REQUESTS AMONG PRIMARY CARE PHYSICIANS, 2019-2022

Lisa Rotenstein^1,2; A Jay Holmgren²; Nate Apathy³; Christine Sinsky⁴; Julia Adler-Milstein²; David W. Bates⁵. ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²University of California San Francisco, San Francisco, CA; ³MedStar Health, Columbia, MD; ⁴Professional Satisfaction, American Medical Association, Chicago, IL; ⁵General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #4064091)

BACKGROUND: During the COVID-19 pandemic, digital technologies that enable patient-clinician communication rapidly transitioned from occasional use for convenience purposes to an essential component of primary care. We characterized changes in patient-physician EHR messaging across PCPs from 2019 to 2022 and identified variation in EHR messaging burden across individual physicians.

METHODS: We used Epic Signal EHR metadata from July 2019 to March 2022. This dataset characterizes the EHR activities of physicians across Epic’s more than 400 US installations. For all PCPs, we extracted information about the number of messages received in each of the following categories: 1) patient-initiated messages, which includes patient medical advice requests (PMARs) and patient-initiated calls, 2) other messages, including results, prescription, system, and team messages. We also derived information about the time that PCPs spent on the EHR. All message quantity and EHR time measures were aggregated at the physician week level.

After using descriptive statistics to evaluate trends in message volume from 2019 to 2022, we characterized how changes in message volume differed by PCPs’ pre-COVID message volume. We then used two-way fixed effects regression models to assess the impact of the post-COVID increase in message volume on PCPs’ total EHR time.

RESULTS: The sample consisted of 128,357 PCPs across 416 institutions. Among the PCPs in the sample, total message volume increased significantly from an average of 179 weekly messages in 2019 to 191 messages in 2021. Patient-initiated messages (PMARs and patient-initiated calls) increased from 29.1 weekly messages in 2019 to 35.9 weekly messages in 2022. While both PMARs and patient calls increased in volume from 2019 to 2022, the increase in patient-initiated messages was largely driven by PMARs, which rose from 9.6 weekly messages in 2019 to 16.6 weekly messages in 2022.

The relative increase in PMARs from 2019 to 2022 was greatest for PCPs who had the highest weekly burden of weekly patient messages pre-pandemic. Additionally, each marginal PMAR was associated with significantly more EHR time post-pandemic vs. pre-pandemic (1.99 minutes (95% CI: 1.60, 1.81) minutes of additional EHR time post-pandemic vs. 1.70 minutes (95% CI: 1.60, 1.81) pre-pandemic). This translated to significant weekly increases in total EHR time for PCPs, from a mean of 668.0 minutes (SD: 433.4) of total weekly EHR time pre-pandemic to 694.6 minutes (SD: 447.3) post-pandemic.

CONCLUSIONS: In this national, cross-sectional study, we demonstrate that PCPs’ message burden has increased significantly since the COVID-19 pandemic. This increase was driven by PMARs and was associated with significant increases in PCPs’ total EHR time from 2019 to 2022. These findings underscore the need to develop novel technology solutions, team-based workflows, and patient education to facilitate long-term sustainability of modern primary care practice.

OURNOTES FOR CARE PARTNERS - A DYNAMIC TOOL FOR RECOGNIZING, ASSESSING, AND SUPPORTING THE WELL-BEING OF INFORMAL CARE PARTNERS THROUGH THE PATIENT PORTAL

Catherine DesRoches¹; Deborah Wachenheim²; Jessica Ameling⁶; Nancy Cibotti Granof⁴; Jennifer Meddings⁵; Jody Naimark³; Jennifer Wolff⁷. ¹Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ³Family Medicine, Winchester Hospital, Winchester, MA; ⁴Medicine, Beth Israel Lahey Health, Cambridge, MA; ⁵Internal Medicine, University of Michigan, Ann Arbor, MI; ⁶Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; ⁷Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4064586)

BACKGROUND: “American’s stealth weapon against chronic illness is a 46-year-old woman…She has no particular training in health care. And… sometimes she doesn’t feel that great herself” (AMA Medical New, 2001). This picture of informal care partners, those helping a friend or family member with medical care or daily living needs, still holds. Given the impact that caregiving activities can have on the health of the care partner, finding simple, low-cost methods of identifying and connecting them with services could be of enormous benefit.

METHODS: We developed and implemented OurNotes for Care Partners (ONCP) at 5 primary care practices – 3 in the Boston MA area and 2 in southeast MI. Three days before a clinic visit, patients with a patient portal account were invited to log on and complete a pre-visit questionnaire asking them to identify important life changes, set the agenda for the upcoming visit, and report care partner responsibilities. Patients with care partner responsibilities were provided with a link to the Caregiver Intensity Index (CII): a 2 minute assessment that 1) provides a score reflecting the intensity of care partner activities, 2) identifies key buffers and drivers of that intensity, and 3) provides resources curated for their community. Patients without a portal account and their care partners could access the CII through materials available in the clinic.

RESULTS: During the first year of the pilot, 19,407 unique patients received the questionnaire and 8,789 completed it at least once (RR = 45.3%). The majority of patients completing the questionnaire were at least 45 years old (45-64: 36.3%; 65+: 30.7%) and female (61.7%). 19.1% of respondents reported care partner responsibilities; approximately 39% of them took the CII after completing the pre-visit questionnaire. In total, 612 patients completed the CII. 16.0% scored in the red, the highest level of intensity, 63.6% in yellow, and 20.4% in green. The most often cited drivers of intensity were “no time for you” and “feeling stressed out or depressed.” In interviews, clinicians and staff reported that ONCP was simple to implement, that they felt more able to ask patients about care partner responsibilities because they had a resource to offer, and that patients appreciated being asked for this information.

CONCLUSIONS: We tested the feasibility of implementing a low-touch, low-cost method of identifying those with care partner responsibilities in clinical settings and connecting them to resources. Findings suggest that ONCP is feasible, acceptable to clinicians, staff, and patients, and can identify care partners with unmet needs. As patient portals become increasing central to the provision of care, creative interventions such as ONCP hold significant promise for meeting care partner needs without adding undue burden on clinicians and staff.

PASSPORT, TICKET, AND CHATGPT? THE FUTURE OF TRAVEL MEDICINE

talar acob, Jama Ainanshe, Rukia Ramza, Syeda Kanza Afzal, Ahmed Almagazzachi, Ashkan Eighaei Sedeh. Internal Medicine, Capital Health Regional Medical Center, Trenton, NJ. (Control ID #4062961)

BACKGROUND: The COVID-19 pandemic, though devastating, was a great reminder of the importance of travel medicine as part of planning a trip to mitigate health-related illnesses during upcoming journeys. Despite that, up to 50% of U.S. travelers do not consult a healthcare provider prior to traveling. An increased reliance on online platforms for health-related information due to ease of access to many complementary resources is likely to play a significant role. Due to the diversity of the online resources available, however, it can be challenging for the layperson to differentiate reliable from unreliable resources. This highlights the need to evaluate the accuracy of information accessed through commonly used resources, including generative AI, particularly ChatGPT. This study aims to examine the accuracy and reproducibility of the information provided by ChatGPT as a travel companion

METHODS: In this qualitative study, which did not involve human subjects, CDC guidelines were used to examine the accuracy and reproducibility of the travel health and safety information offered by ChatGPT. The top 10 most visited countries by U.S. travelers were identified, and 3 study staff members independently queried ChatGPT regarding the recommended preventive measures for each country. Consequently, 3 sets of responses were generated for each country, and the majority response, defined as a response where the same message was echoed at least 2 of the 3 times, was selected for further analysis. Accuracy was assessed by comparing ChatGPT recommendations to CDC guidelines for each country, and responses were categorized into accurate, if aligned with CDC recommendations and were complete; partially accurate, if were in line with CDC recommendations but missing information; and inaccurate, if not in line with the CDC recommendations. Finally, reproducibility was calculated. A response was deemed reproducible if all 3 responses related to the same travel destination conveyed the same message.

RESULTS: Of the total of the 30 sets of responses generated by ChatGPT (3 per country), each response was missing at least 1 key information, either as a subset of a category (e.g., incomplete vaccination list) or missing a category altogether (e.g., food safety). However, none of the recommended information deviated from the CDC guidelines. Therefore, all responses were placed into the partially accurate category. Furthermore, when assessing the reproducibility, ChatGPT had perfect consistency in conveying the same information.

CONCLUSIONS: This study suggests that travel medicine information offered by ChatGPT alone is insufficient, and accessing the CDC website for online information or visiting a healthcare provider would remain the gold standard. However, the high reproducibility of ChatGPT responses and the absence of incorrect information give hope that, with further refinement, it can serve as a reliable and accessible source of information for travel-related health information.

PATIENT REPORTED EXPERIENCE WITH VIDEO AND PHONE VISITS AMONG PATIENTS WITH LIMITED ENGLISH PROFICIENCY IN CALIFORNIA

Jorge A. Rodriguez¹; Elaine Khoong²; Stuart Lipsitz³; Courtney Lyles⁴; David W. Bates³; Lipika Samal⁵. ¹General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Medicine, University of California San Francisco, San Francisco, CA; ³General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ⁴Public Health Sciences, University of California Davis School of Medicine, Sacramento, CA; ⁵Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4064552)

BACKGROUND: Patients with limited English proficiency (LEP) face disparities in telehealth care. While research has focused on access, attention to patient experience is essential. Patients with LEP have worse experience with in-person care. We describe the differences in telehealth access and experience for patients with LEP compared to English proficient (EP) patients in California.

METHODS: We analyzed the 2021 California Health Interview Survey. The exposure was LEP, defined as speaking English not well or not at all. The outcomes were telehealth use and visit experience. For visit experience, participants were asked, “How would you rate the overall experience of your most recent [video visit/phone visit] compared to an in-person visit? Would you say the [video visit/phone visit] was...” We dichotomized visit experience to better/same versus worse. Outcomes were assessed in comparison to EP. Covariates included age, sex, marital status, insurance, education, poverty level, self-reported health status, internet use, and having a usual source of care. We did not include race/ethnicity or living in a metropolitan area due to collinearity. We performed bivariable comparisons using weighted chi-square analysis. We then performed weighted multivariable logistic regression to determine the odds of worse experience after controlling for covariates. Two-sided p < 0.05 was considered statistically significant. Analyses were performed using R software, version 3.6.2.

RESULTS: The survey included 24,453 respondents, representing 29,649,837 people. Patients with LEP accounted for 9.4% of respondents, 7.2% of telehealth users, and differed significantly from their EP counterparts across sociodemographic characteristics and telehealth use. LEP telehealth users differed significantly from EP users across age, education, marital status, poverty level, insurance, usual source of care, health status, and internet use. Among those who reported telehealth use, patients with LEP accounted for 6.8% of video visit users (n = 387 representing 840,764 people) and 8.1% phone visit users (n = 484 representing 1,021,909 people). In adjusted analyses, LEP patients were less likely to report telehealth use (odds ratio (OR): 0.63 [95% confidence interval (CI): 0.52-0.76, p<0.001]) compared to EP patients. Patients with LEP were more likely to report worse experience with video visits compared to in-person visits (OR:1.42 [95% CI: 1.04-1.94, p = 0.026). For phone visits, there was no difference in phone visit experience between LEP and EP patients (adjusted: OR: 1.24 [95% CI: 0.91-1.69, p =0.167]).

CONCLUSIONS: We found not only telehealth access disparities for patients with LEP, but also worse experience with video visits. The worse experience may be explained by perceived effectiveness for in-person care and well-established digital barriers. These findings highlight access to phone visits alongside needed improvements to video visits for patients with LEP.

REGIMEN EDUCATION AND MESSAGING IN DIABETES, THE REMIND TRIAL

Guisselle Wismer¹; Stephanie Batio¹; Mary Kwasny²; Alex Federman³; Michael Wolf¹. ¹General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Northwestern University Feinberg School of Medicine, Chicago, IL; ³Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4063631)

BACKGROUND: Adults with type 2 diabetes (T2DM) manage complex multi-drug regimens, but nearly half of all patients do not consistently take the dose prescribed for them, and so may not receive the full potential benefit. Both patient and health system factors contribute to achieving and maintaining medication adherence. To determine if patients with T2DM could improve their adherence, we tested a primary care-based strategy to provide health literacy-appropriate and language concordant regimen information, guidance and reminders. We sought to test the effectiveness of an electronic health record (EHR) based strategy and text reminders to help patients with T2DM adhere to their medications.

METHODS: We conducted a physician-randomized, 3-arm controlled trial. Adults ages 21+ with T2DM, who were English or Spanish-speaking, taking 5+ prescription medications, and were primarily responsible for administering their own medication were recruited from 2 academic internal medicine practices in the Midwest and East Coast. Enrolled patients (N=750) were randomized to 1 of 3 study arms, receiving either 1) usual care; 2) a Universal Medication Schedule (UMS)-centered intervention that included EHR-embedded instructions that standardized prescribing to morning, noon, evening, and bedtime, coupled with low literacy medication education delivered with After Visit Summaries; 3) the UMS-centered intervention and UMS-timed medication text reminders. An intent-to-treat approach was applied to the study, with primary outcomes being medication adherence as measured by self-report (ASK-12), objective observation (24 hour recall), and pill count.

RESULTS: The mean age was 61 years (SD=10.54); over half (59%) were female, one-third (32%) were Hispanic, and 36% had a high school degree or less. Patients were taking on average 11 medications (SD=4.79). In both bivariate and multivariate analyses, no differences were found between arms in terms of adherence measured by ASK-12 (LSM 23.30 vs 23.10 vs 23.93; p=0.26), 24 hour recall (LSM 0.70 vs 0.71 vs 0.67; p=0.32), or pill count (LSM 0.33 vs 0.30 vs 0.32; p=0.63). When examining an interaction between study arm and health literacy, a significant interaction was found for ASK-12; among patients with low health literacy, those receiving the UMS only study arm had fewer reported adherence barriers compared to participants receiving UMS+text. (21.6 vs. 24.1, p=0.002).

CONCLUSIONS: There are many learning opportunities through the REMinD investigation beyond the evaluation of the interventions. The prevalence of inadequate adherence among such a diverse sample overall was low, and discrepancies in regimen dosing as observed via 24 hour recall also underscores the need for intensive interventions over time to help address issues related to unintentional adherence. Moving forward, a future trial might consider evaluating UMS tools (without COVID-19), comparing the strategies with and without more intensive adherence strategies to finalize a determination on their benefits.

TEMPORAL VARIATION IN CLINICAL COMMUNICATION PLATFORM USAGE

Katie Hsia, Andrew Nguyen, Sankirth Madabhushi, Michael Davis. Medicine, Tufts Medical Center, Boston, MA. (Control ID #4064038)

BACKGROUND: Clinical communication & collaboration (CC&C) messaging platforms are replacing pagers for communication between nurses and physicians. Previous literature focuses on quantifying the volume of pages and when they occur, finding the evening time to have the highest number of pages. We hypothesize that CCC is used similar to pagers, primarily for communication when nurses and intern physicians cannot easily find each other to speak in person regarding patient care. Therefore, we would expect to find that the majority of messages will happen in the evening and overnight when interns are not sitting near their patients.

METHODS: We examined interactions between the 96 medical nurses and 26 internal medicine interns from July 1, 2022 to December 1, 2022 at an academic, tertiary medical center. The CCC company provided us data regarding who sent and received each message (name, title, and department) as well as date and time of sent, delivered, and read. R and dpylr were used to analyze.

RESULTS: There was a total of 31,818 messages sent from nurses to interns and 29,239 messages sent from interns to nurses. Each intern on average sent 19.3 and received 20.8 messages/day (individual interns averaged between 11.6-28.0 sent and 15.0-25.4 received message/day). On average, interns sent and received 39.8 messages/day (range 1-216 messages/day).

For each hour of the day, interns on average sent and received between 2-5 messages/hour, interacting with on average 4-10 messages/ hour. The fewest messages were sent at 7am. The maximum number of messages an intern sent and received in an hour was 63. The time of day that messages were sent and received per intern can be seen in Figure 1.

CONCLUSIONS: The number of messages sent by interns was lowest at 7am and 7pm, consistent with when patients are signed out between the day and night teams for both interns and nurses.

Number of messages are highest in the evening, primarily in the early evening after shift change. This is likely most consistent with when the night shift of nurses and interns have just started, and are communicating about patient care primarily via messages because the interns are not sitting near the nurses or patients overnight. The average number of messages sent by each intern is lowest during the day, likely because interns sit near nurses and patients and can communicate in person. Further research will implement various quality improvement projects to optimize the use of CCC.

USING HEALTH SYSTEM DATA TO PRIORITIZE PRIMARY CARE STRATEGIES TO LOWER RISK OF HOSPITALIZATION FOR HIGH RISK/COMPLEX PATIENTS

Timothy M. Bober^2,1; Franya Hutchins^2,4; Xinhua Zhao²; Joshua M. Thorpe^2,5; Hongwei Zhang²; Karin Daniels²; Linnaea C. Schuttner^3,6; Ann-Marie Rosland^2,4. ¹General Internal Medicine, UPMC Presbyterian-Shadyside, Pittsburgh, PA; ²Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; ³Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA; ⁴University of Pittsburgh Department of Medicine, Pittsburgh, PA; ⁵UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC; ⁶University of Washington School of Medicine, Seattle, WA. (Control ID #4063805)

BACKGROUND: Patients can be identified as “high risk” for hospitalization with health systems data, but it is not easy for providers to determine what care might help most to lower their risk. While individual care plans for patients with complex needs can be effective, they are labor-intensive and difficult to scale. “One size fits all’ interventions are not effective for this population due to their varied healthcare needs. We analyzed VA health system data for six previously identified groups of high-risk patients with distinct clinical profiles to identify unique predictors of hospitalizations and care gaps for each group.

METHODS: 98,605 patients were randomly selected from all VA primary care patients at high-risk of hospitalization (VA CAN Score >90^th percentile) in 2021 and divided into six groups characterized by chronic diagnosis profiles. Descriptive VA administrative and health record data included diagnoses, social/functional determinants of health, hospital admissions, emergency room visits, non-VA care use, outpatient care use, and quality metrics for patients less than and over 65 years old. Least absolute shrinkage and selection operator (LASSO) regression models to identify predictors of hospitalization in the year following a high-risk score were used for variable selection and to avoid overfitting. Predictors included demographics, comorbidities, functional impairments, primary and specialty care utilization, healthcare program use, and disease-specific quality metrics.

RESULTS: Groups of high-risk patients were defined by Tobacco/Lung/Substance Use disorders (TLS, 11%), Cardiometabolic (CM, 23%), Mental Health (MH, 14%), Low Chronic Diagnosis (LD, 26%), High Complexity (HC, 11%), and Advanced Cardiac (AC, 15% of only >65 years old). Descriptive data patterns revealed group-specific care needs. For example, 7% of those in the TLS group under age 65 had documented falls, while those in the MH group had higher outpatient primary and specialty care use than most other high-risk patients. Models identified additional group-specific potential care needs. For example, the strongest predictors of 1-year hospitalization in the CM group ages <65 were non-VA care use and falls, and diagnoses of anemia, coagulopathy, and chronic skin ulcers; but for the MH group <65 were pregnancy program use, substance use disorders, vascular disease diagnosis, and visual impairment.

CONCLUSIONS: Descriptive and model results identified unique care needs and predictors of hospitalization for groups of high-risk patients. These results could tailor care plans intended to reduce hospitalization and improve health, like addressing fall risk in the TLS group or pregnancy care coordination in the MH group. These data-based, group-tailored ‘care steps’ are being incorporated into VA management tools for high-risk patients. Learning health systems could apply this approach to iteratively improve care planning tools and to other clinical contexts.

UTILIZING AN ECHO (EXTENSION FOR COMMUNITY HEALTH OUTCOMES) PLATFORM AND MULTI-SECTOR PARTNERSHIP TO DELIVER STATE-WIDE MONOCLONAL ANTIBODY EDUCATION DURING THE COVID-19 PANDEMIC

Vall Vinaithirthan²; Kyle Leggott¹; Hillary Lum¹. ¹School of Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²University of Vermont Medical Center, Burlington, VT. (Control ID #4065055)

BACKGROUND: With the quickly changing science of the SARS-CoV-2 virus, rapid dissemination of information to health care providers was critical, particularly in rural communities. Here, we describe ECHO (Extension for Community Health Outcomes) Colorado as an effective information dissemination tool to meet the need for health care provider education on ambulatory COVID-19 monoclonal antibodies (mAb) in rural communities. The ECHO model utilizes an interactive online platform to connect interested health care parties and deliver evidence-based best practices through didactic and case-based learning. We also describe the development of a multi-sector partnership between state public health officials, academic researchers, and ECHO Colorado to deliver key information to increase use and access to mAb therapy.

METHODS: The COVID-19 mAb webinar series was developed through collaboration of public health officials, academic researchers, and ECHO Colorado and covered clinical outcomes and guidelines, state-wide mAb infrastructure, and resources for implementation. There were two seminars conducted in August and December 2021, with each iteration including three identical sessions. During each session, baseline data and pre/post questions were obtained. Pre/post surveys assessed respondents’ understanding of evidence supporting the use of mAb treatment, likelihood to refer a patient for mAb treatment, and likelihood to start providing mAb therapy at their clinic.

RESULTS: Across the August and December series, there were 1,129 total participants, and 684 responded to the post-webinar survey. Most participants' primary place of practice was a primary care clinic (56%) and the majority of participants were clinicians (85.5%). Prior to the mAb webinars, 73.3% of participants believed in the overall strength of evidence supporting mAb treatment, compared to 98% after the webinars. Additionally, 81.3% of participants indicated they would refer patients at high-risk for severe illness in the post-webinar survey, compared to 55% of participants in the pre-webinar survey. 82.6% of the respondents believed that the information provided in the seminars would have a potential or definite impact on professional performance.

CONCLUSIONS: Our information dissemination tool, ECHO Colorado, served as a resourceful, accurate, and widely accessible medium for rapid and accurate information dissemination during a time of unpredictability and misinformation. This enabled providers across Colorado to make data-informed decisions regarding appropriate administration of mAb to prevent critical hospital capacity and severe COVID-19 illness. A multi-sector partnership was crucial to the success of widespread, rapid, and accurate dissemination. Our mAb series exemplifies that an effective platform for information dissemination paired with interdisciplinary collaboration can be beneficial in improving provider education of novel and rapidly-evolving therapies in rural communities.

VALIDATION OF AI COLLABORATIVE TOOL: AN OSCE NOTE GRADING ASSISTANT FOR FACULTY

Tavinder K. Ark¹; Andrew Gleave¹; Sondra R. Zabar²; Adina Kalet¹; Abigail Henderson². ¹Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ²Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4064807)

BACKGROUND: The use of Artificial Intelligence in creating tools of medical educators is growing. There are many educational tasks that are time intensive, subjective and require high faculty time such as grading objective structured clinical examination (OSCE) clinical notes. Furthermore, students do not receive timely feedback on their notes due to delays in grading and time intensity of the task. To help solve this problem, Feedback Assist was created, an AI collaborative tool, that works with faculty in grading a student’s clinical note.

METHODS: We created Feedback Assist using various generative models. FeedbackAssist grades students’ clinical note using the RIME framework (Reporter, Interpreter and Management) including an overall clinical reasoning score. In order to create this tool and validate it, we combined both psychometric theory, such as Messick's framework, and the AI explainability models. Through using specific statistical analyses, such as measurement invariance and item response theory, we are presenting a framework for others to use to help tune AI models.

RESULTS: Over 3000 clinical coverage notes from 2020 to 2023 (n=1164) on Oliguria and Hypertension from a near readiness OSCE called Night-onCall (NOC) across a consortium of Medical Schools in the United States was used to train and tune FeedbackAssist. We found that our FeedbackAssist tuning process benefited from using confirmatory factor analysis and measurement invariance techniques that compared the factor loadings, thresholds and error terms between our AI system, FeedbackAssist, and the human rating to determine what aspects of the tuning and training of our AI system was needed. For instance, the measurement invariance models allowed us to determine which anchors in our rating system need to be explicated added to the AI training to increase accuracy. We used Item response theory (IRT) to help us determine if the training set had the appropriate variation required. In addition, we ran a series of experimental tests to see if our AI system could also replicate relevant findings in the field, such as notes getting a higher grade if the number of pertinent positive and negatives were balanced. Our findings provide a framework for others that are interested in training and tuning AI systems using psychometric principles used in training raters when grading written content.

CONCLUSIONS: We learned that using statistical techniques that help validate models, such as internal structure, from validity helped us tune our AI system appropriate. Without conducting such analyses, those developing AI systems may not know where to start in improving their system. We are proposing a technique for others to consider in the development of their AI systems/agents.

VARIATION IN CLINICAL REMINDERS ACROSS VETERANS HEALTH ADMINISTRATION AND PRIMARY CARE BURNOUT

Ashok Reddy^2,1; Eric Gunnink²; Karin Nelson^2,1; Gregory Strandberg³; Mary Lynn Ayers^3,4; Scott A. Pawlikowski³; Kathryn Cillessen³; Joshua Rolnick^3,5. ¹Medicine, University of Washington School of Medicine, Seattle, WA; ²HSR&D Puget Sound, US Department of Veterans Affairs, Washington, DC; ³US Department of Veterans Affairs, Vancouver, WA; ⁴University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ⁵School of Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4064711)

BACKGROUND: Clinical reminders (CR) provide clinical decision support in Veterans Health administration (VHA) to improve care for Veterans. However, primary care teams face enormous pressure to complete an ever-expanding number of guideline-based screenings, and there are concerns that alert burden increases burnout. In addition, to 64 national CR, each VHA medical facility can create additional CR. There is substantial unexplained variability in the number and type of local CRs across different VHA facilities nationwide. Our objective is to understand whether variation in clinical reminder burden is associated with facility-level characteristics and primary care staff burnout.

METHODS: We conducted a cross-sectional study using national VHA data. A national survey was administered across the VHA facilities in 2022 to capture the number of local CRs. Each medical facility is a combination of primary care clinics based at a VA hospital and surrounding community-based clinics. We categorized facilities in 3 groups based on percentile in the number of CRs: low (<25), middle (25-75), and high (>75). We linked this information to data on facility characteristics (e.g. facility complexity) from the VA Corporate Data Warehouse as well as a measure of staff burnout from the 2022 All Employee Survey, an annual confidential survey of VA employees. Burnout among primary care staff (providers, nurses, and support staff) is based on responses to single-item Maslach Burnout Inventory statements about emotional exhaustion (“I feel burned out from my work”) and/or depersonalization (“I worry that this job is hardening me emotionally”). We conducted descriptive statistics to examine associations between CR burden, facility characteristics, and primary care staff burnout.

RESULTS: For 134 VHA facilities, we found CRs at low sites (n=34) had an average of 19 (SD = 5) CRs, middle sites (n=67) had 40 (SD = 10), and high (n=33) had 90 (SD = 39) CRs (p-value <0.001). Low sites had mean patients 51606 (SD = 30395) and mean number of primary care providers 63 (SD = 36); middle sites had mean patients 31720 (SD = 15939) and providers 42 (SD = 20), and high sites had patients 41149 (SD = 24320) and providers 56 (SD = 25) (p-value 0.003). For AES burnout, we found low sites with 38% burnout, middle sites with 40% burnout, and high sites with 39% burnout (p-value <0.001).

CONCLUSIONS: We found wide variation in the number of local CRs across VHA facility. However, we found no directional association in differences in demographic characteristics or primary care burnout between low, middle, and high CR facilities. Our study offers a novel approach to study the association between clinical decision support alert burden and staff burnout, by comparing the 134 facilities in VHA that utilize a common decision support platform with varying local implementation.

Scientific Abstract - Geriatrics and Palliative Care

ACUTE AND AMBULATORY CARE UTILIZATION AMONG OLDER ADULTS WITH HOUSING INSTABILITY

Deborah M. Oyeyemi Walton^1,2. ¹Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA. (Control ID #4064709)

BACKGROUND: Little is known about the association between housing instability—difficulty paying for or spending most of one’s income on housing—and older adults’ healthcare use, specifically use of acute care services versus ambulatory care. Given that state and federal COVID-19-related housing and community protections are in the process of unwinding, we sought to better characterize the relationship between housing instability and healthcare utilization among older adults in California during the pandemic.

METHODS: We conducted a cross-sectional analysis of housing instability and healthcare utilization among respondents aged 65 years and older to the 2021-2022 California Health Interview Survey (N=13,749). The primary predictor was housing instability. The primary outcomes were (a) having an emergency room visit within the past year; (b) having an overnight hospitalization within the past year; (c) having visited a doctor within the past year; and (d) having a usual source of care other than the emergency room (ER).

RESULTS: 3.0% (N=408) of respondents endorsed having an unstable housing situation. Older persons with housing instability were more likely to be female, from a racial or ethnically minoritized group, single/unpartnered, and Medicare-Medicaid beneficiaries when compared to their counterparts with stable housing. They also endorsed acute care utilization—an ER visit or hospitalization— at higher rates and having a usual source of care at a lower rate than respondents with stable housing. After adjusting for sociodemographic, health status (including number of chronic conditions), and health behavior factors, having unstable housing decreased the odds of having visited a doctor in the past year (OR 0.64, P=0.04). Housing instability was not a significant predictor of a recent ER visit or hospitalization, nor did it predict respondents having a usual source of care.

CONCLUSIONS: It is unclear to what extent housing instability is underestimated in the geriatric population. Nonetheless, this study found notable differences in ambulatory care use—specifically doctor’s visits—among persons with unstable housing after adjusting for other factors. Policymakers should consider the potential downstream effects of unwinding housing protections on older adults’ interactions with the health system and overall wellbeing.

A MULTI-MODAL, POSE-TRACKING SYSTEM FOR AUTOMATED ACTIVITY RECOGNITION AND MOBILITY ASSESSMENT AT HOME.

Aysha Pires¹; David Levine¹; Lou Awad²; Roberto Tron³; Johanna Spangler²; Marc Mitjans³; Ashley N. Collimore². ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Neuromotor Recovery Laboratory, Boston University, Boston, MA; ³Department of Mechanical Engineering, Boston University, Boston, MA. (Control ID #4046847)

BACKGROUND: Clinical evaluation of functional status is vital to assess, particularly for older adults, yet these evaluations are time-intensive to perform and often require the presence of a patient in an office setting. To automate and decentralize this, we developed an at-home functional status measurement system to offer data for early intervention and personalized treatment. We examined the precision of the system to recognize various functional tasks and automatically impartially rate performance.

METHODS: Community-dwelling adults aged 18+ who completed a Home Hospital program near Boston participated in at-home mobility assessments. The Short Performance Physical Battery (SPPB; 12 points; more points indicate better performance) was administered and manually rated by a physical therapist as the gold standard. A multimodal system integrating biomechanics data, RGB-Depth vision cameras (Intel RealSense D435), and wearable inertial measurement units (IMUs) independently graded activities. The study assessed the IMU-vision system's recognition and scoring using chi-square tests and the intra-class correlation coefficient (ICC) to scrutinize subtask detection and score accuracy.

RESULTS: Fifty community-dwelling adults (27 males, 23 females, median age 59) participated in the study. Forty-nine participants had at least one comorbidity. The median SPPB score was 9, with an IQR of 4. The IMU-vision system effectively processed 221 out of 270 collected home-based datasets. It demonstrated an accurate recognition rate of 94.6%, with precise classification for walking (100%), standing (97.3%), and sit-to-stand (81.6%). Out of the 221 datasets, 155 were scorable, and the system correctly scored 74% of them, showing variations in score accuracy across different activities (standing balance achieved 87% accuracy, while the 3-meter walk test and sit-to-stand scored 68% and 50%, respectively).

CONCLUSIONS: An IMU-vision system that blends multimodal sensing, activity recognition, and movement assessment algorithms can satisfactorily identify in-home function, although system robustness can be further improved. There is a significant opportunity for this system to improve the assessment and subsequent monitoring of patients in the future.

ASSESSING THE PUBLIC'S KNOWLEDGE AND ATTITUDES TOWARD DELIRIUM

Ryan F. Townshend²; Eduard E. Vasilevskis¹; Blair Golden¹. ¹Medicine, University of Wisconsin System, Madison, WI; ²Internal Medicine, UW Health, Madison, WI. (Control ID #4045483)

BACKGROUND: Delirium is associated with higher mortality, prolonged hospitalization, and increased costs. Patient education may reduce delirium incidence and improve outcomes; however, limited literature exists on current understanding of this condition. Our aim was to characterize the general public’s knowledge of and attitude towards delirium. We also explored whether demographic factors were associated with delirium knowledge.

METHODS: A cross-sectional survey was conducted using Amazon’s Mechanical Turk, an online crowdsourcing platform, and Qualtrics between Oct-Nov 2023. Eligible participants were >/=18 years old, live in the US, and able to complete a survey in English. The survey was based on prior literature and refined via pilot testing with a patient advisory board. Questions assessed delirium knowledge (true/false/unsure) and attitudes (Likert-scale). We also collected demographic data.

We excluded responses with missing data, positive fraud detection (e.g., duplicate IP addresses), or incorrect attention check questions. We calculated descriptive statistics, including individual composite knowledge scores (i.e. % correct). Mean composite scores between groups were compared using Mann-Whitney and Kruskal–Wallis tests with a priori alpha of 0.05 (two-sided).

RESULTS: Of 274 surveys, 220 were included in analysis. Responses were excluded due to missing data (28), fraud detection (22), and failed attention checks (4). Of the 220, 48% were female, 71% were white, and >60% had at least a Bachelor’s degree. Respondents resided in 37 states.

On average, participants answered 60% (SD: 14.6) of knowledge questions correctly. Over 75% correctly identified older age and polypharmacy as delirium risk factors, but only 25% recognized delirium as an acute condition. About 56% knew that delirium is preventable, however, only 20% knew that treatment is supportive. The majority (53%) felt people with delirium should rest in bed. Few (36%) were confident in their understanding of delirium and most (83%) felt that additional education would be helpful. Some (16%) said they would be ashamed if they developed delirium.

There was no significant association between confidence of understanding and knowledge scores. Individuals reporting an income of <$25k scored lower than those in other income brackets (e.g., mean score 53% vs. 62% for those earning >$75k, p<0.01). White respondents scored higher compared to non-White identities (61% vs 56%, p< 0.01). There was no association between age, gender, or education and scores.

CONCLUSIONS: Survey respondents were not confident in their understanding of delirium and felt more education would be beneficial. Important misconceptions also emerged. For example, many identified bedrest as helpful, suggesting that future educational initiatives may need to emphasize the benefits of early mobility. While some demographic factors were associated with lower knowledge scores, misconceptions spanned many demographics, underscoring the need for universal education.

ASSESSING THE RISK OF ADVERSE CLINICAL OUTCOMES IN OLDER ADULTS INITIATING GABAPENTIN VERSUS DULOXETINE

Alexander Chaitoff^1,2; Niteesh K. Choudhry^1,2; Nancy Haff^1,2; Julie Lauffenburger^1,2. ¹Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA; ²Harvard Medical School, Boston, MA. (Control ID #4060018)

BACKGROUND: Recent studies have associated gabapentin use with falls and hospitalization. However, these harms come from observational studies comparing gabapentin users to non-users. This is problematic as the most common indication for gabapentin use, neuropathic pain, is itself associated with the same adverse outcomes attributed to the medication. To address concerns about confounding, we apply pharmacoepidemiologic methods to assess the risk of fall-related injuries and suboptimal healthcare utilization in older adults receiving gabapentin versus an active comparator.

METHODS: We conducted a new user/active comparator cohort study using claims data from IBM MarketScan. We identified adults > 65 with at least one new prescription fill for gabapentin or duloxetine between 2014-2021. Assessing covariates in the 365 days prior to cohort entry, we excluded patients with prior gabapentin or duloxetine fills, without continuous insurance enrollment, or who had a visit including an ICD code for cancer. To further reduce the risk of confounding by indication, we also excluded patients with seizures and depression defined as having a visit with a respective ICD code or filling a prescription for any anti-epileptic or anti-depressant medications. We then employed a multivariable logistic regression model to generate propensity scores and used a nearest-neighbor matching algorithm to generate a final analytic cohort that we followed from the first prescription of gabapentin or duloxetine for the subsequent 720 days censoring for treatment discontinuation and insurance disenrollment. We generated multiple Cox proportional hazard regression models to separately assess the hazard of falls defined by e-code or external cause of morbidity code, all-cause emergency department (ED) visit, and all-cause hospitalization in the follow-up period. We conducted multiple sensitivity and subgroup analyses to check the robustness of our results.

RESULTS: There were 157,459 adults who met inclusion criteria. After propensity score matching, the analytic cohort included 15,258 incident gabapentin and 15,258 incident duloxetine users without clinically significant differences across baseline characteristics. Compared with incident duloxetine users, incident gabapentin users had lower hazard of fall (hazard ratio (HR) 0.66, 95%CI 0.57 - 0.77, p<0.01) and no difference in hazard of ED visits or hospitalizations (HR 1.02 95%CI 0.97 – 1.09, p=0.49 and HR 1.05, 95%CI 0.97 – 1.14, p=0.20, respectively). These results were consistent in sensitivity and subgroup analyses.

CONCLUSIONS: Contrary to findings reported from uncontrolled observational studies, we find that incident gabapentin use, compared with incident use of another common medication used to treat neuropathic pain, is not associated with significantly greater risk of falls or healthcare use. Rigorous examination of medication safety compared with users of alternative agents, not to non-medication users, should be standard to inform shared-decision making.

ASSOCIATION BETWEEN HOME HEALTH CARE, HOME DAYS, AND HEALTH STATUS AFTER HOSPITALIZATION FOR ACUTE MYOCARDIAL INFARCTION IN OLDER ADULTS

Alexandra M. Hajduk¹; Jeph Herrin²; Sui Tsang¹; Jingjing Shang²; Lisa Kern³; Jason R. Falvey⁴; Sarwat Chaudhry¹. ¹Internal Medicine, Yale School of Medicine, New Haven, CT; ²Nursing, Columbia University Irving Medical Center, New York, NY; ³Weill Cornell Medicine, New York, NY; ⁴Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD. (Control ID #4064540)

BACKGROUND: Health care systems are increasingly being incentivized to prevent unnecessary healthcare utilization in older adults after hospitalization for acute myocardial infarction (AMI). While home health care (HHC) is a promising strategy to reduce inpatient healthcare utilization, prior studies have been inconclusive, potentially due to residual confounding introduced by not accounting for the greater medical complexity and worse prognosis of HHC recipients. We sought to evaluate the association between receipt of HHC and days alive at home and change in health status among older adults in the year after AMI hospitalization using approaches that robustly account for confounding by indication.

METHODS: We used data from a prospective cohort of adults age ≥75 years hospitalized with AMI at 94 U.S. hospitals linked with Medicare data. Participants underwent a detailed functional assessment during AMI hospitalization and were assigned a prognosis score. Participants with linked Medicare data who were discharged home after AMI hospitalization were included in the analysis. Receipt of HHC within 14 days of discharge was determined using OASIS data. Number of days not at home within the year after discharge was defined as the count of days alive and institutionalized in a hospital, skilled nursing facility, or inpatient rehab facility. Change in health status was defined as a decrease of ≥5 points from baseline to six months post-discharge on the SF-12. Prognosis-matched, propensity-score weighted generalized linear models with offsets for survival days were used to evaluate associations between receipt of HHC, non-home days, and change in health status.

RESULTS: 491 (26.6%) of the 1846 included participants received HHC within 14 days of discharge. HHC recipients were more likely to be female, have lower education, live alone, have worse functional status, and have poorer prognosis than participants who did not receive HHC. In unadjusted results, HHC recipients had more non-home days (median 15 days, IQR 4-90) than participants who did not receive HHC (median 6 days, IQR 3-31). However, after propensity score weighting, matching on prognosis score (n = 982), and adjusting for remaining unbalanced covariates, receipt of HHC was associated with a lower number of days alive not at home (RR=0.73, 95% CI 0.54-0.97). After propensity score weighting and adjustment for unbalanced covariates, receipt of HHC was associated with decreased risk of clinically meaningful declines in physical health status (OR=0.72, 95% CI 0.62-0.88) and mental health status (OR=0.80, 95% CI 0.66-0.99) at six months post-discharge.

CONCLUSIONS: Receipt of HHC within 14 days after hospital discharge was associated with improvements in clinical and patient-centered outcomes among older adults hospitalized with AMI. Health care systems may consider broadening HHC referral as a tool to improve post-discharge outcomes among older adults hospitalized with AMI.

ASSOCIATIONS BETWEEN 10-YEAR DEPRESSIVE SYMPTOM TRAJECTORIES, COGNITIVE FUNCTION, AND SELF-MANAGEMENT SKILLS AMONG A POPULATION OF OLDER ADULTS

Abigail Vogeley¹; Patrick Cecil¹; Lauren Opsasnick¹; Laura M. Curtis¹; Julia Yoshino Benavente¹; Morgan Bonham¹; Andrea Russell²; Rachel O'Conor¹; Michael Wolf¹; Rebecca Lovett¹. ¹General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4064678)

BACKGROUND: Chronic depression impacts the ability to successfully manage one’s health, yet mechanisms underlying this relationship are not fully understood. Cognitive function, which is known to be impacted by depression, may play a significant role in this relationship. We aimed to determine the relationship between depressive symptom patterns, fluid cognitive ability, and health self-management within a cohort of older adults with high rates of multimorbidity.

METHODS: Data from 369 older adults from Chicago, IL and participating in a longitudinal cohort study on aging was used for this analysis. The Patient-Reported Outcomes Measurement Information System (PROMIS) Depression 8-item survey was administered across 4 time points over 10 years; raw scores were transformed into T-scores. Group-based trajectory modeling was used to identify latent depressive symptom trajectory groups. The Comprehensive Health Activities Scale (CHAS) was used to measure chronic disease self-management skills, including comprehension and recall of print, spoken, and multimedia information. A factor score representing fluid cognitive function was derived from 11 measures across 4 cognitive domains (processing speed, working memory, inductive reasoning, long-term memory). Demographic-adjusted multinomial linear regressions were used to assess associations between depressive symptom trajectory groups and self-management skills, first without and then including fluid cognitive function.

RESULTS: Mean participant age was 71 years (SD 5.3); most participants were female (71%) and non-Hispanic white (54%). 86% had 2+ chronic medical conditions (mean 3.3 (SD 1.8)). Three distinct depressive symptom trajectories emerged: most participants displayed either consistently minimal (42%) or normative (46%) depressive symptoms over time, while 12% displayed persistently elevated symptoms. In multivariable analyses, participants in the persistently elevated group had poorer self-management performance (β=-6.4; 95% CI: -11.1, -1.7; p=0.007). Adjusting for fluid cognitive function attenuated this association to a level of non-significance, while a strong association emerged between fluid cognitive function and self-management skills (β=16.1; 95% CI: 14.4, 17.8; p<0.001).

CONCLUSIONS: The presence of persistent depressive symptoms may interfere with self-care capacity, potentially due to the impact of depressive processes on underlying fluid cognitive skills related to self-management. Future efforts should include further elucidating the roles of specific cognitive domains in this pathway, as well any differential impacts by specific type of self-management task. Improved understanding of cognition’s role in the relationship between chronic depression and health self-management may inform optimal interventions or supports required to improve medical outcomes within an older adult population presenting with both chronic illness and depressive symptoms.

BARRIERS AND ENABLERS OF PROACTIVE DEPRESCRIBING AMONG OLDER ADULTS

Kenya Ie^2,1; Reiko Machino²; Steven Albert³; Shiori Tomita⁴; Hiroki Ohashi⁴; Iori Motohashi^2,1; Takuya Otsuki^2,1; Yoshiyuki Ohira¹; Chiaki Okuse^2,1. ¹General Internal Medicine, St. Marianna University School of Medicine, Kawasaki-shi, Kanagawa, Japan; ²General Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki-shi, Japan; ³Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; ⁴Tama Family Clinic, Kawasaki-shi, Japan. (Control ID #4064135)

BACKGROUND: The concept of deprescribing is broader than simply drug cessation and encompasses dynamic interaction between patients and healthcare providers. Understanding the perspectives and readiness of patients toward deprescribing is essential to develop feasible and effective deprescribing interventions. This study aimed to qualitatively explore the experiences and perspectives of older adults on proactive deprescribing, as well as their barriers and enablers.

METHODS: Semi-structured interviews with patients visiting a community hospital or a primary care clinic were conducted. Inclusion criteria were patients aged 65 years or older and having 5 or more regular medications. Participants were asked about their perceptions and experiences of their own health status, medications, and deprescribing. The interview data was transcribed and conceptualized using thematic analysis to identify major concepts.

RESULTS: Sixteen interviews were conducted with seven female respondents, aged 79.7 years on average (SD 6.1, range 69-92 years). These interviews uncovered three main themes regarding patient attitudes and behaviors towards deprescribing. Theme 1, ‘trust in primary care physicians,’ played a significant role in shaping older adults' medication beliefs. Some patients unquestioningly followed their trusted physicians' recommendations, while others were more receptive to deprescribing when their doctors supported it. Theme 2, ‘patient satisfaction with the status quo,’ hindered deprescribing, as patients were content with their current medications. Many respondents felt distressed by their multiple illnesses but still saw medication adherence as part of their “recovery process.” Theme 3, ‘proactiveness for deprescribing,’ was influenced by factors like polypharmacy-related anxiety and confidence in deprescribing's feasibility. Participants also mentioned alternative strategies, like non-pharmacological treatments and substitute medications, boosting their readiness for deprescribing.

CONCLUSIONS: Patient’s readiness for deprescribing varied considerably according to their trust in primary care physicians, belief regarding own health and medications, and proactiveness towards deprescribing. To focus on patients' proactiveness towards deprescribing and understand these barriers and enablers is essential for informed decision-making and the development of strategies to optimize medication appropriateness.

BRINGING THE DIABETES PREVENTION PROGRAM TO GERIATRIC POPULATIONS IN SPANISH (BRIDGE-S): A COMMUNITY PILOT

Elaine De Leon^1,2; Kenny Decaro⁵; Franzenith de la calle⁴; Jeannette Beasley^3,1. ¹Division of General Internal Medicine & Clinical Innovation, New York University Grossman School of Medicine, New York, NY; ²Population Health, New York University Grossman School of Medicine, New York, NY; ³Nutrition and Dietetics, New York University Steinhardt School of Culture Education and Human Development, New York, NY; ⁴Population Health, New York University, New York, NY; ⁵New York University School of Global Public Health, New York, NY. (Control ID #4063458)

BACKGROUND: One-third of Hispanic individuals in the United States have prediabetes, bearing an increased risk of progression to type 2 diabetes mellitus (T2DM) and its complications. Older (≥65 years) Hispanic adults, constituting a growing demographic, may face challenges in accessing evidence-based diabetes prevention programs due to linguistic and cultural barriers. Previous adaptations of the CDC's National Diabetes Prevention Program (DPP) lack focus on this subgroup and highlight disparities in engagement of the general Hispanic population, underscoring the need for culturally tailored interventions for older Hispanic adults.

METHODS: This study included Spanish-speaking adults affiliated with an Older Adult Center (OAC) in Brooklyn, New York, inviting them to participate in 4 in-person, interactive DPP sessions. Sessions were translated into Spanish by a team comprised of two physicians and two medical students, all native Spanish speakers. Participants were invited to complete surveys after each session, gathering demographic information and feedback. To glean in-depth insights, two Spanish language focus groups were conducted with 18 participants after the fourth session. The recorded focus group discussions underwent thorough analysis to identify and elucidate primary themes.

RESULTS: Sessions averaged 15 (9-21) Spanish-speaking participants who were typically 77% (76-92%) female with mean age of 70.8 (45-86) reflecting various Hispanic origins with Ecuador (16-42%), Mexico (10-21%), and Puerto Rico (11-26%) as most common. Many participants reported hyperlipidemia (25-56%), hypertension (25-43%), and T2DM (22-32%) as chronic conditions. Surveys and focus groups revealed that participants felt the sessions shared culturally appropriate content with accessible vocabulary. In focus groups, participants were highly receptive to diabetes prevention programming, expressing an understanding of the importance of modifying dietary habits. They additionally expressed their preference for receiving this information at the OAC. Participants recommended future sessions include information on medication side effects, natural remedies, and varied perspectives on the role of willpower versus environmental factors in dietary choices.

CONCLUSIONS: This study demonstrates strong interest among older Hispanic adults in diabetes prevention topics, reflected in positive feedback on culturally appropriate content and a preference for information dissemination at the OAC. These findings suggest the potential effectiveness of community-based interventions and underscore the need for further research to systematically adapt the DPP to enhance sustained participant engagement and address attrition.

CARE PARTNER ATTITUDES TOWARDS DIGITAL TOOLS FOR MEDICATION OPTIMIZATION IN PERSONS LIVING WITH DEMENTIA

Katharina T. Jungo^1,2; Niteesh K. Choudhry^1,2; Edward R. Marcantonio^3,4; Gauri Bhatkhande^1,2; Katherine L. Crum^1,2; Nancy Haff^1,2; Kaitlin Hanken^1,2; Molly Blair^1,2; Julie Lauffenburger^1,2. ¹Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; ²Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; ³Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ⁴Harvard Medical School, Boston, MA. (Control ID #4028105)

BACKGROUND: Care partners are critical to making treatment decisions, including medication management, in persons living with dementia (PLWD). Efforts to promote stopping or reducing high-risk medications have typically had insufficient care partner involvement. Little is known about the perspectives of care partners about using digital health tools (e.g. portals, applications, and other online support tools) for enhancing care partner involvement in making medication-related decisions for PLWD.

METHODS: In this survey study, we identified 261 care partners of PLWD ≥65 years of age using ≥1 high-risk medication (benzodiazepine, sedative hypnotic, or antipsychotic) in the electronic health records (EHR) of a large healthcare system. The survey was delivered and collected through REDCap in Fall 2023 and contained 26 questions about sociodemographic characteristics of care partners and PLWD, the use of digital health tools to support medication management, and care partners’ willingness to deprescribe medications. Survey questions were based on previously-validated questionnaires and most used a 5-point Likert scale for non-free text responses. Care partners were contacted by patient portal if there were a designated proxy for the patient, mail, and then phone for survey completion. Non-proxy care partners were contacted by mail and then phone. Those completing the survey received compensation. The data were analyzed using descriptive statistics.

RESULTS: In total, 22%(57) care partners (mean age 72±12 years and 61%(35) women) completed the survey within 3 weeks of delivery. Of these, 75%(43) were the spouse or life partner and 25%(14) were the child of the PWLD. PLWD had a mean age of 80±11 years and 46%(26) were female, with the following cognitive conditions reported by care partners: 22%(13) Alzheimer’s disease, 24%(14) unspecified dementia, and 56%(32) other types of cognitive impairment or thinking problems. Among the respondents, 65%(37) reported being the primary decision maker, 86%(47) reported being very or extremely confident being involved in the medication management of the PLWD, 69%(38) were very or extremely confident making changes to their medication regimen, 82%(47) reported being satisfied with their care recipients’ medications but still said that they would be willing to deprescribe one of the medications if their physician said this was possible. 57%(32) were very or extremely interested in using digital tools to assist with treatment decisions while 7%(4) of care partners were not at all interested. 54%(31) were very or extremely interested in using digital tools to manage the medication use of their care recipient whereas 12%(7) were not at all interested.

CONCLUSIONS: We found a high confidence in responding care partners of PLWD to be involved in medication management and making medication-related treatment decisions. Over half of the respondents showed a great interest in using digital health tools for making treatment decisions and managing medication use.

CHATGPT AS A FALLS RISK-ASSESSMENT TOOL IN THE GERIATRIC POPULATION

Hajra Nadeem, Hafsah Ijaz, Hesha Patel, Oscar Perez Gutierrez, Mathew Thomas Murikan, Ashkan Eighaei Sedeh. Internal medicine, Capital Health, Trenton, NJ. (Control ID #4064861)

BACKGROUND: Falls are a major healthcare crisis in the US, costing the healthcare system upwards of 50 billion dollars per annum. Every year, 25% of the geriatric population in the US suffers a fall, of which 5.7% result in hospitalization. Falls also account for 70% of accidental deaths in the geriatric population. With advancements in artificial intelligence, there has been a growing interest in using generative AI (GeAI) as a fall risk assessment tool. This study aims to examine the accuracy of GeAI in identifying geriatric patients at risk of falls.

METHODS: This non-human subject study employed a qualitative methodology. Three study staff familiar with treating geriatric patients in an inpatient setting composed 30 hypothetical clinical vignettes reflecting real-life scenarios. These vignettes were then reviewed by 2 board-certified internal medicine physicians working independently. Each scenario was scored twice, once by the study staff using the Morse criteria as a baseline and once by GeAI using OpenAI’s ChatGPT. Two study staff scored each scenario using the Morse scoring system, and in case of a disagreement in scoring, a third staff member performed consensus scoring. Next, each scenario was entered into ChatGPT 3 times, using the following prompt: "The following patient will be admitted to the hospital for inpatient care. In terms of fall risk, rate the patient as low-risk, medium-risk, or high-risk”: “ insert scenario here ”. This process resulted in 3 scores, and the majority score was selected. The majority score was defined as one that was repeated at least 2 times. Accuracy was calculated by comparing the compatibility of the fall risk category suggested by ChatGPT to the baseline calculated risk category using the Morse score, according to which responses were categorized into accurate or inaccurate. Reproducibility was calculated based on the consistency of responses by ChatGPT. A response was considered reproducible if ChatGPT placed the patient from the same hypothetical scenario into the same risk category each of the 3 times; otherwise, it was scored as non-reproducible.

RESULTS: Of the 30 proposed vignettes, ChatGPT matched the category calculated using Morse in 27/30 scenarios, giving it an overall accuracy score of 90%. ChatGPT categorized 80% (24/30) of the cases as high-risk (true high-risk: 22, false high-risk: 1, false low/medium-risk: 1, true low/medium-risk: 6), resulting in a sensitivity of 95.8% (CI:78.9-99.9), a specificity of 83.3% (CI:35.9-99.6), a positive predictive value of 95.8% (CI: 79.3-99.3), and a negative predictive value of 83.3% (CI:41.5-97.2). Furthermore, identical answers were obtained each of the 3 times a scenario was put through ChatGPT, giving it a reproducibility score of 100%.

CONCLUSIONS: This study suggests that ChatGPT, as a fall risk assessment tool, has a high accuracy and reproducibility compared to a commonly used standardized scoring system, when used for the geriatric population in the in-patient setting.

CLINICIAN PERCEPTIONS ON UTILITY OF A MACHINE LEARNING TOOL (ALERT) TO PREDICT MORTALITY AND IMPROVE END-OF-LIFE OUTCOMES FOR ADVANCED CANCER PATIENTS

Nithya Krishnamurthy¹; Melissa Mazor¹; Melanie besculides²; Jose Morillo¹; Marsha Augustin¹; Marcos Vargas³; Cardinale Smith⁴. ¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY; ³SUNY Downstate Health Sciences University College of Medicine, New York, NY; ⁴Medicine, Icahn School of Medicine at Mount Sinai Tisch Cancer Institute, New York, NY. (Control ID #4055201)

BACKGROUND: There are significant disparities in outcomes at the end-of life (EOL) for minoritized patients with advanced cancer, with most dying without a documented serious illness conversations (SIC). Machine learning (ML) models have the potential to address key factors preventing early SIC, including an inability of current tools to identify patients at risk for short-term mortality and the impact of structural racism in hindering provider-initiated SIC. This study aims to assess clinician perceptions of the utility and challenges of implementing a ML model (ALERT) to predict six-month mortality among patients with advanced solid cancers to prompt timely SIC.

METHODS: One-on-one semi-structured interviews were conducted with physicians, advanced practice providers, registered nurses, and social workers providing care for patients with advanced solid cancers until knowledge saturation was reached (N=19). Interviews were transcribed verbatim and coded independently by two coders. Themes were derived using an inductive coding approach and reviewed by a team of four interdisciplinary investigators.

RESULTS: Clinician-perceived benefits were 1) guiding prognostication, especially in areas of uncertainty ( i.e. newly diagnosed patients with metastatic disease); 2) the objectivity of the prediction easing clinician distress with EOL treatment planning; 3) standardizing prognosis discussions across specialties to limit aggressive procedures at EOL; 4) respecting patient values by providing them time to get affairs in order, spend time with family, and plan for cultural EOL rituals; 5) facilitating earlier SIC and palliative care referrals, encouraging provider-initiated discussions on treatment risks versus benefits. Challenges identified were 1) integration of predictions with clinical expertise, with clinicians recommending that communication of the prediction with patients and families carry a caveat of the limitations of statistical predictions; 2) balancing the reliability and accuracy of the model with incorporation of rapidly evolving therapies and trials, with participants calling for patient and clinician education on the model’s validation, predictive value, and adaptations to new data and 3) concern about patients, at different stages of acceptance, feeling fear and distress due to poor communication- clinicians acknowledged the difficulty in delivering the news directly but delicately, to “not disturb the peace.”

CONCLUSIONS: Clinicians expressed widespread acceptability of ALERT and identified clear benefits, particularly in triggering earlier SIC and standardizing prognosis discussions across care teams to avoid aggressive hospital interventions at EOL and respect patients’ cultural values. Challenges identified, including concerns regarding communication of the prediction and integration with clinical expertise and new research, will guide ongoing refinement and eventual implementation of the ALERT model.

CLOSING THE OSTEOPOROSIS CARE GAP: FACTORS ASSOCIATED WITH PRESCRIBING OF OSTEOPOROSIS MEDICATIONS AFTER FRAGILITY FRACTURE

William K. Silverstein^1,2; Sping Wang³; Mahnaz Alavinejad³; Ania Sarnocinska³; Nathan M. Stall^2,4; Kamil Malikov³; Michael Hillmer³; Jonathan S. Zipursky^1,2. ¹Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; ²Medicine, University of Toronto, Toronto, ON, Canada; ³Government of Ontario Ministry of Health, Toronto, ON, Canada; ⁴General Internal Medicine and Geriatrics, Sinai Health, Toronto, ON, Canada. (Control ID #4064573)

BACKGROUND: Osteoporosis medications are recommended following fragility fracture to prevent recurrence and associated complications, yet many patients do not receive treatment after their first fragility fracture. This phenomenon is termed the “osteoporosis care gap (OCG).” Contemporary prescribing rates are poorly described, including after recent system-wide efforts to improve post-fracture prescribing. We quantified Ontario’s OCG and determined factors that predict prescribing of osteoporosis medications after a fragility fracture.

METHODS: We performed a population-based retrospective cohort study using linked administrative databases at the Ontario Ministry of Health. We included all patients aged >66 years admitted to an Ontario hospital with their first osteoporotic hip/pelvic/spinal fracture from January 1/2017 to December 31/2021. We excluded patients if they received an osteoporosis medication prescription in the preceding year, had chronic kidney disease, had a previous atypical femur fracture or osteonecrosis of the jaw, had a traumatic fracture, or if they died during admission or were discharged to a palliative care unit after index admission. We used ICD-10 codes to identify hospitalizations and comorbidities and employed validated algorithms where possible. The primary outcome was time to fill of a prescription for osteoporosis pharmacotherapy (bisphosphonate, denosumab, raloxifene, teriparatide) in the year after discharge. We used multivariable Cox proportional hazards regression to model time to prescription adjusting for demographics, hospitalization factors, and comorbidities. We censored outcomes at 365 days following discharge or upon death. Hazard ratios (HR) were reported with 95% confidence intervals (CIs) and a type I error rate of 0.05 was the threshold for statistical significance. Analyses were performed using SAS v.9.4.

RESULTS: We included 37,874 patients who had a fragility fracture and were admitted to an Ontario hospital during the study interval. Of these, 18,170 (48.0%) were aged ≥85 years, 26,196 (69.2%) were female, and 30,427 (80.3%) had a hip fracture. Among patients hospitalized with a fragility fracture, 11,853 (31.3%) received an anti-osteoporosis drug prescription in the year after discharge. Female sex (HR 1.22; 95% CI: 1.17-1.28), vertebral fracture (HR 1.31; 95% CI: 1.21-1.41), discharge to rehabilitation facility (HR 1.65; 95% CI: 1.57-1.73), and having a 25-OH-vitamin D level measured during hospitalization (HR 1.40, 95% CI: 1.34-1.47) were all positively associated with prescription of an anti-osteoporosis medication.

CONCLUSIONS: Greater than two-thirds of eligible patients admitted to Ontario hospitals with a fragility fracture did not receive treatment for osteoporosis in the year following their fracture. Renewed and novel efforts by clinicians, patients, and health systems are needed to close the OCG, with particular emphasis on those at risk for under prescribing.

COMMUNITY-DWELLING PATIENTS WITH DEMENTIA WERE COMMONLY PRESCRIBED LOW-VALUE HIGH-RISK PSYCHOACTIVE DRUGS BETWEEN 2010-2018

Annie Yang¹; Mei Leng²; Julia Arbanas²; Chi-Hong Tseng³; A. Mark Fendrick⁴; Catherine Sarkisian³; Cheryl Damberg⁵; Nina Harawa⁶; John N. Mafi⁷. ¹Internal Medicine, University of California Los Angeles, Los Angeles, CA; ²GIM & HSR, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁴University of Michigan Medical School, Ann Arbor, MI; ⁵Health Care, RAND Corporation, Santa Monica, CA; ⁶General Internal Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA; ⁷Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4064288)

BACKGROUND: High-risk psychoactive drugs increase risk of delirium, falls, and death among older adults with mild cognitive impairment or dementia (MCID). Since 1991, guidelines such as Beers’ lists have recommended against routinely prescribing these drugs. It remains unknown if prescriptions have declined for community-dwelling older adults with MCID in the context of more recent American Geriatrics Society and Choosing Wisely campaigns to discourage overuse.

METHODS: We used nationally-representative survey data from the Health and Retirement Study (HRS) linked to Medicare fee-for-service claims from 2010-2018. For each year, we identified beneficiaries ≥65 years old with MCID with ≥3 years of continuous Medicare Parts A, B and D coverage. We analyzed Part D claims for six classes of psychoactive drugs: anticholinergics, antipsychotics, appetite stimulant (mirtazapine), barbiturates, benzodiazepines, non-benzodiazepine hypnotics. Primary outcomes were potentially low-value and potentially-indicated (e.g., hospice, severe depression) prescriptions using ICD9/10 code-based algorithms and validated cognitive and depression HRS instruments. For each year, we calculated the percentage of beneficiaries prescribed any psychoactive drug. We estimated trends in low-value and potentially-indicated prescribing using multivariable mixed linear regression models adjusting for age, sex, year, comorbidities, self-reported race, and Medicare-Medicaid dual eligibility. We applied survey weights for representativeness and response rate.

RESULTS: We identified 1479-1906 HRS participants per year, representing 5.2-7.0 million Medicare beneficiaries with MCID during the study period. Between 2010-2018, the percentage of patients prescribed low-value psychoactive drugs did not change, from 35% in 2010 to 36% in 2018 (p=0.49). In contrast, the percentage prescribed potentially-indicated psychoactive drugs rose from 6.7% in 2010 to 11.5% in 2018 (p<0.001). Black and Hispanic patients received fewer low-value psychoactive drugs at 29% and 37%, vs 38% for white patients (p<0.001 and p=0.017). For potentially indicated drugs, rates were 6% and 9% for Black and Hispanic patients, vs 11% for white patients (p<0.001 and p=0.008). Dual-eligible patients received more low-value and potentially indicated prescriptions at 41% and 11%, vs 33% and 9% for non-dual eligible patients (p<0.001 for both).

CONCLUSIONS: Over one third of community-dwelling older adults with MCID were prescribed low-value high-risk psychoactive drugs. Black and Hispanic patients received fewer psychoactive drugs than white patients, whereas dual-eligible patients received more than non-duals, meriting further investigation into the socioeconomic determinants influencing disparate utilization. Despite decades of worldwide guideline dissemination, prescribing among older adults with MCID has not decline raising safety concerns. Reducing iatrogenic harm in this vulnerable population will require alternative approaches to improve prescribing behavior.

COMPARATIVE EFFECTIVENESS AND SAFETY OF ORAL ANTICOAGULANTS IN PATIENTS WITH ATRIAL FIBRILLATION LIVING WITH HIV

Claire Quinlan^1,2; Jerry Avorn²; Aaron S. Kesselheim²; Daniel Singer³; Yichi Zhang²; Alexander Cervone²; Kueiyu J. Lin^2,3. ¹Department of Medicine, Harvard Medical School, Boston, MA; ²Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital Department of Medicine, Boston, MA; ³Department of Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4055824)

BACKGROUND: People living with HIV are rapidly aging into the geriatric demographic. They will develop multiple comorbidities as they age, such as atrial fibrillation (AF), requiring anticoagulation which may interact with their antiretroviral therapy (ART). How HIV and the use of ART impact the effects of oral anticoagulants (OACs) in patients with AF is unknown. We sought to determine the comparative safety and effectiveness of specific OACs in older patients with HIV and non-valvular AF taking ARTs.

METHODS: We used US Medicare claims data to establish two cohorts with nonvalvular AF and HIV aged ≥ 65 years, comparing new use of warfarin vs. apixaban, and new use of rivaroxaban vs. apixaban, from January 2013 to December 2020 (cohort entry date = first dispensing date; baseline assessment period 180 days before entry). The primary outcome was a composite endpoint of hospitalization for ischemic stroke or major bleeding, and we studied each specific outcome in secondary analyses. We used propensity score-weighting to adjust for 96 potential confounders. We stratified our analysis in two subgroups: (1) patients with an active ART prescription at the time of anticoagulation prescription, and (2) patients without an overlapping ART prescription.

RESULTS: The study cohort compared 1,126 warfarin users (weighted mean age 73.9 years, female 30.4%) with 1,525 apixaban users (weighted mean age 74.0 years, female 29.5%). The second cohort compared 667 rivaroxaban users (weighted mean age 73.9 years, female 32.4 %) with 1,545 apixaban users (weighted mean age 74.0 years, female 31.4 %). Among our subgroup of ART users taking warfarin vs. apixaban, the rate of the composite endpoint in those starting warfarin was higher than that of those starting apixaban (84.77 vs 24.56 per 1000 person-years; adjusted hazard ratio [aHR], 3.08; 95% confidence interval [CI] 1.35-7.00). We did not see this difference in risk in patients not taking ARTs (aHR 3.08 vs. 1.03 in ART users vs. non-users; p for heterogeneity by ART use=0.03). The treatment effect heterogeneity in those on ART in this cohort was largely driven by the higher risk of gastrointestinal (GI) bleeding for those on warfarin vs. apixaban (aHR 4.75 vs. 0.87 in ART users vs. non-users; p for heterogeneity by ART use <0.01). Comparing rivaroxaban with apixaban users, we also observed a trend towards a higher risk of GI bleeding in ART users (aHR 4.78 vs. 1.11 in ART users vs. non-users; p for heterogeneity by ART use=0.06). However, we did not observe treatment effect heterogeneity by ART use for other outcomes when comparing rivaroxaban with apixaban users.

CONCLUSIONS: In a national cohort of older adults with HIV and AF, apixaban was associated with a lower risk of major bleeding compared with warfarin or rivaroxaban in ART users but not in ART non-users. Our findings suggest concomitant use of ART in this underserved population may potentiate the bleeding risks of warfarin and rivaroxaban.

COMPARING FRAILTY INDICES IN SURGICAL OUTCOMES OF TRANSSPHENOIDAL PITUITARY ADENOMAS

Ryan Sicard, Alex Devarajan, Vikram Vasan, Jonathan Dullea, Ikaasa Suri, Tirone Young, John Rutland, Daniel Ranti, Joshua Bederson, Raj Shrivastava. Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4062866)

BACKGROUND: Pituitary adenoma resection accounts for a substantial portion of the typical neurosurgical volume, particularly in the elderly population, and identifying suitable surgical candidates is a key component of decision-making. Up until recently, transsphenoidal surgery in the elderly has been a controversial topic, due to reported increased complication rates. Recently, methods of patient-specific metrics to determine surgical candidacy, regardless of age, have been developed. Frailty as a concept has gained traction for its multidimensional approach to describing patient outcomes and multiple indices have been developed. Thus, we aim to compare two frailty indices within a cohort of patients who received pituitary adenoma resections to characterize their validity.

METHODS: A single-institution retrospective review was performed on 420 patients, aged between 15 to 92, who received surgery for skull-based pituitary adenoma between 2016 and 2019. Pre- and post-operative morbidities, disease features, surgical course, adjuvant treatment, recurrence, and survival rate were recorded. Components of the modified frailty index (mFI) and Johns Hopkins Frailty Assessment (JHACG) were used to calculate each patient’s mFI-5 and JHACG scores. Frailty scores were compared based on the incidence of adverse outcomes.

RESULTS: The median subject age was 55 with an interquartile range of 24. There were 112 subjects 65 or older. 395 subjects had a JHACG score of 0 while 23 had scores of 1+. For mFI, 177 subjects had a score of 0, 130 had a score of 1, and 111 had scores of 2+. The American Society of Anesthesiologists (ASA) score was significantly superior to both indices independently and patient age at predicting length of stay (p=0.02). Postoperative complications were noted in 85 patients, but no significant difference between the mFI-5 and JHACG was identified in predicting them (p=0.23). Patients experienced intraoperative complications in 13 instances and, again, there was no significant difference between the mFI-5 and JHACG’s predictive ability (p=0.87). The mFI-5 trended toward significance in predicting outcomes better than the JHACG (p=0.09).

CONCLUSIONS: The mFI-5 and JHACG were found to be equal predictors of outcomes, post- and intra-operative complication rates, and length of stay in patients receiving pituitary adenoma resection. ASA status was superior to both indices for predicting length of stay. Limited number of high frailty patients, particularly for the JHACG, limited the ability to determine statistical significance. Further studies should be conducted on larger samples, but the mFI-5 and JHACG may be of limited prognostic value for patient selection for pituitary adenoma resection.

DECLINE IN CENTERS FOR MEDICARE & MEDICAID SERVICES NURSING HOME HEALTH INSPECTION SURVEY SCORES IN MASSACHUSETTS FROM 2012 - 2022

Marcus Ruopp. Geriatrics and Extended Care, VA Boston Healthcare System Brockton Division, Brockton, MA. (Control ID #4063704)

BACKGROUND: Nursing homes continue to have unprecedented challenges as a result of the Covid-19 pandemic. Staffing shortages and rising patient complexity have caused strains on the post-acute care industry. To evaluate the impact over time on quality in nursing homes, the publicly reported health inspection survey scores by the Centers for Medicare & Medicaid Services (CMS) can be utilized.

METHODS: CMS publishes a set of quality ratings for each nursing home. The health inspection survey score for a nursing home is the additive value of the individual deficiencies based on scope and severity. Facility star ratings are then determined: the top 10 percent with the lowest number of deficiencies receive a 5 star, each of the next 23.3 percent receive a rating of 2, 3, or 4 stars respectively, and the bottom 20 percent receive a 1 star rating. The cut points are recalibrated each month so that the distribution of star ratings within states remains relatively constant over time.

RESULTS: From 2012 to 2022 there was an overall decline in the Massachusetts (MA) nursing home health inspection scores as shown in figure 1. The upper limit of cumulative deficiencies for the 10^th, 33^th, 67^th, and 80^th percentile of nursing homes changed from 4 to 18, 13.3 to 29.3, 22.6 to 61.3, and 61.3 to 101.3 during this time respectively. In addition, the yearly rate of change in deficiencies with regression pre and post pandemic increased, with the pre-pandemic (prior to March, 2020) to post pandemic changing from 1.13 to 1.98 deficiency points a year (10^th), 1.97 to 4.67 deficiency points a year (33^th), 2.78 to 6.40 deficiency points a year (67^th) and 4.15 to 6.74 deficiency points a year (80^th).

CONCLUSIONS: There has been a marked decline in MA nursing home health inspection scores from 2012 - 2022 and has been accelerated during the pandemic. This is a concerning trend for the nursing home industry in MA and one that must be addressed systematically moving forward in order to maintain quality care in the nursing home environment.

DEMENTIA IDENTIFICATION WITH CLAIMS VS. MINIMUM DATA SET MEASURES IN RESIDENTS OF VETERANS AFFAIRS (VA) AND MEDICARE NURSING HOMES

Carolyn T. Thorpe^1,2; Joshua D. Niznik^3,2; Florentina E. Sileanu²; Laura C. Hanson³; Cathleen S. Colón-Emeric⁶; Jennifer L. Lund⁴; Xinhua Zhao²; Alan C. Kinlaw¹; Thomas R. Radomski^5,2; Casey J. Kelley³; Alexa Ehlert^1,2; Binxin Cao¹; Meredith Gilliam³; Loren J. Schleiden². ¹Pharmaceutical Outcomes and Policy, The University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC; ²VA Pittsburgh Healthcare System, Pittsburgh, PA; ³The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ⁴The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC; ⁵Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ⁶Duke University School of Medicine, Durham, NC. (Control ID #4044297)

BACKGROUND: Linked claims and Minimum Data Set (MDS) assessments are often used for research in nursing home (NH) residents with dementia. We compared claims and MDS-based methods for identifying possible dementia in 2 national cohorts: 1) Veterans in VA Community Living Centers (CLCs) and 2) Medicare beneficiaries in Medicare-certified NHs.

METHODS: This was a retrospective analysis of real-world healthcare data. We used the VA Residential History File, MDS, Corporate Data Warehouse (CDW), and Medicare claims for Veterans to build a cohort of VA CLC admissions over 2015-21 for Veterans aged ≥65 dually enrolled in VA and Medicare. We used Medicare claims and MDS for a 20% sample to build a cohort of admissions for nonskilled care to Medicare-certified NHs for continuously enrolled Medicare beneficiaries aged ≥67 over 2018-19. We defined 3 measures of possible dementia: 1) claims/CDW diagnosis using Chronic Conditions Warehouse (CCW) algorithms for Alzheimer’s disease or non-Alzheimer’s dementia; 2) MDS active diagnosis items for Alzheimer’s Disease and non-Alzheimer’s dementia; and 3) MDS Cognitive Function Scale (CFS) indicating mild, moderate, or severe cognitive impairment. For each cohort, we calculated proportions identified by each indicator, and sensitivity, specificity, and positive predictive value (PPV) of the claims/CDW and MDS active diagnosis indicators for identifying CFS impairment.

RESULTS: In the VA Cohort (n=54,234), 61% met ≥1 criterion for possible dementia, including 39% with claims/CDW, 23% with an MDS active diagnosis, and 51% with CFS impairment (mild 24%, moderate 17%, severe 10%). In the Medicare Cohort (n=346,013), 57% met ≥1 criterion, including 41% with claims, 26% with an MDS active diagnosis, and 45% with CFS impairment (mild 23%, moderate 19%, severe 3%). In both VA and Medicare, the CFS uniquely identified the greatest proportion of admissions with possible dementia (34% in VA, 26% in Medicare) compared to claims/CDW (11% in VA, 13% in Medicare) and MDS active diagnoses (1% in VA, 1% in Medicare). Claims/CDW had 57% sensitivity, 80% specificity, and 74% PPV for identifying at least CFS mild impairment in the VA Cohort, vs. 64% sensitivity, 78% specificity, and 70% PPV in the Medicare cohort. The MDS active diagnosis had 38% sensitivity, 92% specificity, and 83% PPV for any CFS impairment in VA, compared to 47% sensitivity, 91% specificity, and 81% PPV in Medicare.

CONCLUSIONS: Claims-based and MDS-based dementia indicators performed similarly for identifying residents with cognitive impairment in both VA and Medicare cohorts. Using the CFS to identify residents with possible dementia results in the inclusion of a substantial number of residents without a documented dementia diagnosis. Cohorts defined using CFS are more inclusive, and likely capture undiagnosed dementia as well as other causes of persistent cognitive impairment. Optimal identification of dementia cohorts may require combining data sources.

DIGITAL HEALTH SCREENER USE AMONG OLDER ADULTS: A SCOPING REVIEW

Saphira Cherfils^1,2; Elaine De Leon⁴; Antoinette Schoenthaler³; Jeannette Beasley⁵. ¹Chemistry, Hunter College, New York, NY; ²Clinical and Translational Science, NYU Langone Health, New York, NY; ³Population Health, NYU Langone Health, New York, NY; ⁴Internal Medicine, NYU Langone Health, New York, NY; ⁵Nutrition and Dietetics, New York University Steinhardt School of Culture Education and Human Development, New York, NY. (Control ID #4063683)

BACKGROUND: Increased virtual health delivery has emphasized the crucial role of digital literacy in ensuring fair access to healthcare. Though various studies have explored digital literacy in the general population, only a few validated screening tools exist. Importantly, decreased digital literacy among older adults may place them at risk of receiving disparate care. The aim of this scoping review is to identify validated digital literacy screening instruments that have been used among or created for adults aged 65 and above. These tools can be helpful in filling the existing literature around digital literacy barriers within this demographic.

METHODS: We searched PubMed and Web of Science databases with keywords and MeSH terms corresponding to digital literacy and screening tools. We applied the following criteria to articles identified: (1) explicit focus on screening tools for digital health literacy and (2) inclusion of older adults (65+) in the sample. After applying these criteria and removing duplicates, a total of 25 articles were selected for inclusion.

RESULTS: Among the 25 studies included, the Electronic Health Literacy Scale (eHEALS) was utilized in 60% of the articles. Other tools such as the Digital Health Literacy Scale, the eHealth Literacy Questionnaire and the Digital Health Literacy Assessment appeared in 8% of the studies. The Multidimensional Digital Proficiency Questionnaire, MDPQ-16, Health Information National Trends Survey, eHealth Literacy Assessment, and an Individual Questionnaire were each used in 4% of the studies. The studies focused on diverse populations and health conditions with mean age ranging from 19.5 - 80.6. Beyond the general U.S. population (age <65 years), studies included community-dwelling older adults in China, hospitalized geriatric patients in Denmark, older Hispanic adults with Type 2 Diabetes Mellitus in New York City and individuals with chronic kidney disease in the U.S.

CONCLUSIONS: Despite pragmatic use, existing surveys for digital health literacy lack explicit creation or validation within older adult populations. While eHEALS serves as a validated measure in many studies, the samples included may not be representative of the general older adult patient population. Many of the studies focused on specific cohorts based on disease state and location. This review reveals a consensus among researchers regarding the pressing need for further investigation in digital literacy among older adults. These screening tools can be used to drive targeted interventions to enhance digital health literacy in older populations. Collaborating with older adults in designing and deploying digital health screeners and tools is crucial, enabling more effective, accessible, and personalized interventions that meet their distinct needs within the evolving healthcare landscape.

E-CONSULTATION FOR DEPRESCRIBING AMONG OLDER ADULTS IN PRIMARY CARE: EVALUATING BARRIERS TO AND FACILITATORS OF IMPLEMENTATION

Matthew E. Growdon^1,3; Lauren Hunt^2,7; Matthew Miller⁴; Madina Halim⁵; Leah S. Karliner⁶; Ralph Gonzales⁶; Rebecca Sudore^1,3; Michael Steinman^1,3; Krista L. Harrison^1,7. ¹Geriatrics, University of California San Francisco, San Francisco, CA; ²Department of Physiological Nursing, University of California San Francisco School of Nursing, San Francisco, CA; ³San Francisco VA Health Care System, San Francisco, CA; ⁴Physical Therapy, University of California San Francisco School of Medicine, San Francisco, CA; ⁵Neurology, University of California San Francisco School of Medicine, San Francisco, CA; ⁶Medicine, UCSF, San Francisco, CA; ⁷Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA. (Control ID #4060429)

BACKGROUND: Electronic consultations (eConsults) allow for asynchronous consultation between primary care providers (PCPs) and specialists. eConsults have been used successfully to manage a variety of conditions and have potential to help PCPs manage polypharmacy and promote deprescribing. To develop an eConsult deprescribing intervention, we elicited clinician perspectives on barriers to and facilitators of using eConsults for deprescribing among older adults within a large university health network.

METHODS: We recruited PCPs, geriatricians, and pharmacists for semi-structured interviews. Interviews explored barriers/facilitators of 1) successful deprescribing among older patients and 2) potential use of eConsults to facilitate deprescribing. We used the COM-B (Capability, Opportunity, Motivation, and Behavior) model to structure the interview guide and used rapid analysis methods to identify barriers/facilitators of deprescribing behaviors.

RESULTS: Of 28 participants, 19 were PCPs (13 physicians, 4 residents, and 2 nurse practitioners), 7 were geriatricians, and 2 were pharmacists. Successful deprescribing: Most PCPs considered deprescribing to be an important component of medication optimization among older adults in their clinical practice but identified myriad barriers to deprescribing (e.g. time constraints, fragmented clinical care, lack of pharmacist integration, and patient/family resistance). Among these, time constraints were paramount, as summarized by this PCP: “For people who want to get things done, the most efficient thing to do is just hit refill. Every time you want to stop something, from a time or RVU standpoint, deprescribing is more time and work than hitting refill. Same thing in the visit, deprescribing is a conversation that will slow the visit down.” Use of eConsults for deprescribing: Both PCPs and geriatricians highlighted the limits of contextual information available through electronic health record (vs. face-to-face) to render specific and actionable eConsults (e.g. knowledge of prior deprescribing attempts, patient/family attitudes). Participants from all groups expressed interest in a targeted process whereby eConsults could be offered for selected patients based on key factors (e.g. polypharmacy or certain comorbidities) and accepted or declined by PCPs, with pithy recommendations delivered in a timely manner relative to patient appointments. This was encapsulated by one PCP: “they need to be crisp and to the point to be helpful, with specific suggestions of something that could be discontinued or switched…not, ‘did you know your patient is on over 12 medicines?’”

CONCLUSIONS: Clinicians identified multifaceted factors influencing the utility of eConsults for deprescribing among older adults in primary care. Deprescribing eConsult interventions should be timely, actionable, and mindful of limitations of electronic chart review.

ENGAGING HISTORICALLY MARGINALIZED RURAL CAREGIVERS OF PERSONS LIVING WITH DEMENTIA IN RESEARCH: AREA DEPRIVATION PROFILE AND SUCCESSFUL OUTREACH CHARACTERISTICS

Jasmine Santoyo-Olsson¹; Jing Cheng¹; Dolores Gallagher-Thompson²; Leah S. Karliner¹; Elizabeth López Macias¹; Maritza Luzanilla¹; Veronica Yank¹. ¹University of California San Francisco, San Francisco, CA; ²Stanford University, Stanford, CA. (Control ID #4064870)

BACKGROUND: While recruitment of historically marginalized rural caregivers is often discussed, little is known about how best to accomplish this. The Area Deprivation Index (ADI) is a pragmatic tool for identifying socioeconomically deprived locations. In a retrospective study, we applied the ADI to caregivers of persons living with dementia (PLWD) in a national randomized controlled trial (RCT) to determine if recruitment efforts reached caregivers from historically marginalized groups living in disadvantaged rural areas and which recruitment efforts were successful.

METHODS: We performed subgroup analyses of screener and baseline data from a national RCT of an online skills-building workshop among rural caregivers of PLWD. The subgroup (n=187) included caregivers who self-identified as being from historically marginalized racial/ethnic groups and/or LGBTQ+ communities. ADI is measured at the state-level using US Census-tract indicators (score range 1–10; higher=more disadvantage). ADI scores were applied based on ZIP+4 codes. State was used to classify Census region of residence. Outreach efforts were tracked. Caregivers were asked how they heard about the trial and responses were categorized into mutually exclusive categories.

RESULTS: Caregivers from historically marginalized groups comprised 10% (187 of 1816) of all caregivers who responded to outreach efforts and 16% (66 of 418) of those enrolled. Among the 66 who enrolled, 26% identified as Black, 26% as Latino, 23% as White, 12% as Native American, and 14% as other race/ethnicity; and 35% identified as LGBTQ+ (including 23% identifying as LGBTQ+ and White, 12% LGBTQ+ and non-White). Caregivers were aged 57.8±12.6 years; 88% identified as women, 11% as men, 2% preferred not to say; and 94% had ≥some college education. Most provided care to a parent (59%) or spouse (21%), and 73% lived with the PLWD. Caregivers lived in all Census regions: 41% West, 26% South, 18% Northeast, and 15% Midwest. 59% were from the most disadvantaged areas (ADI≥7). Among caregivers from the most disadvantaged areas, 36% lived in states not traditionally thought of as rural: California, Massachusetts, and New York. Effective recruitment approaches were emails from community aging organizations (33%), small local newspapers (20%), word of mouth from a trusted person (9%), email/mail from healthcare providers (9%), social media (9%), tribal focused newspapers/Facebook pages (8%), and posts on national organization websites (6%).

CONCLUSIONS: Applying the ADI, we identified rural caregivers from historically marginalized groups living in disadvantaged areas including states not traditionally considered rural. Successful outreach efforts were primarily local. The ADI may identify target areas for successful local recruitment of caregivers from historically marginalized populations.

EXPLORING THE IMPACT OF STRUCTURAL RACISM ON END OF LIFE CARE AMONG OLDER AFRICAN AMERICANS: AN ORAL HISTORY APPROACH

Amber N. Martin¹; Lorraine M. Pereira²; Desiree Anderson³; Karen Vickers⁴; Stephanie Morgan⁴; Wesselyne McKinney⁴; Cinnamon Etta⁴; Sofia Weiss Goitiandia⁵; Catthi Ly¹; Elizabeth Dzeng⁶. ¹Hospital Medicine, University of California San Francisco, San Francisco, CA; ²Harvard University, Cambridge, MA; ³Prairie State College, Chicago Heights, IL; ⁴University of California San Francisco, San Francisco, CA; ⁵Division of Hospital Medicine, University of California San Francisco, San Francisco, CA; ⁶Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4065091)

BACKGROUND: Older African Americans experience unequal treatment within healthcare. Studies show they are less likely to receive appropriate pain management, palliative care, and hospice services compared to their White counterparts, leading to unnecessary suffering and decreased quality of life towards the end of their lives. Structural racism is defined as how mutually reinforcing systems woven into laws, policies, and institutions result in racial discrimination, limiting resources and opportunities based on race and ethnicity. Structural racism is a root cause of racial inequities, particularly in end-of-life care, due to the accumulation of experiences across the life course. This study aims to illuminate older African Americans’ experiences facing serious illness and to critically examine structural racism’s role in shaping their end-of-life care.

METHODS: We conducted oral history interviews lasting up to 1.5 hours with a diverse group of older African Americans (aged 55 and older) living with serious illness. Participants were selected from the hospital and community to capture a range of lived experiences. We identified recurring themes and patterns in the interviews using thematic, content, and narrative analysis.

RESULTS: So far we have conducted five interviews. Our findings underscore the pervasive influence of structural racism on the end-of-life care experiences of older African Americans. Participants have shared narratives of inequities in healthcare access, unequal treatment, limited communication with healthcare providers, and barriers to making informed decisions. These inequities intersect with age, gender, socioeconomic status, and geographic location across the life course.

CONCLUSIONS: The oral histories shed light on the enduring impacts of structural racism on end-of-life care for older African Americans. The findings underscore the need for policies and interventions to dismantle these inequities, promoting access to high-quality, culturally responsive, and patient-centered end-of-life care for all. By amplifying the voices of those most affected by these issues, this study contributes to broader dialogue on healthcare inequities and social justice. This abstract delves into the profound consequences of structural racism on end-of-life care for older African Americans, employing an oral history approach which preserves personal narratives and perspectives authentically. It underscores the urgent need to address disparities and foster equitable access to compassionate and dignified end-of-life support for marginalized communities.

FACILITATORS OF AND BARRIERS TO DEPRESCRIBING DIABETES MEDICATIONS IN OLDER ADULTS: A QUALITATIVE STUDY

Aimee N. Pickering¹; Sam Richardson¹; Shari Rogal¹; Carolyn T. Thorpe²; Walid Gellad³; Thomas R. Radomski⁴. ¹Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²Pharmaceutical Outcomes and Policy, The University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC; ³Medicine, University of Pittsburgh, Pittsburgh, PA; ⁴Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4064725)

BACKGROUND: Over half of older adults with diabetes remain on overly intensive medication regimens to treat diabetes and its complications, leading to falls, polypharmacy, and increased risk of hospitalization and death. Implementation science offers novel approaches to evaluate and address barriers to deprescribing (i.e., discontinuing or de-intensifying medications when risks outweigh benefits); however, there has been limited application of implementation science frameworks to systematically identify factors influencing successful deprescribing in older adults with diabetes. Our objective was to identify facilitators of and barriers to deprescribing diabetes medications in older adults.

METHODS: We conducted 15 semi-structured interviews with adults aged ≥65 with diabetes on ≥1 of the following diabetes medications: insulin, sulfonylurea, meglitinide or ≥1 of the following medications to treat diabetic peripheral neuropathy: gapapentinoids, tricyclic antidepressants; and 10 family caregivers of older adults meeting inclusion criteria. Informed by the updated Consolidated Framework for Implementation Research (CFIR), we explored 1) participants’ general views on diabetes medications; 2) barriers to and facilitators of following a prescriber’s recommendation to deprescribe; and 3) reactions to specific barriers and facilitators. Interviews were audio recorded and transcribed verbatim. Two members of the research team developed a codebook, coded the transcripts, and met to reconcile differences. We then conducted a thematic analysis to identify salient themes.

RESULTS: We identified the following facilitators of deprescribing: trust in prescriber, good understanding of prescriber rationale, side effects of medication, and collaboration between prescribers. For example, one caregiver stated, “We have been taken care of by our doctor for such a long time that we really do trust her, and I know that she would not make any recommendation without careful thought so I would have no problem following her orders." We also found the following barriers: perceived benefit of the medication, lack of side effects, perceived lack of expertise of prescriber, and poor relationship with prescriber. For example, when asked about barriers to deprescribing, one patient expressed, “My primary reluctance would be that I have had no bad side effects with insulin, and so that then makes me reluctant to want to change the dosage even at the recommendation of a healthcare provider.”

CONCLUSIONS: We identified key facilitators and barriers that influence patients’ and caregivers’ willingness to have diabetes medications deprescribed. Our findings will inform the ongoing development of strategies to support deprescribing diabetes medications in older adults.

FACTORS ASSOCIATED WITH DOCUMENTATION OF LIFE-SUSTAINING TREATMENT PREFERENCES IN A NATIONAL COHORT OF VETERAN DECEDENTS

David Lazris^8,2; Yaming Li²; Maria K. Mor²; Carolyn T. Thorpe^3,2; Ann-Marie Rosland⁴; Melissa E. Dichter^5,6; Tony Rosen⁷; Ann Kutney-Lee⁶; Lena K. Makaroun^1,2. ¹Geriatrics, University of Pittsburgh, Pittsburgh, PA; ²VA Pittsburgh Healthcare System, Pittsburgh, PA; ³Pharmaceutical Outcomes and Policy, The University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC; ⁴Internal Medicine, University of Pittsburgh, Pittsburgh, PA; ⁵Temple University School of Social Work, Philadelphia, PA; ⁶Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA; ⁷Emergency Medicine, Weill Cornell Medicine, New York, NY; ⁸Medicine, UPMC, Pittsburgh, PA. (Control ID #4056653)

BACKGROUND: Advanced care planning (ACP) is a critical component of patient-centered care, particularly at the end of life, but studies show that completion rates remain low. There has been limited examination of factors associated with ACP documentation. In 2018, the Veterans Health Administration (VHA) introduced the Life-Sustaining Treatment (LST) Decisions Initiative as a standardized approach to document Veterans’ goals and preferences using an LST progress note in the Veteran’s electronic health record (EHR), providing a unique opportunity to study ACP documentation nationally. The objective of this study was to describe LST completion patterns and assess sociodemographic, clinical, and care utilization factors associated with completion in a cohort of Veteran decedents.

METHODS: This was a retrospective cohort study of a national sample of Veterans aged ≥65 years who died in 2021 and received VHA care in the two years before death. VHA EHR and Medicare claims data were used to identify LST completion and other forms of ACP documentation, and to obtain data on Veteran sociodemographic, clinical and care utilization variables. We used descriptive statistics and bivariate analyses to compare differences between LST completers and non-completers.

RESULTS: Of 23,591 unique VHA-engaged Veterans who died in 2021, 6,684 (28%) completed an LST ≥1 time, with 2,789 (42% of completers) completing an LST ≥2 times. Completers had their most recent LST documented a median of 142 days (IQR 22 – 476) before death, and 2,260 (34%) were completed by a surrogate rather than the patient. Among the decedents, 5,896 (25%) had an Advanced Directive but no LST whereas 2,262 (10%) had an LST but no Advanced Directive. Compared to Veterans without an LST, Veterans who completed an LST were more likely to identify as non-Hispanic Black (16% v. 11%) or Hispanic (8% v 5%) and less likely to be married (48% v. 59%). Gender was not associated with completion. Compared to non-completers, LST completers were more likely to be frail (91% v 66%), have dementia (33% v. 18%), have higher multimorbidity (Elixhauser score ≥8 75% v 43%), and receive more money in VA financial benefits in the year before death (median $5,268 v. $1,714). LST completers lived closer to VHA primary and tertiary care sites and were more likely to die in a VHA facility (22% v. 1%) and have a VHA inpatient (74% v. 9%) or nursing home (30% v. 7%) admission in the 2-years before death than non-completers. All differences were statistically significant at p<0.001.

CONCLUSIONS: These findings suggest that LST completion before death among VHA-enrolled Veterans is associated with VHA health system utilization, particularly in acute and nursing home care settings, and generally occurs close to the time of death and often by a surrogate. Opportunities may exist to improve documentation of patient preferences in outpatient settings farther in advance of health declines.

FEASIBILITY OF ENGAGING CARE PARTNERS FOR ELECTRONIC OUTREACH INTERVENTIONS IN PRIMARY CARE

Julie Lauffenburger¹; Katharina T. Jungo²; Edward R. Marcantonio³; Gauri Bhatkhande⁴; Katherine L. Crum⁵; Nancy Haff⁶; Kaitlin Hanken⁷; Niteesh K. Choudhry⁸. ¹Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; ²Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA; ³Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ⁴Department of Medicine, Brigham and Women's Hospital Division of Pharmacoepidemiology and Pharmacoeconomics, Boston, MA; ⁵Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA; ⁶Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; ⁷Medicine, Brigham and Women's Hospital, Boston, MA; ⁸Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, MA. (Control ID #4062026)

BACKGROUND: Care partners are important stakeholders for persons living with dementia (PLWD), playing a critical role in patient support and medication decision-making. However, effectively identifying and engaging care partners within electronic health record (EHR) systems remains a challenge, particularly in a scalable manner that could be used for outreach. Therefore, we sought to evaluate the feasibility of strategies for reaching care partners of PLWD using EHR data. We focused on care partners of PLWD using cognition-affecting medication as an anchoring clinical problem.

METHODS: We identified PLWD ≥65 years of age using validated EHR algorithms who were taking a benzodiazepine, sedative hypnotic, and/or antipsychotic in a large northeastern US health system. Within these PLWD, we used structured EHR data to identify: how many PLWD had care partners with sufficient contact information for mail/telephone outreach and/or had care partners who had an official patient portal account set up for electronic outreach about the PLWD (i.e., a “proxy” account). To specifically assess care partner engagement strategies, we sent these care partners a brief survey about their experiences in a staged manner: 1) by patient portal (if portal proxy use was established), 2) by postal mail, and 3) by telephone, twice through the portal and once each through mail and telephone in Fall 2023. We also measured the specific reach rates of these care partners, independent of survey completion, by measuring portal read receipts and telephone call answer rates.

RESULTS: In total, 4139 PLWD met eligibility. Of these, 2555 (62%) had any care partner in the EHR data, but only 1085 (23%) had a specific name for a care partner recorded in structured EHR data. Of these 1085 care partners, 261 (24%) had complete telephone and address information from structured EHR data, including 86 (8%) had a proxy patient portal account set up. (All care partners with proxy access had complete telephone and address information.) In total, 59 out of these 261 (23%) care partners returned the survey; 13 (22%) completed it via the portal, 28 (47%) completed it by mail, and 18 (31%) completed it by telephone. Most care partners with portal access (54/86, 63%) viewed the electronic message about the survey. Similarly, most care partners (who had not previously responded) also were reachable via the telephone call about the survey (103/184, 56%).

CONCLUSIONS: Relatively few persons living with dementia in this population had a care partner who had a patient portal account set up or had contact information within structured EHR data sufficient for outreach. However, reach rates were high for care partners who did have portal accounts or sufficient contact information, indicating that it may be feasible to contact these care partners as part of health system or clinic outreach. Thus, more concerted effort should also be made to formalize care partners within EHR systems and establish proxy portal accounts to help facilitate care for PLWD.

FROM CLINICAL TRIALS TO REAL WORLD PRACTICE: HEALTH STATUS OF COMMUNITY-DWELLING VETERANS RECEIVING LUNG CANCER SCREENING COMPARED TO RANDOMIZED TRIAL PARTICIPANTS

Alison S. Rustagi^1,2; Francis J. Graham³; Emily Lum³; Marzieh Vali³; Louise C. Walter^1,4; Amy L. Byers^6,5; Katherine Hoggatt^1,2; Beth Cohen^1,2; Salomeh Keyhani^1,2. ¹Dept of Medicine, University of California San Francisco, San Francisco, CA; ²Division of General Internal Medicine, San Francisco VA Health Care System, San Francisco, CA; ³Northern California Institute for Research and Education, San Francisco, CA; ⁴Division of Geriatrics, San Francisco VA Health Care System, San Francisco, CA; ⁵Depts of Psychiatry and Medicine, University of California San Francisco, San Francisco, CA; ⁶Research Service, San Francisco VA Health Care System, San Francisco, CA. (Control ID #4064774)

BACKGROUND: Lung cancer screening (LCS) via low-dose computed tomography (LDCT) prevents death from lung cancer. Two randomized trials, the National Lung Screening Trial (NLST) and Dutch-Belgian Randomized Lung Cancer Screening Trial (Dutch: NELSON), were powered to detect a mortality benefit of LCS among healthy smokers. Because poor health increases potential harms and decreases potential benefits, all national guidelines recommend against screening those in poor health. However, little is known how these guidelines are being applied in real world healthcare settings. The VA has prioritized LCS. This study sought to compare the health of screen-eligible and screened veterans relative to participants in LCS trials.

METHODS: We sampled from a national cohort of community-dwelling veterans in VA primary care. Veterans ages 65-80 years with a 30+ pack-year smoking history and current smokers or those who quit within 15 years were included. To ascertain LCS eligibility, individual interviews were conducted to obtain a detailed lifetime cigarette smoking history. To ascertain LCS use, we validated an automated algorithm to identify chest imaging done for screening purposes; scans ordered due to signs/symptoms of occult lung cancer were excluded.

RESULTS: Among n=3,889 in the cohort, n=761 were LCS-eligible. Of these, n=419 received LCS in the 5 years prior to cohort enrollment. LCS-eligible veterans were significantly less healthy than participants in LCS trials, with 12-month all-cause mortality of 4.4% (95% CI: 2.9-6.4%) compared to 0.56% (NELSON) and 0.64% (NLST) observed in the control arms of LCS trials (Table). Of LCS-eligible veterans who were not healthy enough to meet NELSON’s basic health eligibility criteria, 21% (95% CI: 14-30%) were screened. Of LCS-eligible veterans with a higher predicted all-cause mortality than those in the NLST, 72% (95% CI: 65-78%) were screened.

CONCLUSIONS: LCS-eligible veterans were significantly less healthy than trial participants, with all-cause mortality rates that were 7- to 8-fold higher than in trial populations. Many who were screened are unlikely to benefit from LCS and may be exposed to unnecessary downstream harms including overdiagnosis.

FUNCTIONAL OUTCOMES OF POST-ACUTE CARE IN SKILLED NURSING FACILITIES FOR COMMUNITY-DWELLING OLDER ADULTS WITH AND WITHOUT ALZHEIMER’S DISEASE AND RELATED DEMENTIAS

Casey Krickus¹; Seiyoun Kim²; Brandi Peacock²; Rebecca T. Brown¹; Kira Ryskina². ¹Internal Medicine, Penn Medicine, Philadelphia, PA; ²Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4047594)

BACKGROUND: Activities of daily living (ADLs) are an important indicator of functional status and have been shown to independently predict health outcomes among older adults. Acute illness requiring hospitalization often leads to functional decline in older adults. Post-acute care in skilled nursing facilities (SNFs) typically includes physical therapy and other rehabilitative care with the aim to recover function for return to independent living in the community. Our objective was to assess the degree to which patients with Alzheimer’s disease and related dementias (ADRD) recover function after discharge to a SNF and to compare functional recovery between individuals with and without ADRD.

METHODS: This was a retrospective cohort study of 6,127,650 community-dwelling adults ages 65 and older who had an acute care hospitalization and were discharged to a SNF for short-term rehabilitation. We used the Medicare facility and professional claims and the nursing home Minimum Dataset (MDS) between 2012-2019. Individuals without continuous Medicare Parts A and B coverage between hospital admission and SNF discharge were excluded. ADRD diagnosis was obtained from the Medicare Chronic Conditions Warehouse file. Change in functional status was measured by calculating the difference between the MDS ADL score at admission vs. discharge from SNF. The MDS ADL score is a validated measure of functional status in SNFs. A change in MDS ADL score of 1.0 point is considered clinically meaningful. We measured degree of cognitive impairment on admission to SNF using the MDS Cognitive Function Scale (CFS).

RESULTS: In our cohort, 2,539,488 (41.4%) patients had ADRD. At SNF discharge, the improvement in functional status among patients with ADRD was 1.1 points lower compared to patients without ADRD (p<0.001). Among patients with ADRD, greater cognitive impairment on admission to SNF was associated with lower functional improvement (Figure).

CONCLUSIONS: ADRD diagnosis and cognitive impairment on admission to SNF are associated with lower improvement in functional status for patients discharged to SNFs for post-acute care. Nevertheless, the majority of individuals achieved clinically meaningful improvement in function including those with mild or moderate degree of cognitive impairment.

GRANDMA IS MOVING IN WITH US? COMMUNICATING THE LONG-TERM-CARE PLANS OF OLDER ADULTS

Raven Relerford^1,2; Charlie Olvera^1,2; Amber Winder^1,2; Allie Schierer^1,2; Alaine Murawski¹; Vanessa Ramirez^1,2; Lee Lindquist³. ¹Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ²General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ³Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4060177)

BACKGROUND: Most older adults require long-term care (LTC) support as they age and hope their care preferences are honored (e.g. remaining in home with caregivers vs assisted living). Besides planning ahead for LTC, communicating these LTC goals with loved ones prior to a health event is vital for this to occur. We sought to understand what factors influence older adults communicating their LTC support plans.

METHODS: The PlanYourLifespan (PYL) study examines the longitudinal LTC decision-making process among a cohort of older adults age 65+. PYL is a planning tool that has been proven effective in helping older adults make decisions. Subjects were surveyed at baseline, administered PYL, and then followed with surveys every 6 months for 24-months. Participants were asked whether they had made LTC support plans in the event of hospitalizations or Alzheimer’s Disease (AD), and if they’ve communicated their plans to others. Repeated measures statistical analysis was performed on the sets of “planners” using GLMM to identify factors associated with statistically significant increases or decreases in the likelihood of communicating plans.

RESULTS: Of the 293 subjects enrolled, mean age was 73.5 years, 72.7% female, and 40.4% were URM. Subjects were more likely to communicate plans on LTC living preferences (home vs senior building) if they displayed high health activation (OR 2.51 [p<0.05, 1.29-4.84]), higher social connectedness (OR 1.06 [p<0.05, 1.040-1.09])) and higher self-efficacy in social interactions (OR 1.06 [p<0.05, 1.03-1.09]);a decreased likelihood to communicate was seen among unmarried (OR.49 [p<0.05, 0.31-0.79]) and with limited health literacy (OR 0.495 [p<0.05, 0.25-0.99]). There was an increased likelihood to communicate about AD in-home care with high health activation (OR 2.54 [p<0.05, 1.39-4.63]) and more chronic health conditions (OR 1.15 [p<0.05, 1.02-1.29]); a decreased likelihood to communicate was seen among unmarried (OR 0.54 [p<0.05, 0.35-0.83]) and with limited health literacy (NVS- (OR 0.618 [p<0.05, 0.397-0.961]). Subjects were more likely to communicate their plans for post-hospitalization rehab if they had adequate social support (OR 2.14 [p<0.05,1.04-4.42]) while less likely to communicate if unmarried (OR.62 [p<0.05, 0.39-0.99]. There was an increased likelihood in communication of in-home care post-hospitalization with high health activation (OR 1.92 [p<0.05, 1.07-3.43]) and less likely to communicate if unmarried (OR 0.562 [p<0.05, 0.364-0.867]).

CONCLUSIONS: Older adults with higher health activation, higher health literacy, and stronger perceived social support from a spouse or strong social connections are more likely to communicate their LTC support plans. Communicating LTC plans are vital to ensuring older adult LTC wishes are followed. These results provide insight on where future communication interventions can target, in order to improve sharing of LTC support goals between older adults and their loved ones.

HEALTHCARE STAFF AND TRAINEE EXPERIENCES OF THE EFFECTS OF RACISM ON HOSPITAL-BASED SERIOUS ILLNESS CARE FOR OLDER BLACK ADULTS

Natalie Sohn¹; Sally Oh²; Sofia Weiss Goitiandia⁵; Lorraine M. Pereira³; Catthi Ly⁵; Julia Axelrod⁵; Elizabeth Dzeng^5,4. ¹Geriatrics and Palliative Care, Mount Sinai Health System, New York, NY; ²Pediatrics, University of California San Francisco, San Francisco, CA; ³Harvard Medical School, Boston, MA; ⁴Cicely Saunders Institute, King's College London, London, United Kingdom; ⁵Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4061428)

BACKGROUND: Decades of research have documented extensive racial inequities in serious illness care. These inequities are profoundly shaped by institutionalized and interpersonal racism. Institutionalized racism is defined as structural, differential access to services and opportunities based on race. Interpersonal racism is defined as prejudice and discrimination that an individual perpetrates against another, whether consciously or unconsciously. There is a critical gap in our understanding of how these levels of racism cause inequities in serious illness care. In this study, we sought to understand hospital staff member and medical trainee perspectives on the ways racism drives inequities in serious illness care for hospitalized older Black adults.

METHODS: This study was conducted at a large, urban, academic medical center. We interviewed residents, medical students, and hospital staff members, including patient care assistants, ward clerks, and custodial staff. We analyzed the interviews using thematic analysis. The core research team group coded 30% of the interviews to develop and refine the codebook. We iteratively discussed emerging patterns as additional transcripts were coded and summarized these patterns into themes.

RESULTS: We interviewed a total of fifteen trainees (53% identified as Asian, 27% White, 20% Black; 13% Hispanic) and twelve hospital staff members (58% identified as Asian, 25% Black, 8% White; 17% Hispanic). Hospital staff and medical trainees described racist beliefs held by colleagues, often resulting in discrimination against Black adult patients and inequities in their quality of care. Common themes related to stereotypes included perceptions of Black patients as “threatening and aggressive,” “pain-medication seeking,” and “difficult.” Respondents felt these perceptions led to avoidance of patient assessments, poorer communication between clinicians and Black patients, involvement of hospital security, and ultimately lower quality clinical care. Interviewees felt hospital teams were more likely to deliver equitable care if Black patients were perceived to have higher socioeconomic status, were housed, had intact cognition and mental status, and did not use substances. Respondents identified key factors that improved care including involvement of patient caregivers, increased hospital resources, such as sufficient staff time to perform their duties, racial concordance between staff and patients, and open communication.

CONCLUSIONS: Analysis of these interviews revealed patterns in perceptions of discriminatory beliefs and in the inequitable provision of care for hospitalized Black adults. This study elucidates individual and institutionalized factors that contribute to inequitable care. Future directions include leveraging this knowledge to determine targeted interventions to improve the quality of serious illness care for older Black adults.

IDENTIFIYING UNMET NEEDS: SUPPORTING COMPLEX OLDER VETERANS AND THEIR PRIMARY CARE PROVIDERS USING THE PATIENT PRIORITIES CARE APPROACH

Gwen M. Bernacki^2,1; Amy Thomas^2,3; Erica Martinez²; Terri May²; Katherine C. Ritchey^2,3; Julie Moorer²; Kirk B. Williams². ¹Medicine, Cardiology, University of Washington, Seattle, WA; ²Geriatrics/GRECC, VA Puget Sound Geriatric Research Education and Clinical Center, Seattle, WA; ³Medicine, Geriatrics and Gerontology, University of Washington, Seattle, WA. (Control ID #4064399)

BACKGROUND: Patient Priorities Care (PPC) has been shown to reduce the burden of care for older adults, limit unwanted or unnecessary care and make health care planning more transparent for the patient. Dissemination has not been explored in lower resourced, rural clinics with a high degree of clinical workload. We explored how the PPC approach in Geriatric consultation could identify unmet needs and how the PPC process was supportive of both referring providers and veteran patients in the context of consultative care.

METHODS: Patients were referred to a VA Geriatric Consultation clinic and seen by geriatricians who were trained in the PPC approach. Recommendations and alignment of care was guided by a veteran-derived specific, realistic health outcome goal. Electronic health records were reviewed for rehabilitative or social services; durable medical equipment; medication changes recommended and ordered by consultive physician; and post-visit care coordination. Surveys and interviews with veterans and providers provided feedback about the consultative process.

RESULTS: A total of 52 veterans (mean 78 years, 33% rural, 10% non-White, 2% female, mean Care Assessment Need Score 80.2) received consultation over a 8 month period. One quarter (25%) received ≥ 1 new referral for social work (12%), rehabilitative care services (38%), exercise program (19%), and/or durable medical equipment (15%). A substantial proportion (88%) received care coordination across multiple domains including social work (12%), physical therapy (12%), occupational therapy (10%), mental health (13%), and pharmacy (15%). 21% had a medication stopped, 42% had a medication added and an additional 30-40% received a recommendation to either start or stop a medication. All Veterans stated that the provider ‘included what matters most to you in your plans for what to do next to manage your health and wellbeing’ and ‘made recommendations regarding your medications or referrals for therapy/treatment based on your clinical visit.’ Referring providers were generally appreciative of consultative care and did not find recommendations more burdensome to their workload.

CONCLUSIONS: The PPC approach can identify unmet healthcare needs by aligning treatment plans with what matters most to rural, complex older veterans. Consultative care is generally well-received by veterans and referring providers suggesting the PPC approach may offer a model for co-management of rural complex veterans.

IDENTIFYING MISSED OPPORTUNITIES FOR HOME HEALTH CARE IN MEDICARE CLAIMS DATA AMONG OLDER ADULTS LIVING WITH DEMENTIA

Emma Chant¹; Ishani Ganguli². ¹Medicine, Hackensack Meridian School of Medicine, Nutley, NJ; ²Division of General Medicine and Primary Care, Brigham and Women's Hospital, Chestnut Hill, MA. (Control ID #4062954)

BACKGROUND: For older adults with dementia, accessing health care outside of the home is often important but can also be burdensome. We previously showed that older adults with dementia in Traditional Medicare spent 31 “health care contact days” in a year accessing medical care outside the home, 22 of which were ambulatory contact days (i.e., for office visits, tests, imaging, procedures, and treatments in the ambulatory setting). Shifting ambulatory services to the home setting could benefit these individuals and their care partners, but the extent of this opportunity is unclear. Therefore, we characterized the number and share of ambulatory contact days that could be replaced with existing home health or telehealth options, which can help clinicians and policymakers target efforts to expand these home-based approaches.

METHODS: We used 2019 Medicare Current Beneficiary Survey data linked to claims for community-dwelling, ≥65-year-old adults in Traditional Medicare. We identified three categories of services amenable to home health or telemedicine provision based on literature descriptions of current home care: behavioral health office visits, laboratory testing, and occupational, physical, or speech therapy, and identified days in which home-amenable services were the only types of health care contact. We described patterns of these contact days among those with dementia (based on Chronic Conditions Warehouse and self-report) and those who also self-reported “trouble getting places like the doctor’s office.”

RESULTS: In weighted analyses, 887 older adults with dementia (weighted: 2.9 million) had mean (SD) 5.0(10.3) health care contact days that were amenable to home health care, comprising nearly a quarter (23%) of total ambulatory contact days (21.7(20.6)). The biggest contributor was occupational, physical, or speech therapy (2.6(8.3) days per year), followed by laboratory testing (1.9(3.3) days per year). Behavioral health visits comprised only 0.6(5.5) contact days per year. Days spent on occupational, physical or speech therapy alone represent 12% of all ambulatory contact days in older adults with dementia. Adults with dementia who also reported trouble getting places (379, weighted: 1.2 million) had 21.8(21.8) ambulatory contact days. Of these days, 6.0(28%) were spent only accessing any of the potentially home-health amenable services: 3.2(9.4) days on occupational, physical, or speech therapy, 2.1(4.7) days on laboratory tests, and 0.9(8.2) days on behavioral health.

CONCLUSIONS: Days spent on occupational, physical or speech therapy and laboratory tests comprised a large share of ambulatory contact days in older adults with dementia, especially for the subset who also reported trouble getting places like the doctor’s office. Clinical workflows and policies that expand home-based therapy and testing may benefit this vulnerable population.

IMPACT OF AN AI-BASED NEGOTIATION TRAINING INTERVENTION (NEGOTIAGE) ON FAMILY CAREGIVERS OF OLDER ADULTS WITH ALZHEIMER’S DISEASE

Alaine Murawski¹; Celie Joblin¹; Marianne Tschoe⁴; Vanessa Ramirez¹; Charlie Olvera¹; Johnathan Mell⁵; Jeanne Brett²; Lee Lindquist³. ¹Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Kellogg, Northwestern University, Evanston, IL; ³Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁴Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁵University of Central Florida, Orlando, FL. (Control ID #4063751)

BACKGROUND: Family caregivers of older people living with Alzheimer’s Disease (PLWD) experience conflicts with the older adult, family members, and the healthcare system (e.g., increasing home support, disputing healthcare). Caregivers often are inadequately equipped to resolve these challenges. We sought to evaluate NegotiAge, a web-based intervention which leverages artificial intelligence (AI) to teach caregivers negotiation skills to assist in conflicts and dispute resolution. We specifically assessed the impact that NegotiAge had on how caregivers resolve conflicts and knowledge of negotiation skills.

METHODS: Family caregivers of PLWD were recruited nationally and enrolled in a randomized controlled trial of the NegotiAge intervention. With NegotiAge, participants received online training resources (e.g., videos, planning aids, and tip sheets about effective negotiation tactics) and then provided exercises to negotiate in real-time with AI-powered avatars who exhibit emotional tactics and irrational behaviors to simulate real-life conflicts. Conflict handling and negotiation knowledge was measured with baseline (T1) and 1-wk. post-intervention (T2) surveys. Caregiver conflict behaviors were measured with the Dutch Test for Conflict Handling (DUTCH), which examines conflict behavior domains: yielding, compromising, forcing, problem-solving, avoiding. Knowledge was assessed with a 15-item questionnaire evaluating negotiation terms and identification of conflict statements (interests, rights, power). For both conflict handling and knowledge, matched pair analyses and paired t-tests were conducted between T1 and T2 for each participant.

RESULTS: Sixty-one (n=61) caregivers (mean age 54.9 yrs., 78.7% female, 42.6% Black) were randomized to control or exercises arms and completed both T1 and T2 surveys. After receiving the NegotiAge intervention (T2), caregivers exhibited changes in conflict behaviors. Caregivers were less likely to avoid conflicts or display ‘forcing’ behaviors (p<0.05) and showed improved comprising and problem solving skills. We observed a marginal mean change (-0.11) in knowledge; however, we observed high levels of skills in identifying both interests (90.4%) and power (85.2%) conflict statements correctly at T2.

CONCLUSIONS: NegotiAge, an AI-based online negotiation training intervention, positively impacted the conflict resolution skills of family caregivers of PLWD. Family caregivers improved in compromising and problem-solving conflict behaviors as well as decreased conflict avoidance. NegotiAge improved the ability to identify common interests domains which is essential to determine the root of the conflict. Future research will examine the impact of NegotiAge on long-term caregiver outcomes (e.g. well-being, stress, burden) and care of PLWD

IMPACT OF GOALS OF CARE CONVERSATIONS ON INPATIENT DIALYSIS INITIATION: EMPOWERING PRIMARY CARE PHYSICIANS FOR PROACTIVE DIALOGUE IN DIALYSIS DECISION-MAKING

Allison J. Hare¹; Samantha L. Gelfand^3,4; Kathryn Corelli^2,5. ¹Department of Medicine, Brigham and Women's Hospital, Boston, MA; ²Department of Population Health, Mass General Brigham Inc, Somerville, MA; ³Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; ⁴Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA; ⁵Division of Women’s Health, Brigham and Women's Hospital, Boston, MA. (Control ID #4060365)

BACKGROUND: Chronic kidney disease affects an estimated 14% of U.S. adults, with around 130,000 individuals progressing to end-stage kidney disease (ESKD) and initiating dialysis annually. Despite its vital role, dialysis is an invasive measure associated with significant complications. Insights from conservative care models for ESKD indicate that the survival and quality of life for older adults with significant comorbidities may not be inferior to those treated with dialysis. Dialysis initiation is thus pivotal; however, the extent of conversations between patients who experience adverse outcomes after dialysis initiation and their clinicians regarding goals of care (GOC) remain inadequately understood.

METHODS: A chart review was conducted on patients participating in a Medicare Accountable Care Organization who passed away within one year of dialysis initiation within a multisite academic health system in New England. Patients initiated on dialysis between 2020 and 2022 were included, and patients with a nephrologist outside of the health system were excluded. Outcome measures included the documentation of outpatient GOC discussions about dialysis, specialty of the clinician who conducted the discussions, eGFR at the time of the GOC discussion, location of dialysis initiation, and eGFR at the time of dialysis initiation. GOC discussions were identified through a manual review of notes that included “dialysis” as a search term.

RESULTS: 48 patients were initiated on dialysis between 2020 and 2022, had a nephrologist within our health system, and passed away within one year. 25 (52.1%) patients were age 80 or older and 37 (77.1%) were male. 47 (98.0%) patients had hypertension, 32 (66.7%) had diabetes, 28 (58.3%) had heart failure, and 20 (41.7%) had malignancy. 35 (73.0%) patients required inpatient dialysis initiation, and 33 (68.8%) had a documented outpatient GOC discussion about dialysis. Of these, 27 (81.8%) discussions were with a nephrologist and 3 (9.1%) were with primary care physicians (PCPs). Of the 35 patients who required inpatient dialysis initiation, 21 (60%) had a documented GOC discussion; of the 13 patients who underwent elective outpatient dialysis initiation, 12 (92.3%) had a documented GOC discussion. Mean eGFR at patients’ GOC discussion was 16.2 mL/min/1.73m2 and fell to 12.3 mL/min/1.73m2 at dialysis initiation, slightly higher than the national mean eGFR at dialysis initiation in 2021 (9.9 mL/min/1.73m2).

CONCLUSIONS: Our findings highlight a critical need for GOC discussions before dialysis initiation – especially for older adults with significant comorbidities for whom avoiding unnecessary hospitalizations is a priority – and an opportunity for PCPs to take a more prominent and collaborative role in these discussions. By leveraging enduring relationships and their ability to elicit patients’ goals and values, PCPs can contribute to a more patient-centered approach for ESKD, potentially improving outcomes and quality of life for those navigating its complexities.

INITIATION AND PERSISTENCE OF ANTIPSYCHOTIC PRESCRIPTIONS AT HOSPITAL DISCHARGE AMONG COMMUNITY-DWELLING US VETERANS WITH DEMENTIA

Audrey D. Zhang¹; Lindsay Zepel²; Sandra Woolson³; Katherine Miller⁴; Loren J. Schleiden⁵; Megan E. Shepherd-Banigan³; Joshua M. Thorpe⁶; Susan N. Hastings³. ¹Department of Medicine, Duke University School of Medicine, Durham, NC; ²Department of Population Health, Duke University School of Medicine, Durham, NC; ³Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC; ⁴Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; ⁵Center for Health Equity Research and Promotion, Pittsburgh VA Health Care System, Pittsburgh, PA; ⁶Division of Pharmaceutical Outcomes and Policy, UNC Eschelman School of Pharmacy, Chapel Hill, NC. (Control ID #4048842)

BACKGROUND: Adults with dementia are frequently prescribed antipsychotic medications despite concerns that risks associated with antipsychotics outweigh benefits. Understanding conditions in which antipsychotics are initially prescribed to adults with dementia, such as hospitalization, may offer insights into how to reduce inappropriate use. We characterize antipsychotic initiation at hospital discharge and discontinuation in the subsequent year among veterans with dementia.

METHODS: We used Veterans Health Administration (VA) and Medicare administrative data to construct a national cohort of community-dwelling veterans aged ≥68 with dementia with VA hospitalizations in 2014, excluding those with psychotic or bipolar disorders or prior antipsychotic use. Our primary outcome was outpatient antipsychotic prescription within -2/+7 days of hospital discharge date. We used a generalized linear model to study the association between antipsychotic initiation and patient, hospitalization, and facility characteristics, accounting for clustering at the facility level. Among veterans with antipsychotic initiation, we evaluated for discontinuation in the year following hospitalization, defined as a ≥90-day gap between fills, using a cumulative incidence function to account for competing risks of re-hospitalization, admission to skilled nursing facility or hospice, or death.

RESULTS: 4,719 community-dwelling veterans with dementia were hospitalized in the VA in 2014, who were 97.8% male with a median age of 83. Most veterans were discharged from medical units (n=4,032, 85.4%); median length of stay was 3 days, and 350 (7.4%) hospitalizations included delirium as a diagnosis. 264 (5.6%) veterans filled a new outpatient antipsychotic prescription around hospital discharge, with a median days’ supply of 30 days (IQR 30-30); most were atypical antipsychotics (n=222, 84.1%). Antipsychotic initiation was associated with discharge unit (surgical vs medical, OR 0.41, 95% CI 0.19-0.87; psychiatric vs medical, OR 6.58, 95% CI 4.48-9.67), length of stay (OR 1.03 per day, 95% CI 1.02-1.05), and presence of delirium (OR 2.61, 95% CI 1.78-3.83), but not with demographic or facility characteristics. Among veterans with new antipsychotic initiation, the 1-year cumulative incidence rate of discontinuation was 18.2% (n=47); 15.9% (n=42) remained on an antipsychotic at 1 year. Most veterans (n=169, 64.0%) experienced competing events in the intervening time.

CONCLUSIONS: Antipsychotic initiation at hospital discharge was relatively uncommon in this national cohort of community-dwelling veterans with dementia. However, once initiated, antipsychotics were continued at least 1 year in many veterans with dementia who remained community-dwelling. These findings highlight hospitalization as a contributor to potentially-inappropriate medications, and suggests the importance of medication review after hospitalization.

INTERACTIVE TEACHING IN GERIATRIC MEDICINE IMPROVES INTERNAL MEDICINE RESIDENTS' PERCEPTIONS OF THEIR ABILITY TO CARE FOR OLDER ADULTS

Elise H. Binder^1,2; Nam-Ha Brown^1,2; Shivani Jindal¹. ¹Medicine, Cincinnati VA Medical Center, Cincinnati, OH; ²University of Cincinnati College of Medicine, Cincinnati, OH. (Control ID #4064558)

BACKGROUND: By 2030, it is expected one in five Americans will be 65 years or older and the population 85 years or older is projected to grow nearly 200 percent by 2060. The number of physicians trained in Geriatric Medicine will not meet this growing need. Medical trainees have expressed low confidence managing complex older adults. The Accreditation Council for Graduate Medical Education competencies highlight the importance of incorporating geriatric medicine training in residency. Our team created an interactive geriatric medicine didactic session as part of the Ambulatory Bootcamp (ABC) for second-year internal medicine residents at an academic medical center and assessed participants’ confidence in practicing these skills.

METHODS: Internal medicine residents in our program spend one year in a longitudinal ambulatory medicine experience. ABC is a two-week immersive curriculum for residents during which they participate in didactic sessions. We provide one interactive education session per block. This small group session focuses on geriatric medicine and includes the Institute for Healthcare Improvement’s Age-Friendly Health Systems (AFHS) 4Ms framework. We used case-based learning, scripted role-play, and interactive lecture. Before and after each session, we assessed learners’ perceptions of their confidence in evaluating geriatric syndromes and applying these skills in practice by optional pre- and post- session surveys.

RESULTS: Eighty matched surveys were collected for a response rate of 56%. After the session, 91% of learners surveyed ‘Agreed,' ‘I am confident in my ability to care for older adults’ (pre-session 59% ‘Agreed’) and 93% ‘Agreed’ in their confidence in their ability to deprescribe potentially inappropriate medications (pre-session 45% ‘Agreed’). Please see Table 1 for the full survey questions with pre-/post-session self-rated confidence rating. Qualitative data was also obtained. One participant commented, “The presentation was very thorough and applicable to what we will be seeing in clinic. Going through specific cases and talk[ing] about strategies to de-prescribe the medications was very helpful.”

CONCLUSIONS: This geriatric medicine session with mixed teaching methods is an effective way to increase internal medicine residents’ confidence in identification and management of geriatric syndromes. We plan to continue these sessions, expand topics to include acute care medicine and equity in care delivery for older adults, and further integrate the AFHS framework into the residency curriculum.

LOWER PRIMARY CARE FOLLOW-UP AND HIGHER 30-DAY HOSPITALIZATION AFTER NON-VA TREAT-AND-RELEASE EMERGENCY DEPARTMENT VISITS BY OLDER VETERANS: A COHORT ANALYSIS OF A REGIONAL HEALTH INFORMATION EXCHANGE

Elina Kurkurina^3,1; Kimberly M. Judon¹; Matthew R. Augustine^1,2. ¹Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY; ²Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ³Quinnipiac University Frank H Netter MD School of Medicine, North Haven, CT. (Control ID #4064590)

BACKGROUND: Older adults treated in emergency departments (EDs) are at increased risk of repeat visits, hospital admissions, and death. Use of multiple facilities can exacerbate the problem and negatively impact quality of care through duplication of services and poor care transitions. Following up with primary care after discharge is protective against serious adverse outcomes. In addition to VA coverage, most veterans retain a second form of insurance giving them unique flexibility to seek care at both VA and non-VA sites. To improve care transitions and patient outcomes, it is important to identify factors associated with non-VA ED use and determine if non-VA ED use impacts primary care follow-up or hospital utilization.

METHODS: We conducted a retrospective, observational study of patients ≥ 65 years who had established primary care at the James J Peters VA Medical Center and at least one VA or non-VA treat and release ED visit between October 2017 and February 2020. VA data were sourced from the VA Corporate Data Warehouse. Non-VA data were obtained from the Bronx Regional Health Information Exchange Organization, which captures electronic health information from healthcare institutions in the Bronx, NY. We examined the association of key patient characteristics with non-VA ED utilization including age, sex, marital status, race and ethnicity, comorbidities, distance to VA, and prior health care utilization within 30 and 60 days. The second analysis focused on the association between non-VA ED use and primary care follow up within 7 or 14 days, repeat ED use, and hospitalization within 30 days of discharge. We used generalized linear mixed models that allowed for clustering adjustments at patient-level for all analyses.

RESULTS: Of the 3,345 veterans in the sample, 2,762 (83%) sought emergency care at the VA, 177 (5%) outside of the VA, and 406 (12%) at both VA and non-VA sites. Veterans who were Non-Hispanic Black (Odds Ratio [OR] 1.38, Confidence Interval [CI] 1.02 – 1.88, P 0.03), presented after hours (OR 1.35, CI 1.23 – 1.50, P <0.001), or had a hospitalization in the prior 60 days (OR 1.66, CI 1.27 - 2.16, P <0.001) were more likely to use non-VA EDs. Veterans who used non-VA EDs were less likely to follow up with VA primary care within 7 (OR 0.24, CI 0.12 – 0.48, P <0.001) or 14 days (OR 0.23, CI 0.13 – 0.38, P <0.001), and were more likely to be hospitalized within 30 days of discharge (OR 1.83, CI 1.16 – 2.88, P 0.009).

CONCLUSIONS: Use of non-VA EDs was associated with a substantial decrease in the likelihood of following up with primary care, placing this group of veterans at increased risk for poor care transitions and hospitalizations within 30-days. For older veterans, rapidly identifying non-VA ED use and facilitating VA primary care follow-up may improve outcomes and decrease hospitalization.

NATIONWIDE FINANCIAL INCENTIVES FOR IN-HOME VACCINATION: EARLY RESULTS FROM A MEDICARE COVID-19 INITIATIVE

Robert M. Zimbroff, William J. Deardorff, Matthew E. Growdon. Division of Geriatrics, University of California San Francisco, San Francisco, CA. (Control ID #4063992)

BACKGROUND: Homebound older adults are among the most vulnerable to transmissible disease due to high rates of multimorbidity and frailty. However, vaccine access for homebound adults is difficult as most vaccines are administered at pharmacies and medical clinics.

In June 2021, the Centers for Medicare and Medicaid Services (CMS) implemented Healthcare Common Procedure Coding System (HCPCS) code M0201, which augmented reimbursement for in-home COVID-19 vaccination. We sought to evaluate the implementation of this financial incentive for in-home vaccination, the first of its kind for in-home preventive care.

METHODS: We performed a cross-sectional study using publicly available data from the 2021 Provider Utilization and Payment Data Physician and Other Practitioner Data Set. We identified all providers associated with >10 billed claims for HCPCS code M0201. We used National Provider Identifier (NPI) numbers to identify provider specialty. We used provider zip codes and Rural-Urban Commuting Area Codes to describe the geographic distribution of where M0201 was billed.

RESULTS: M0201 was billed 104,932 times between June and December 2021, serving 101,352 beneficiaries. Of 865 unique NPIs associated with claims for M0201, 85.5% represented pharmacies. Pharmacies billed the vast majority of M0201 claims (89.4%). Medical providers (MDs, NPs) represented 12.0% of all NPIs and billed 8.6% of all M0201 claims. Municipal health departments represented 1.8% of NPIs and 1.3% of all M0201 claims.

Most claims (81.9%) were billed in metropolitan areas. Suburban or micropolitan areas accounted for 8.3% of all claims. Small towns and rural areas represented 9.8% of claims. Figure 1 shows the geographic distribution of M0201 claims nationally.

CONCLUSIONS: A novel HCPCS procedure code, M0201, designed to incentivize in-home COVID-19 vaccination for homebound Medicare beneficiaries, was used predominantly in metropolitan areas, and by pharmacies, during the first six months of implementation. As M0201 will expand in 2024 to incentivize in-home influenza, pneumonia, and Hepatitis B vaccination, further study should investigate the characteristics of patients receiving in-home vaccination and the impact of M0201 implementation on health equity in immunization.

NEEDING HELP WHILE GIVING HELP: OLDER ADULTS WITH OVERLAPPING CAREGIVING RESPONSIBILITIES AND CARE NEEDS IN A U.S. NATIONAL COMMUNITY-BASED SAMPLE

Wagahta Semere¹; Veronica Yank¹; Nadra Lisha¹; Lee Lindquist²; Alison Huang¹. ¹Medicine, University of California San Francisco, San Francisco, CA; ²Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4057590)

BACKGROUND: Older adults comprise a significant proportion of individuals in caregiving roles, with nearly one in five U.S. caregivers being age 65 or older. While studies of caregiving often presume that caregivers are functionally independent, older caregivers may have some degree of functional impairment even as they fulfill caregiving roles. Existing research has neglected to examine the extent to which older caregivers are themselves recipients of care for activities of daily living (ADLs) or independent activities of daily living (IADLs). We examined the understudied area of overlapping caregiving and care receiving status among a national community-based sample of older adults.

METHODS: This is a cross-sectional analysis of a national sample of community-dwelling U.S. adults over age 60 in 2015-2016 who self-identified as caregivers. Caregiving was defined by self-reported assistance of another adult with day-to-day activities due to age or disability; overlapping care-receiving was defined by simultaneous receipt of help for at least one ADL or IADL. Multivariable logistic regression models examined attributes associated with overlapping care-receiving among older caregivers, adjusted for caregiver characteristics (age, gender, spousal caregiving, self-reported physical and mental health, and cognitive function). To account for unequal probabilities (selection and nonresponse), weights provided in the dataset were used for all analyses, and design-based standard errors (taking account of the strata and clustering) were obtained.

RESULTS: Among the 444 older caregivers, the mean age was 67.8 (SD 0.29) years, 55.8% were women, 78.1% were non-Hispanic White, 54.7% self-identified as primary caregivers, and 30.7% were caring for a spouse. Thirty two percent of older caregivers were caregiving while themselves receiving assistance with at least one ADL or IADL. Compared to caregivers who were not simultaneously receiving care, caregivers reporting overlapping care-receiving had greater odds of being older (AOR 1.30 [95% CI 1.14, 1.48] per each 5-year age increase), caregiving for a spouse (AOR 1.93 [95% CI 1.20, 3.13]), having limited household assets (AOR 2.10 [95% CI 1.17, 3.80] for <$50,000 in assets compared to ≥$50,000), and having poor or fair self-reported physical health (AOR 2.94 [95% CI 1.43, 6.02]).

CONCLUSIONS: Over 30% of older adult caregivers report simultaneously receiving care for their own daily activities. Caregivers who receive care are more likely to be older, spousal caregivers with limited assets and worse physical health. The worse physical health and limited financial resources reported by older adults in overlapping caregiving and care-receiving roles point towards a high risk for experiencing challenges that can be detrimental to both themselves and the recipients of their care. Targeted strategies are needed to support older caregivers who may be uniquely vulnerable due to their overlapping care needs.

NEGOTIAGE: THE REAL-WORLD UTILIZATION OF AN AI-BASED NEGOTIATION PROGRAM FOR FAMILY CAREGIVERS OF OLDER ADULTS

Marianne Tschoe¹; Alaine Murawski¹; Celie Joblin¹; Vanessa Ramirez¹; Johnathan Mell¹; Jeanne Brett²; Lee Lindquist³. ¹Geriatrics, Northwestern University, Evanston, IL; ²Kellogg, Northwestern University, Evanston, IL; ³Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4062357)

BACKGROUND: Family caregivers act as important support systems for older adults, but even well-intentioned support can cause conflict that adds to caregiver burden. We developed an online negotiation training program, NegotiAge, which utilizes artificial intelligence (AI) to train caregivers in negotiation and dispute resolution. Users receive instructional resources and practice negotiating with AI-based avatars who simulate real-life disagreements. We sought to characterize how caregivers apply NegotiAge to real-life conflicts with their older adults.

METHODS: Family caregivers were recruited nationally and enrolled in a randomized controlled trial of the NegotiAge intervention. One month after completing the program, caregivers were surveyed with open-ended questions about their utilization of NegotiAge training in interactions with older adults. Results were coded by two coders and assessed using constant comparative thematic analysis.

RESULTS: 41 caregivers (mean age 54.9 , 78.7% female, 42.6% Black) completed the NegotiAge program and the one-month survey. 73% (n=30) reported handling conflicts related to the care of older adults in the month following NegotiAge. Themes of the conflicts involved 1) handling health-related issues, 2) completing activities of daily living, 3) finances, 4) accepting support, 5) family member duties. As a result of their use of NegotiAge, 86% reported handling conflicts differently. Themes that emerged were that subjects 1.) Shifted behaviors away from power dynamics to shared interests. I pulled back from what I might had said prior to thinking that I was using a "Power" statement. I consciously thought out my negotiation choice of words; I used to give in to what my grandma wanted even when it wasn't in her best interest. Now when we have a conflict I focus on the interest of both of us and find common ground - helped tremendously 2.) Identified reasons behind conflict. I try to think more about the discussions within a conflict and focus on steering the conflict toward closure. 3.) Improved communication. It improved the way I communicate with my grandparents in a way to get my point across without conflict. Instead of saying things flat out I maneuver around the question in a way to get them to understand better. Subjects were able to apply their negotiation skills to other settings, including those at work, retail, real estate and with partners. All subjects had positive reflections on NegotiAge. It's reality living with a senior; There was a time when my mother was sad and crying. Because of the training I was able to calm her.

CONCLUSIONS: NegotiAge had a positive impact on how family caregivers manage real-life conflict. Caregivers implemented skills gained through its AI-based simulation to disputes with older adults, family, and work. Future research will examine the effect of NegotiAge on caregiver burden, stress, and the care of the older adult.

OLDER ADULTS’ AND CLINICIANS’ PERSPECTIVES ON USING, PRESCRIBING, AND DEPRESCRIBING OPIOIDS FOR CHRONIC PAIN: A QUALITATIVE ANALYSIS

Brianna Wang⁵; Julia Lindenberg¹; Shoshana J. Herzig²; Mara A. Schonberg³; Dylan Berens⁵; Timothy Anderson⁴. ¹General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Brookline, MA; ³Medicine, Beth Israel Deaconess Medical Center, Brookline, MA; ⁴Medicine/General Medicine, University of Pittsburgh, Boston, MA; ⁵General Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4017638)

BACKGROUND: There is increasing attention to the risks of opioids in light of the opioid overdose epidemic. Guidelines recommend deprescribing opioids in older adults due to risk of adverse effects; yet little is known about patient-clinician deprescibing conversations. The objective of this study is to understand older adults’ and primary care practitioners (PCPs) experiences with using opioids for chronic pain and discussing opioid deprescribing.

METHODS: We conducted semi-structured individual qualitative interviews with PCPs and adults >65 years prescribed opioids for chronic pain. PCPs were asked about their experiences prescribing and deprescribing opioids to older adults. Patients were asked about their experiences using opioid medications and discussing medications with PCPs. Thematic analysis was conducted to identify shared and conflicting themes between patients and clinicians regarding perceptions of opioid prescribing and barriers to deprescribing.

RESULTS: Eighteen PCPs (10 [56%] women, 17 [94%] internal medicine) and 29 older adult patients (19 [66%] female; 10 [34%] Black, 19 [66%] White) participated. All participants conveyed that conversations between PCPs and patients on opioid use for chronic pain were typically challenging and that conversations regarding opioid risks and deprescribing were uncommon. Three common themes related to experiences with opioids for chronic pain emerged: opioids are used as a last resort, opioids are used to improve function and quality of life, and opioids need to be prescribed in the setting of a trusting clinician-patient relationship. Patients and PCPs expressed conflicting views on risks of opioids, with patients focusing on addiction and clinicians focusing on adverse drug events. Both groups felt deprescribing conversation were often unsuccessful but had conflicting views on the barriers that prevent successful conversations. Patients felt deprescribing was often unnecessary unless an adverse event occurred and many had prior negative experiences tapering. PCPs described gaps in knowledge on how to taper, a lack of clinical access and time to monitor patients during tapering, and concerns over patient resistance.

CONCLUSIONS: PCPs and older adults on chronic opioid therapy view opioids as a beneficial last resort for treating chronic pain but express dissonant views on the risks of opioids and the importance of deprescribing, making these conversations challenging. These findings demonstrate the need to develop tailored resources to support older adults and PCPs in having successful conversations on the risks and benefits of continued opioid use.

OPPORTUNITIES FOR PALLIATIVE CARE INTEGRATION AMONG CANCER DECEDENTS ENROLLED IN A VALUE-BASED PROGRAM

Tina Kantaria¹; Anne Walling²; Neil Wenger³; Sidharth Anand²; John Glaspy². ¹Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Medicine, University of California Los Angeles, Los Angeles, CA; ³Medicine, University of California, Los Angeles, Los Angeles, CA. (Control ID #4063813)

BACKGROUND: Palliative care quality metrics for oncology care endorsed by the National Quality Forum recognize that intensive treatments and health care utilization toward the end of life may reflect treatment inconsistent with prognosis and preferences for patients with advanced cancer. Some value-based programs encourage integration of palliative care in oncology care to incentivize less intensive end of life utilization. We assessed whether decedents with advanced cancer who received intensive treatment at the end of life were receiving goal concordant care and, in cases for which goal concordance could not be assessed, we searched for missed opportunities for goals of care discussions and palliative care integration.

METHODS: Using a list of 88 oncology decedents provided by a payer for a value-based program, we performed structured and implicit chart abstraction to identify patients who died with active cancer and were followed in our health system for their cancer care during the last six months of life. For these patients, we identified patient goals from provider documentation, advance directives, and other notes. We matched those goals to treatment received to measure goal concordant care.

RESULTS: Forty patients (45%) met inclusion criteria; 23 (58%) of these patients died at home with hospice and 17 patients (42%) died in the hospital. Among the 17 patients that died in the hospital, 8 (47%) had documentation of goals that translated into aggressive treatment received. Five patients (29%) had an unexpected rapid clinical decline, precluding timely exploration of goals. Four patients (24%) had limited or no documentation about discussion of prognosis and goals or lacked palliative care consults. Each of these 4 patients had pivotal points in care that represent missed opportunities for exploration of goals of care and palliative care integration, such as multiple hospitalizations in a short time, new diagnosis of brain metastases, need for dose reduction of chemotherapy, and decline in functional status prior to exhaustion of treatment options.

CONCLUSIONS: In this small sample of oncology decedents, 42% (17/40) of patients received intensive treatment at the end of life, leading to in-hospital death. About half of those who died in the hospital receiving intensive treatments were found to have care that matched documented preferences. The four patients for whom goals were not identified all had clear opportunities for exploration of goals and integration of palliative care that may have limited intensive treatment at the end of life. If confirmed in a larger sample, these findings have implications for measurement and intervention.

PATTERNS OF END-OF-LIFE CARE AND HEALTHCARE SPENDING AMONG PERSONS WITH DEMENTIA IN MEDICARE ACCOUNTABLE CARE ORGANIZATIONS VERSUS TRADITIONAL MEDICARE

Jessica J. Zhang^1,2; Hiroshi Gotanda³; David B. Reuben⁴; Anne Walling^1,5; David S. Zingmond¹; Cheryl Damberg⁶; Neil Wenger¹; Haiyong Xu¹; Ryo Ikesu^1,7; Gillian Kaneshiro¹; Yusuke Tsugawa^1,8. ¹General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²National Clinician Scholars Program, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ⁴Multicampus Program in Geriatric Medicine and Gerontology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA; ⁶Health Care, RAND Corporation, Santa Monica, CA; ⁷Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA; ⁸Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA. (Control ID #4058046)

BACKGROUND: Medicare Accountable Care Organizations (ACO) aim to incentivize high quality care at lower spending. We compared patterns of end-of-life (EOL) care and healthcare spending among persons with dementia in ACO versus traditional Medicare (non-ACO).

METHODS: Cross-sectional study of Medicare beneficiaries with dementia ≥66 years who died in 2016-2019 (n=362,644). Exposure was ACO. Outcomes were 1) advance care planning (ACP); 2) palliative care counseling or hospice in the last 6 months of life; 3) hospital death or high-intensity care in the last 30 days of life (i.e., emergency department [ED] visit, hospitalization, intensive care unit [ICU] admission, cardiopulmonary resuscitation [CPR] or mechanical ventilation, feeding tube placement); and 4) healthcare spending in the last 6 months of life. We used multivariable linear regression models adjusting for beneficiary characteristics.

RESULTS: 23% of decedents were in ACO. Decedents in ACO had higher proportions of ACP (15.2% for ACO vs. 14.0% for non-ACO; difference +1.1 percentage points [pp]; 95% CI +0.8 to +1.4 pp; p<0.001) and ED visits (52.3% vs. 51.6%; +0.7 pp; 95% CI +0.3 to +1.1 pp; p<0.01). Decedents in ACO had lower proportions of hospital deaths (15.9% vs. 16.4%; -0.5 pp; 95% CI -0.8 to -0.1 pp; p<0.05) and feeding tube placement (1.4% vs. 1.5%; -0.2 pp; 95% CI -0.3 to -0.1 pp; p<0.05). No evidence that other outcomes differed for ACO vs. non-ACO. Healthcare spending was lower in ACO vs. non-ACO ($40,827 vs. $43,005; -$2,178; 95% CI -$2,489 to -$1,868; p<0.001).

CONCLUSIONS: Decedents with dementia in ACO vs. non-ACO had higher proportions of ACP and ED visits and lower proportions of hospital deaths and feeding tube placement. Total healthcare spending in the last 6 months of life was lower for decedents in ACO vs. non-ACO. For persons with dementia, Medicare ACO may deliver marginally less intensive care at EOL with lower healthcare spending.

PHENOTYPES OF OLDER ADULTS PLANNING FOR ALZHEIMER’S DISEASE SUPPORT

Amber Winder^1,2; Raven Relerford^1,2; Allision Schierer^1,2; Charlie Olvera¹; Vanessa Ramirez^1,2; Lee Lindquist². ¹Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4060152)

BACKGROUND: Providers often encounter older adults with Alzheimer’s disease (AD) who need additional support (e.g., home caregivers, senior buildings) but are unprepared. Research has shown that older adults can plan ahead for this need. We sought to model the types of older adult planning towards long-term care/ home support in the event of worsening AD.

METHODS: The PlanYourLifespan study examines the longitudinal decision-making process about long term care/home support. Subjects receive PlanYourLifespan.org, an intervention that facilitates decision making for support services in the event of worsening AD, and are surveyed every 6 months for 24-months. Surveys include cognitive, social, functional, environmental variables, and ask if they were to develop worsening AD, if they decided on living/support preferences. A mixed-methods approach was used to analyze variables through GLMM modelling and coding of qualitative responses through constant comparative analysis to develop phenotypes.

RESULTS: Of the 293 subjects enrolled (mean age 73.5 yrs,72.7% female, 40.4% URM) almost half (47.4%,n=139) experienced cognition decline with 10.3% identifying worsening memory loss from prior 6 mo timepoint. Phenotypes were determined:

1) Deniers. Overlook the possibility of developing AD, or have unrealistic perception of support required. Deniers display higher inductive reasoning (OR 0.91 [p<0.05,.84-.99). Higher reasoning trends towards higher health literacy levels, education, and income. Stating, “I don't see myself getting Alzheimer's, but when I thought about it, it just came and went.”

2) Dumpers. Choose to leave planning to their family. Dumpers display sufficient social support (OR 3.39 [p<0.05, 1.19- 9.70]). Stating, “I haven't actually sat down and discussed it… my son bought a bigger house so if something ever happens.”

3) Do-gooder: Created plans to avoid burdening family. Often completing a living will (OR 2.43 [p<0.05,1.11-5.33], with increased self-efficacy (OR 1.07 [p<0.01, 1.04-1.11]), and larger social network (OR 1.08 [p<0.05, 1.01-1.15]). Stating, “I would want to go to a facility rather than have my husband take care of me. I don't want to be a burden.”

4) Defeaters: Chooses not to plan due to external limitations. Often due to minimal knowledge of support options or lack of finances to support their preferences. Defeaters trend towards, lower income, lower education, and low social support. Stating, “I'd stay at home, and then if I have to go to a facility. Medicare will pay for 100 days and then they won't pay.”

CONCLUSIONS: In helping older adults consider their support needs in worsening Alzheimer’s, providers can identify the different phenotypes of planners and intervene early. Phenotypes heavily depend on one’s health literacy, social support, self-efficacy, and finances. Further research will examine how phenotypes may change over time and how plans are implemented to best care for older adults with Alzheimer’s.

PREVENTION, DETECTION, AND MANAGEMENT OF DELIRIUM ON AN ACUTE CARE FOR ELDERS UNIT: A QUALITY IMPROVEMENT PROJECT

Reaves Houston¹; Rebecca Fenner²; Christie Martin²; Kittra Felton²; Kimberly Mournighan³; John Gotelli³; Jacky R. Davis²; Joshua D. Niznik⁴; David H. Lynch³. ¹School of Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ²UNC Health, Chapel Hill, NC; ³Medicine, Geriatrics, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ⁴Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC. (Control ID #4046038)

BACKGROUND: Hospitalized older adults are at risk of developing delirium, particularly those with cognitive impairment. Delirium is associated with poor functional outcomes and increased mortality. Our project aimed to improve the detection of cognitive impairment and delirium.

METHODS: Our interdisciplinary quality improvement (QI) team utilized Plan-Do-Study-Act methodology to address delirium screening on our 25-bed Acute Care for Elders (ACE) unit. Prior to this study, the Confusion Assessment Method (CAM) was scored each shift, but there was no standard practice for documenting symptoms or assessing risk of delirium. Thus, we implemented the CAM-S for Delirium Severity and the Six-item Cognitive Impairment Test (6CIT) to measure baseline cognitive status. Staff nurses were trained and asked to complete the 6CIT once per admission and CAM and CAM-S once per shift for patients ≥65 years old. Scores were documented using a discrete template in the electronic medical record. To enhance uptake, we sent weekly emails with individual adherence rates, posted workstation reminders, and distributed “Badge Buddies” with the 6CIT tool. We measured adherence with CAM and CAM-S documentation per patient, per shift and 6CIT documentation per patient, per admission over 14 weeks. Documentation and demographic data were abstracted via chart review.

RESULTS: Patients admitted to the ACE unit during this period were average 80.6 years old (65-101, n=255), 61% female, 84% white, 12.5% Black, and 17% had dementia. Forty-five percent of patients had a normal 6CIT score, 26% had a score significant for cognitive impairment, and 28% did not have a score recorded. Twenty-six percent of patients were CAM positive at some point during admission. The average length of stay was 6 days (1-39), with most patients discharged home (31% independent, 30% with home health) or to a facility (27%). Documentation improved from baseline to Week 14 for all three measures: CAM 68 to 98%, CAM-S 0% to 81%, and 6CIT 0% to 100%.

CONCLUSIONS: A low-resource QI intervention facilitated adoption and uptake of multiple screening tools. Improved detection of cognitive impairment and delirium will allow the provider team to create prevention and management plans for patients with or at risk of delirium. The next PDSA cycle will utilize the 4Ms Framework to optimize prevention and management of delirium on the ACE unit.

QUALITATIVE FORMATIVE RESEARCH TO DEVELOP AN ADVANCE CARE PLANNING INTERVENTION FOR NATIVE HAWAIIAN ELDERS

Mapuana C. Antonio²; Martina L. Kamaka¹; Bridgette P. Kekauoha³; Adrienne Dillard³; Damien Hanakeawe⁵; Liana Honda⁵; Gerard Akaka⁵; Lisa Quintiliiani⁴; Lori E. Henault⁶; Kaitlyn A. Aoki¹; Michael Paasche-Orlow⁷; Angelo Volandes⁸; Aretha Delight Davis⁹; Marjorie Mau¹. ¹School of Medicine, University of Hawai'i System, Honolulu, HI; ²University of Hawai'i at Manoa, Honolulu, HI; ³Kula No Na Po'e Hawai'i, Honolulu, HI; ⁴Tufts Medical Center, Boston, MA; ⁵The Queen's Health Systems, Honolulu, HI; ⁶Boston Medical Center, Boston, MA; ⁷Tufts Medical Center, Boston, MA; ⁸Massachusetts General Hospital, Boston, MA; ⁹Nous Foundation, Waban, MA. (Control ID #4054177)

BACKGROUND: Advance Care Planning (ACP) continues to be an underutilized medical resource among older adults in the USA. With the growing number of older adults, there is an urgent need to increase effective ACP interventions that are relatable and relevant for this population. In particular, gaps in the literature demonstrate the need to promote ACP interventions, especially for the Indigenous populations of the USA including Native Hawaiians, the Indigenous people of Hawaii. To address these gaps, a qualitative study was conducted to understand perspectives, insights, knowledge, and experiences related to ACP among Native Hawaiian elders, their caregivers, and health service providers and staff. The research team also wanted to explore whether the development of tailored video decision support tools for Native Hawaiian elders would be perceived as valuable for an ACP intervention designed for Native Hawaiian kupuna (elders) and their caregivers.

METHODS: Key informant interviews (n=9) and small focus groups (n=33) were conducted after written informed consent was obtained from Native Hawaiian kupuna (elders), their family members, and healthcare providers. Audio recordings were transcribed verbatim and were analyzed using a thematic analysis approach.

RESULTS: Three major themes emerged: 1) Native Hawaiian worldviews; 2) Approaches to ACP conversations; 3) Video tools and resources to promote informed ACP conversations and documentation. These themes emphasize the importance of integrating Native Hawaiian ways of knowing, identity, and culture as part of the ACP process, while also ensuring ACP video interventions and facilitators were cognizant of appropriate places and times to have conversations around ACP. The expressed need for open access to the most current information tools and resources in plain language to assist Native Hawaiian elders and their families in completing ACP documentation was strongly supported.

CONCLUSIONS: The results indicate that an ACP intervention for Native Hawaiians should be tailored to include Native Hawaiian worldviews and culture, be written in plain language, and be delivered by community-based health workers and facilitators using a storytelling format. Enrollment and program evaluation are underway.

QUANTIFYING PILL DISUTILITY ASSOCIATED WITH STARTING VERSUS CONTINUING A CARDIOPROTECTIVE MEDICATION IN OLDER ADULTS: A RANDOMIZED EXPERIMENT

Alexander Chaitoff^1,2; Julie Lauffenburger^1,2; Nancy Haff^1,2; Niteesh K. Choudhry^1,2. ¹Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA; ²Harvard Medical School, Boston, MA. (Control ID #4064358)

BACKGROUND: In addition to causing side effects, adverse events, and financial toxicity, medications also cause harm via pill disutility. Pill disutility is the negative sentiment one feels about being on a medication that arises from factors related to medication use itself, such as the reminder of imperfect health that might come with taking a pill. However, studies that quantify pill disutility associated with taking cardioprotective medications have been conducted in samples of mostly younger adults and only assessed disutility associated with starting a new medication but not with continuing an existing medication. We aimed to quantify pill disutility associated with starting versus continuing a medication in a sample of older adults more likely to be having conversations about medication optimization.

METHODS: We recruited adults >60 from Prime Panels, which is an aggregation of market research panels with favorable data quality compared with other online survey samples. Respondents completed an online survey with one experimental intervention. In this intervention, respondents were randomized to one of two scenarios: 1) their doctor recommended they “start” or 2) their doctor recommended they “continue” a hypothetical daily pill that prevented heart attacks and strokes. We used a triple-bounded contingent valuation design to determine the maximum amount of time respondents would be willing to give up at the end of their life to either not have to start or not have to a continue taking the hypothetical pill but to still receive the pill’s benefits. We used a time-tradeoff calculation to determine pill disutility and employed Kruskal-Wallis tests to assess differences in pill disutility between respondents randomized to the starting versus continuing scenario. We then used fractional logistic regression to determine which respondent characteristics were associated with pill disutility within each scenario.

RESULTS: Our sample included 309 and 312 respondents randomized to the starting and continuing scenarios, respectively. Respondents had a mean age of 69 (SD 5.6), and there were no meaningful differences between the randomized groups. Starting a new medication was associated with a significantly higher pill disutility (0.0662, SD 0.13) than continuing an existing medication (0.0378, SD 0.10, p<0.001). Few respondent characteristics were associated with pill disutility. Notably, within the starting scenario those reporting excellent health (versus poor) indicated lower pill disutility (OR 0.21, 95%CI 0.10-0.44, p<0.001) while increasing age was associated with indicating higher pill disutility (OR 1.06, 95%CI 1.01-1.11, p<0.013). There were no notable associations within the continuing scenario.

CONCLUSIONS: Disutility associated with starting a new medication is on average much greater than the disutility associated with continuing an existing medication. These results should be considered in patient discussions about medication optimization and used in cost-effectiveness modeling.

RACIAL/ETHNIC DISPARITIES IN POTENTIALLY INAPPROPRIATE MEDICATION (PIM) USE IN PATIENTS WITH DEMENTIA

Justin Choi¹; William Hung²; Mary Sano²; Carolyn W. Zhu². ¹SUNY Downstate Health Sciences University, Brooklyn, NY; ²Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4054395)

BACKGROUND: Older adults with Alzheimer’s Disease and other dementias take more medications than those without dementia and more often use potentially inappropriate medications (PIMs), putting them at greater risk for adverse events. Patients with dementia from racial/ethnic minority groups also face disparities in their healthcare, such as lower use of anti-dementia medications and less access to research trials. We investigate the racial/ethnic disparities in PIM use among research participants with dementia.

METHODS: Data were drawn from the National Alzheimer's Coordinating Center-Uniform Data Set (NACC-UDS) from 9/2005 to 12/2022. We included baseline visits of participants >= 60 years old diagnosed with dementia per NACC-UDS guidelines, took at least one medication, and self-reported as one of four race/ethnicity groups: non-Hispanic white, non-Hispanic Black, Hispanic, and Asian.

Using the 2019 American Geriatrics Society (AGS) Beers Criteria for PIM use in older adults (excluding insulin), our main outcomes were: total number of medications, rate of exposure to any PIMs, and rate of exposure to PIMs by medication category. Multivariable analyses using generalized linear models were performed to assess the independent effect of race/ethnicity on these outcomes, controlling for age, sex, education, level of independence, cognition, function, behavioral and depressive symptoms, BMI, and comorbidities (reference group = white participants).

RESULTS: Sample included 10,208 White, 1407 Black, 1119 Hispanic and 284 Asian participants (n = 13,018). Multivariable analyses showed Black (incident rate ratio (IRR) ± standard error (SE) = 0.90±0.02), Hispanic (IRR±SE = 0.88±0.02), and Asian (IRR±SE = 0.91±0.04) participants reported fewer total medications (p < .001). Only Asian participants (IRR±SE = 0.62±0.12) had a difference in exposure to PIMs (p < .05). There were no significant differences in exposure to antihistamine or endocrine PIMs. Compared to white participants, Black ((odds ratio (OR) ± SE = 0.61±0.09, p < .01) and Asian (OR±SE = 0.51±0.20, p < .05) participants were exposed to fewer benzodiazepine PIMs. Black participants were also exposed to fewer antidepressant PIMs (OR±SE = 0.42±0.10, p < .001) but greater antipsychotic (OR±SE = 1.50±0.20, p < .01) and cardiovascular (OR±SE = 2.19±0.26, p < .001) PIMs. Black (OR±SE = 2.98±0.86, p < .001) and Hispanic (OR±SE = 2.47±0.91, p < .05) participants were exposed to greater skeletal muscle relaxant PIMs.

CONCLUSIONS: Among research participants with dementia, there were significant differences by race/ethnicity group in exposure to PIMs and PIMs by medication category. Further studies are needed to understand the impact of potential confounders such as socioeconomic status, cultural differences, and access to dementia care on these findings. Nevertheless, our findings underscore the importance of careful clinician review of medications, especially CNS-active medications, in the management of patients with dementia.

REDUCING POLYPHARMACY IN HOSPITALIZED OLDER VETERANS THROUGH DEPRESCRIBING: A RANDOMIZED CLINICAL TRIAL

Amanda S. Mixon^1,4; Emily Hollingsworth²; Matthew S. Shotwell^3,4; Eduard E. Vasilevskis⁵; Sandra Simmons^6,4. ¹Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN; ²Medicine, Vanderbilt University Medical Center, Nashville, TN; ³Biostatistics, Vanderbilt University Medical Center, Nashville, TN; ⁴VA Tennessee Valley Healthcare System, Nashville, TN; ⁵Medicine, University of Wisconsin-Madison, Madison, WI; ⁶Medicine, Geriatrics, Vanderbilt University Medical Center, Nashville, TN. (Control ID #4064412)

BACKGROUND: Polypharmacy is associated with poor health outcomes and is prevalent in older Veterans. Deprescribing, reducing or stopping medications, can mitigate polypharmacy and potentially improve health outcomes. We hypothesized that a hospital-based deprescribing intervention would safely reduce the total number of medications for older Veterans.

METHODS: VA Drug Reduction in Older Patients was a randomized clinical trial of a patient-centered deprescribing intervention. Hospitalized Veterans aged ≥ 50 years, prescribed at least 5 medications prior to admission, and recommended for post-acute care (PAC) were eligible. Participants were randomized to receive the intervention (pharmacist or nurse practitioner-led medication review, patient-approved deprescribing recommendations, and changes to medication orders at hospital discharge) or usual care (control arm). The primary outcome was total number of medications at hospital discharge, PAC discharge, and 90 days after PAC discharge. Intervention effects were assessed using mixed effects regression methods, adjusted for baseline medication number.

RESULTS: A total of 260 Veterans, predominately male (91%) and White (77%) with a median age of 72 years, were randomized. The median number of preadmission medications was 17. There was a statistically significant decrease in total medications for the intervention group at hospital discharge, with a mean of 9% fewer medications (mean ratio 0.91, confidence interval 0.84-0.97, P=0.006). There was no statistically significant decrease in total medications at PAC discharge or 90 days thereafter (mean ratio 0.93, CI 0.85-1.02, P=0.11; mean ratio 0.92, CI 0.85-1.00, P=0.06, respectively), although the total number of medications remained lower in the intervention group at each time point.

CONCLUSIONS: The patient-centered deprescribing intervention significantly reduced the total number of medications in hospitalized Veterans discharged to PAC. Although the intervention’s effects were not statistically significant past hospital discharge, there was a trend for intervention participants to maintain fewer medications at these timepoints. Future studies will examine the effect of the intervention on geriatric syndromes and the incidence of adverse drug events associated with deprescribing.

RELATIONSHIP OF STATE ADOPTION OF POLST WITH NURSING HOME RESIDENT HOSPITALIZATION

David S. Zingmond²; David Powell³; Jose Escarce²; Lee A. Jennings¹; Neil Wenger². ¹The University of Oklahoma, Norman, OK; ²Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³RAND Health, Santa Monica, CA. (Control ID #4064837)

BACKGROUND: Physician Orders for Life Sustaining Treatment (POLST) contains physician orders for end of life care intensity. This intervention is intended to guide the care that patients receive, which for residents in nursing homes often focuses the response to clinical deterioration toward comfort rather than burdensome care. POLST is nearly ubiquitous across the US, but it was instituted in states at different times. One study showed that states with POLST adoption had fewer long stay nursing home residents die in the hospital. It is not known whether implementation of POLST is related to hospitalization or number of hospital days among nursing home residents.

METHODS: We examined the relationship between POLST implementation and hospitalization among nursing home residents using the Minimum Data Set linked to the Medicare Beneficiary Summary File, Medicare Provider Analysis and Review file, and Medicare line item claims. Data were available from 2011 to 2018. POLST state implementation date was obtained from National POLST and we classified POLST implementation based on the year that the program started, excluding states in which the program started before 2011. Using difference-in-difference analysis, we evaluated the relationship between annualized nursing home resident hospitalization rate and year of POLST implementation from up to 4 years before to up to 2 years after implementation. Analysis was adjusted for patient and nursing home characteristics. The same analysis was performed for number of hospital days per year.

RESULTS: Across the 21 states that adopted POLST during this period, there were 8,980,726 annual observations among 1,913,836 residents. The mean number of hospitalizations per resident was 1.05 annually and this was relatively flat in the 4 years prior to POLST adoption, but decreased to 0.96 by 2 years later (Figure). Similarly, the baseline number of hospital days was nearly stable at 7.4 days per year and decreased to a mean of 6.6 days annually by 2 years after implementation.

CONCLUSIONS: Implementation of POLST at the state level is associated with a decrease in hospitalization and hospital days among nursing home residents.

RESPECT FOR THE PATIENT-ONCOLOGIST RELATIONSHIP MAY LIMIT CONVERSATIONS ABOUT GOALS OF CARE AND RECOMMENDATIONS FOR HOSPICE BY NON-ONCOLOGY CLINICIANS AFTER DISCHARGE TO A SNF

Sarguni Singh¹; Ashley Dafoe²; Brooke Dorsey Holliman²; John Cagle³; Hillary Lum¹; Stacy Fischer¹. ¹Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO; ³University of Maryland School of Social Work, Baltimore, MD. (Control ID #4063935)

BACKGROUND: ALIGN is a palliative care intervention for hospitalized older adults with advanced cancer discharged to skilled nursing facilities (SNFs) who are at risk for poor outcomes. In prior work, we demonstrated the acceptability of ALIGN and facilitators and barriers to implementation in community SNFs from the perspective of interdisciplinary SNF clinicians. To refine ALIGN, this study gathered multilevel perspectives from other involved clinicians and administrative leaders to describe perceptions and challenges regarding the care of older patients with cancer after discharge to a SNF.

METHODS: We conducted semi-structured interviews with clinicians and leaders in hospital medicine, oncology, palliative care, home health care, and hospice. Participants were recruited from an NCI designated cancer center, a tertiary academic center, and community agencies in the state of Colorado. The Practical Robust Implementation and Sustainability Model (PRISM) framework was used to develop the interview guide that explored barriers to care, prognosis discussions, care preferences, and hospice recommendations. Interviews were coded and analyzed using content-analysis.

RESULTS: Thirty-seven participants completed interviews (n = 12 hospital medicine, n = 9 oncology, n = 6 home health care, n =12 palliative care, n = 4 hospice, n = 3 leadership). Analysis identified 4 themes: (1) Discharge to a SNF is recognized as a time of worsening prognosis; (2) Care silos create communication and information barriers during a period of increasing palliative care need; (3) Family caregiver distress escalates following care transitions; (4) Lack of clarity of roles and respect for the patient-oncologist relationship limits prognostic communication and changes in focus of treatment.

CONCLUSIONS: These findings suggest that non-oncology clinicians are deferring serious illness conversations to the oncologist during a time when patients are on a steep trajectory of decline, experiencing multiple care transitions, and may have limited contact with their oncologist. Family caregivers struggle to navigate a complex health care system while grappling with a new understanding of a patient's illness. This analysis underscores the need for further clarity of roles amongst non-oncology and oncology clinicians in discussing prognosis and recommending hospice for older adults with advanced cancer discharged to SNF.

RESTARTING MEDICATIONS AFTER SUCCESSFUL DEPRESCRIBING: RETROSPECTIVE ANALYSIS OF A RANDOMIZED CLINICAL TRIAL

Thomas J. Reese¹; Sandra Simmons²; Eduard E. Vasilevskis³; Emily Hollingsworth⁴; Matthew S. Shotwell⁵; Amanda S. Mixon⁶. ¹Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN; ²Medicine, Geriatrics, Vanderbilt University Medical Center, Nashville, TN; ³Medicine, University of Wisconsin-Madison, Madison, WI; ⁴Medicine, Vanderbilt University Medical Center, Nashville, TN; ⁵Biostatistics, Vanderbilt University Medical Center, Nashville, TN; ⁶Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN. (Control ID #4059158)

BACKGROUND: Among hospitalized older patients, 45% have polypharmacy, and 90% have at least one unnecessary or inappropriate medication. In 2023, we published trial results demonstrating a patient-centered intervention decreased the total number of medications from hospital admission to 90 days post skilled nursing facility (SNF) discharge. The primary aim of this sub-analysis was to identify factors associated with restarting medications to inform future efforts to improve the durability of deprescribing interventions.

METHODS: The clinical trial included hospitalized patients in an academic medical center who were ≥ 50 years and had ≥ 5 prehospital medications. We randomized patients to the intervention or usual care. The intervention consisted of a comprehensive medication review during hospitalization, and deprescribing actions continued through the SNF encounter. We used structured interviews with patients or caregivers to assess patient characteristics and medication regimens during the intervention and at 7, 60, and 90 days after SNF discharge. We assessed the frequency of restarting medications (or return to previous or higher dose) among drug classes at each interval, and we assessed factors associated with restarting medications using mixed-effects models.

RESULTS: Among 4,272 deprescribed medications (281 patients), 903 (21%) were restarted. Across time periods, most medications were restarted between 7 and 60 days (38%) (Figure). Patients had a slight increased odds of restarting medications if they had a higher number of providers (OR = 1.02; 95% CI, 1.00–1.03; P = .049) and if they were discharged home from SNF alone (OR = 1.13; 95% CI, 1.05–1.25; P = .002) or with family (OR = 1.10; 95% CI, 1.03–1.18; P = .006), compared to assisted living. Patients had a decreased odds of restarting medications if they had higher health literacy (OR = 0.99; 95% CI, 0.99–0.99; P = .041).

CONCLUSIONS: Although our approach to deprescribing was safe and effective, one in five medications were restarted. Patients with multiple providers and lower health literacy who transition home to manage their own medications may be at higher risk for restarting deprescribed medications. Future deprescribing interventions should include support for both providers and patients following discharge to reinforce deprescribing decisions.

SEX, ETHNIC AND RACIAL DIFFERENCES IN HEALTHCARE UTILIZATION AND ADVANCE CARE PLANNING OUTCOMES IN OLDER, HOSPITALIZED PATIENTS

Myrna K. Serna¹; Efstathia Polychronopoulou²; Yong-fang Kuo²; Sunil K. Sahai¹; Mukaila Raji¹; Fernando Riosmena³; Abbey Berenson⁴. ¹Internal Medicine, The University of Texas Medical Branch at Galveston Department of Internal Medicine, Galveston, TX; ²Biostatistics and Data Science, The University of Texas Medical Branch at Galveston, Galveston, TX; ³Sociology and Demography, The University of Texas at San Antonio, San Antonio, TX; ⁴OB/GYN, The University of Texas Medical Branch at Galveston, Galveston, TX. (Control ID #4064282)

BACKGROUND: Ethnic and racial minority patients face socioeconomic barriers or engage in sociocultural practices that can lead to lower advance care planning and more intensive end-of-life care. Females experience more life years with disability, decreased social support, higher rates of poverty and have less healthcare utilization and higher rates of advance care planning compared to males. The aim of this study is to assess sex, ethnic and racial differences in health care utilization and advance care planning outcomes among older patients with an unplanned hospitalization.

METHODS: In this retrospective cohort study, patient encounters ≥70 years with an admission to a general medicine, family medicine or geriatrics service at an academic medical center from January 2018 to February 2023 were included. All data was collected using our electronic health record (Epic Systems, Inc., Verona, WI). Patient age, sex, ethnicity, and race are described. Multivariable logistic regression models adjusted for age, sex, Charleson Comorbidity Index, and hospitalizations in year prior to index admission are used to assess ethnic and racial differences in healthcare utilization, 6-month, post discharge mortality and advance care planning (ACP) documentation and associated outcomes (i.e. palliative care consult, Do Not Resuscitate (DNR) order). Multivariable logistic regression models were also used to assess sex differences in these outcomes.

RESULTS: Among a total of 5,376 patients, 3,601 (67%) were non-Hispanic White, 912 (17%) were non-Hispanic Black, and 863 (16%) were Hispanic with mean (SD) age of 80.8 (SD 7.3), 80.7 (7.5) and 80.2 (SD7.3) years, respectively. There were 2,895 (54%) females and 2,481 (46%) males. Hispanic patients were statistically less likely to be discharged to a skilled nursing facility (SNF) (odds ratio (OR) 0.75, confidence interval (CI) 0.60-0.93) compared to non-Hispanic White patients. There were no other statistically significant differences in outcomes between ethnic and racial groups. Rates of ACP documentation were low (9-10%) despite high 6-month, post-discharge mortality rates (18-21%) across groups. Multivariable, logistic regression models evaluating sex differences found that females were less likely to receive a palliative care consult (OR 0.79, CI 0.68-0.92), less likely to have 6-month, post discharge mortality (OR 0.83, CI 0.73-0.95) and more likely to go to SNF (OR 1.17, CI 1.01-1.36) compared to males.

CONCLUSIONS: Hispanic patients were less likely to be discharged to a SNF compared to non-Hispanic White patients, potentially due to cultural preferences. Females were less likely to receive a palliative care consult and more likely to be discharged to a SNF. These results may be explained by the lower mortality rate in females compared to males. More research is needed to assess how intersection of sex, ethnicity and race identities affect healthcare utilization, advance care planning and medical decision-making at the end-of-life.

SOCIAL NAVIGATION IN AGING: UNDERSTANDING DISTANCING BEHAVIOR IN AN ONLINE SOCIAL NAVIGATION TASK

Shaun Kohli¹; Matthew Schafer²; Daniela Schiller². ¹Medical Student, Icahn School of Medicine at Mount Sinai, New York, NY; ²Center for Computational Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4062545)

BACKGROUND: Studying social behavior in aging populations is crucial due to its implications for mental health and social isolation. Loneliness has been identified as a notable risk factor for many physical and mental health conditions, significantly affecting overall quality of life. This relevance is accentuated amid the COVID-19 pandemic, where social distancing measures have heightened social isolation among the elderly. However, conventional self-report questionnaires possess limitations when studying age-related changes in social behavior, stemming from biases associated with cognitive decline and memory deficits. Naturalistic experiments then emerge as a more suitable approach for exploring social dynamics in aging populations. Previous research in our lab demonstrated that a computer-based social navigation task reflects real-world social behavior. Participants engage in role-playing, making decisions on how to interact with fictional town characters. They can push characters away or pull them closer based on attributes of affiliation and relative power, effectively shaping relationships in an abstract social space framed by these two attributes. This study aims to examine how age influences a participant’s tendency to push characters away from oneself– a measure of socially isolating behavior.

METHODS: This cross-sectional study analyzed 890 participants who completed the task online (original sample: 629, validation sample: 261). Three factors ("social anxiety," "compulsivity," and "mood") were computed using a factor analysis of mental-health questionnaires from a post-task survey. Socially isolating behavior in the task was measured using the average distance between the participant and the other characters in the abstract social space. COVID-19 stringency scores from the OxCGRT database were also considered. Multivariable models were created to explore the relationship between age and these and other task variables, while controlling for relevant covariates.

RESULTS: The analysis showed a significant association between age and heightened socially isolating behavior in the task, irrespective of the aforementioned factors. These results were consistently replicated in an independent sample and remained statistically significant after accounting for the severity of COVID-19 restrictions. Moreover, our investigation revealed that while age, higher levels of social anxiety, and more depressed mood all correlated positively with increased distancing behavior in the task, only age significantly correlated with participants' subjective perception of their own distancing behavior, as assessed through post-task reflections.

CONCLUSIONS: The study indicates that as participants age, they may exhibit changes in social behavior which lead to increased social isolation. Additional research is needed to explore the neural mechanisms responsible for these behavioral shifts and gain a deeper understanding of the underlying processes.

THE BRAFV600E INDUCED MITOCHONDRIAL UNFOLDED PROTEIN RESPONSE INFORMS THE MELANOMA IMMUNE LANDSCAPE AND PATIENT SURVIVAL

Sach Thakker¹; Ahmed Elsaadi^3,2; Camila Rubio-Patiño^3,2; Juan Henao^3,2; MIn Hsu^4,5; Ata Morishi^4,5; Julide Celebi^4,5; Jerry E. Chipuk^3,2. ¹Georgetown University School of Medicine, Washington, DC; ²The Tisch Cancer Institute, New York, NY; ³Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY; ⁴Dermatology, New York University Grossman School of Medicine, New York, NY; ⁵Pathology, New York University Grossman School of Medicine, New York, NY. (Control ID #4028979)

BACKGROUND: Melanoma incidence is globally increasing and it the most fatal dermatological disease. Moreover, the elderly are at greater risks of mortality compared to younger counterparts. With age, dermal melanocytes often develop oncogenic mutations (e.g., BRAF^V600E) that result in dysregulated growth and activation of the oncogene-indcued senescence (OIS) program. This program results in significant changes to the structure and function of the mutated melanocytes via the acquisition of a senescence-associated secretory phenotype (SASP). Unpublished data from our laboratory demonstrates that BRAF^V600E coordinately activates the mitochondrial unfolded protein response (mtUPR) in primary human melanocytes during OIS. The mtUPR is uniquely mediated by the transcription factor, ATF5, and our work shows that the ATF5-dependent mtUPR dynamically regulates OIS, melanocyte metabolism, and numerous aspects of mitochondrial biology and repair. In addition, we describe that the BRAF^V600E-induced mtUPR markedly impacts upon the expression of cytokines and chemokines in primary melanocytes and multiple models of melanoma in situ. Based on these preliminary data, we hypothesize that BRAF^V600E-induced ATF5 expression not only impacts the SASP, but also the immune cell recruitment in premalignant and early-stage melanoma lesions providing both mechanistic and prognostic insights into disease.

METHODS: BRAF^V600E status, ATF5 expression, and ATF5 transcriptional signatures within the continuum of melanocytic disease progression (normal skin, dysplastic nevi, intradermal nevi, and melanoma in situ) were determined by RNA-seq, immunofluorescence, immunohistochemistry, metabolic phenotyping, and qPCR. Selected lesions were subjected to multiplexed chromogen-based IHC staining assay and/or Visium^TM RNA-seq to identify immune infiltrate. Additionally, using a unique cohort of formalin-fixed, paraffin-embedded patient tissues, ATF5-based transcriptional signatures and prognosis were investigated. All data were statistically analyzed by combinations of Fisher’s Exact Test, T-test/Wilcoxon Rank-Sum Test, Benjamini-Hochberg Procedure, and Multivariate Analysis approachs.

RESULTS: Preliminary data from our lab showed ATF5 expression was upregulated in the early stages of melanomagenesis. Additionally, it was found that high-risk early disease melanoma lesions demonstrate ATF5-dependent mtUPR activation. RNA-seq of primary melanomas revealed an increased mtUPR signature in High-Risk melanoma. When looking at patient survival, high ATF5 levels was significantly associated with shorter % survival compared to low ATF5 (p=0.031).

CONCLUSIONS: BRAF^V600E status was associated with high ATF5 expression and ATF5-dependent transcriptional signatures in primary human melanocytes and numerous models of early disease. High risk melanoma patients also displayed BRAF^V600E-dependent ATF5-signatures that predicted metastasis and reduced long-term survival.

THE IMPACT OF HEARING LOSS ON ANNUAL INCIDENT AGE-ASSOCIATED DEMENTIA CASES AND QUALITY ADJUSTED LIFE EXPECTANCY IN THE US

Ethan D. Borre¹; Julie N. Deleger⁴; Lauren K. Dillard⁵; Juliessa M. Pavon²; Sachin J. Shah³; Judy R. Dubno⁵; Sherri L. Smith¹; Kenneth A. Freedberg^4,6; Howard W. Francis⁷; Christine S. Ritchie^8,9; Gillian D. Sanders Schmidler¹; Emily P. Hyle^6,4. ¹Internal Medicine, Massachusetts General Hospital, Boston, MA; ²Internal Medicine, Duke University School of Medicine, Durham, NC; ³Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; ⁴Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA; ⁵Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC; ⁶Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA; ⁷Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC; ⁸Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA; ⁹Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA. (Control ID #4064360)

BACKGROUND: Two-thirds of persons age 70+ years have hearing loss (HL), and HL is a leading preventable cause of dementia. We used simulation modeling to estimate the annual number of incident age-associated dementia (AAD) cases and impact of HL on quality-adjusted life expectancy in the US.

METHODS: We used DeciBHAL, a validated microsimulation model of HL across the lifespan that includes age- and sex-specific annual probabilities of incident HL (0.1-10.4% [NHANES]). After HL onset, hearing thresholds decline (mean, 1 dB/year). We then incorporated incident AAD (0.3-10.8%) from the Adult Changes in Thought cohort. Utility decrements are incorporated yearly and based on HL (-0.1 to -0.3) and dementia severity (-0.1 to -0.5) using the additive approach (summing the utility decrements from HL and AAD for all simulated persons) to calculate per-person quality-adjusted life-years (QALYs). We estimated AAD incidence with and without the proportion attributable to HL by removing the estimated proportion attributable to HL (adjusted incidence risk ratio, 2.0 [95% CI, 1.5-2.8] calibrated from NHATS). We projected 2 cohorts: the general US population and a hypothetical US population without HL (counterfactual). We applied model-projected AAD incidence and utility among both cohorts to the 74,299,100 adults older than 60y and without AAD in 2022 from CDC lifetables.

RESULTS: Model-projected incident cases of AAD were 415,000/year (males) and 535,000/year (females) in 2022, which were validated using Framingham Heart Study data (Table). Model-estimated prevalence of HL (M/F) at ages 65, 75, and 85 years were 35%/16%, 61%/42%, and 87%/76%. In the simulation without HL, AAD cases/year fell to 345,000 for males and 475,000 for females. The difference in model-projected cases/year suggests that 133,000 new AAD cases in 2022 were attributable to HL. Mean per-person undiscounted QALYs from age 40y were 27.9 QALYs (males) and 31.9 QALYs (females). In the simulation without HL, QALYs increased to 29.6 QALYs and 33.4 QALYs, indicating that preventing all HL would increase average per-person lifetime QALYs by 1.8 and 1.5 in males and females. In sensitivity analysis, results were most sensitive to variations of the proportion of AAD attributable to HL.

CONCLUSIONS: Model-projected estimates support that HL prevention could substantially reduce AAD cases, improve quality-adjusted life expectancy in the US, and should be a priority.

THE IMPACT OF TOPICAL OXYGEN THERAPY ON WOUND HEALING: ASSESSING EFFICACY AND THE INFLUENCE OF PATIENT CHARACTERISTICS IN A SINGLE-INSTITUTION RETROSPECTIVE CHART REVIEW

Anya Wang²; Martina Brozynski²; Benjamin Jacobs¹; Nargiz Seyidova²; Olachi Oleru²; Harvey Himel². ¹The University of Chicago, Chicago, IL; ²Department of Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4031815)

BACKGROUND: Aging can diminish wound healing due to insufficient tissue oxygenation. Hyperbaric oxygen therapy (HBOT) poses systemic risks, while topical oxygen treatments (TOT) offer a safer localized alternative and increased convenience for elderly patients. This study examines TOT's impact on wound healing and how patient and wound characteristics influence its effectiveness.

METHODS: A retrospective chart review (8/1/2011 - 7/1/2023) analyzed patients aged 23 to 97 who used TOT (GWR Medical inc.) after unsuccessful alternate treatments. The device was used 90 minutes daily for four days, followed by a three-day break. Patient demographics (gender, patient age, race, smoking status, comorbidities, radiation usage, nutrition level), wound details (wound age, dimensions, location, etiology), and device usage interruptions were collected from EPIC. Wound dimensions were measured using a centimeter ruler. Healing was gauged by percent changes in surface area, depth, and volume. Analysis included two linear mixed effects (LME) models—one for comorbidity groups and one for individual comorbidity counts. Variables with high collinearity and variance inflation factor (VIF) > 10 were removed.

RESULTS: From 45 patients, 84 wounds were reviewed, averaging 1.86 wounds and 7.27 comorbidities per individual. Wound sizes ranged from 0.08 cm² to 482.5 cm² (median: 10.25 cm²). About 68% of wounds shrank, 2% remained unchanged, and 30% enlarged. Complete healing was more prevalent in nourished patients (94%), those without radiation history (88%), and non/former smokers (53%, 41%). No wound exceeding 27 cm² completely healed.

The LME model with comorbidity count showed the percent of days used enhanced healing for surface area (β = 1.092, p = 0.017), depth (β = 0.954, p = 0.030), and volume (β = 1.021, p = 0.027). Certain locations (foot: β = 1.597, p = 0.022; leg: β = 1.259, p = 0.027; toe: β = 2.498, p = 0.003) and being male (β = 1.537, p = 0.012) promoted healing. Initial depth (β = -0.472, p = 0.018) and white ethnicity (β = -2.033, p = 0.013) reduced healing. Overall comorbidity count had an insignificant effect (β = 0.093, p = 0.422).

The LME model with comorbidity categories found that percent of days used (β = 1.002, p = 0.032), being male (β = 1.486, p = 0.019), and bone disease (β = 2.327, p = 0.008) increased surface area healing, while initial depth remained detrimental (β = -0.519, p = 0.007). Age was a non-factor in both models.

CONCLUSIONS: Uninterrupted TOT usage enhanced healing in terms of surface area, depth, and volume, although deeper initial wounds hindered healing. Healing outcomes varied with wound location and patient factors like gender and comorbidities, but were not notably influenced by the number of comorbidities or patient age. These factors may be valuable for consideration by physicians when personalizing wound treatment to individual patients.

TREATMENT TOLERABILITY AND OUTCOMES IN OLDER ADULTS WITH OROPHARYNGEAL SQUAMOUS CELL CARCINOMA

Daniel E. Cohen, Daniel R. Dickstein, Richard Bakst. Medical School, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4045495)

BACKGROUND: The rising number of older patients with oropharyngeal squamous cell carcinoma (OPSCC) is driven by a combination of an aging population and an evolving Human Papilloma Virus (HPV) epidemic, with HPV now recognized as the leading cause of OPSCC in the elderly. Given this, there will be an increased disease burden for this cohort. Still, there is a lack of information regarding how HPV status affects treatment tolerability and clinical outcomes between different older adult groups.

METHODS: We identified patients from a database who were treated curatively for nonrecurrent locally advanced OPSCC from 2007-2020. Patients were categorized into sexagenarians (6Gs), septuagenarians (7Gs), and octogenarians (8Gs), and compared by HPV status to assess treatment tolerability and clinical outcomes. Demographics, clinical covariates and treatment tolerability outcomes were collected. Differences were analyzed using a chi-square test. Disease specific survival (DSS) and overall survival (OS) were analyzed with Kaplan-Meier curves.

RESULTS: Of 534 HNSCC patients between the sixty to ninety years old, 43% (n=229) had OPSCC, 128 6Gs, 82 7Gs, and 19 8Gs. Research subjects had a median age of 69 (IQR: 64-73), 84% were males, 69% white, and a median smoking history of 10 pack years (IQR: 0-40). Patients had AJCC Stage I (29%), II (33%), III (15%), IV (23%). There was no significant difference in demographics or stage between the three subpopulations (p=0.098). Patients were treated with adjuvant radiation (RT) (17%), adjuvant chemoradiation (CRT) (16%), induction/concurrent CRT (32%), concurrent CRT (22%), surgery alone (8%) or RT (6%). Among patients who received HPV testing and underwent RT (n=186), 6Gs were 80% HPV+, 7Gs were 67 % HPV+, and 8Gs were 88% HPV+ (p=0.082). Overall, 25% of patients had a treatment interruption with 6Gs with 19%, 7Gs with 27%, and 8Gs with 50% (p= 0.024). There was no difference between the age groups in treatment toxicities with acute 3+ dysphagia, xerostomia, or mucositis (p values: 0.053, 0.456, 0.880, respectively). There was no significant difference in the estimated three-year overall survival (6Gs: 74%, 7Gs: 69%, 8Gs 50%, p=0.0758) when stratified by age. However, there was a significant difference between disease specific survival (DSS) (6Gs: 85%, 7Gs: 74%, 8Gs 57%, p=0.0106) when stratified by age group. HPV+ OPSCC significantly increased the estimated 3-year OS compared to HPV- OPSCC in the 6Gs (HPV+: 81%, HPV- 45%, p= 0.0004 and 8Gs (HPV+: 57%, HPV-: 0%, p= <0.0001). However, there was no significant difference for the 7Gs (HPV+: 72%, HPV-: 61%, p=0.423)

CONCLUSIONS: The 8Gs had the highest relative percentage of HPV+OPSCC, indicating potential viral latency. HPV+ was associated with improved disease outcomes in two of the three older adult populations. Still 8Gs had the most treatment interruptions despite the highest HPV+ population, indicating that future studies should be focused on treatment de-escalation for this patient population.

TRENDS IN ANTIPSYCHOTIC PRESCRIBING AMONG COMMUNITY-DWELLING OLDER ADULTS WITH DEMENTIA, 2010-2018

Annie Yang¹; Mei Leng²; Julia Arbanas²; Chi-Hong Tseng³; A. Mark Fendrick⁴; Catherine Sarkisian³; Cheryl Damberg⁵; Nina Harawa⁶; John N. Mafi⁷. ¹Internal Medicine, University of California Los Angeles, Los Angeles, CA; ²GIM & HSR, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁴University of Michigan Medical School, Ann Arbor, MI; ⁵Health Care, RAND Corporation, Santa Monica, CA; ⁶General Internal Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA; ⁷Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4064588)

BACKGROUND: Antipsychotic prescriptions for dementia-related agitation carry an FDA “black box” warning label for heightened risk of stroke and death, prompting specialty societies to publish Choosing Wisely (CW) recommendations between 2013-2015 against their use as a first-line agent for dementia-related agitation. While antipsychotic use among institutionalized older adults with dementia has declined, recent trends in community-dwelling populations with dementia remain unknown. We sought to examine national trends in antipsychotic prescriptions in the context of CW recommendation publication.

METHODS: We used nationally-representative survey data from the Health and Retirement Study (HRS) linked to Medicare fee-for-service claims from 2010-2018. For each year, we identified beneficiaries ≥65 years old with MCID with ≥3 years of continuous Medicare Parts A, B and D coverage. We looked at prescribing trends during the pre-publication, publication, and post-publication periods of CW recommendations, utilizing multivariable mixed regression models. We calculated the percentage of patients prescribed any, potentially low-value, and potentially indicated antipsychotics. Antipsychotic prescriptions for patients on hospice and with serious mental illness (e.g., schizophrenia) were considered “potentially-indicated,” whereas prescriptions without guideline-concordant indications were considered “potentially low-value”.

RESULTS: We identified 1,420-1,462 participants per year, representing 4.6-5.6 million community-dwelling U.S. Medicare beneficiaries living with dementia during the study period. Antipsychotic prescribing increased from 7.7% (95% CI 5.7%-9.7%) during the pre-publication period (2010-2012) to 12.6% [95% CI 10.7%-14.6%] (P<.001) during the period when recommendations were issued (2013-2015). In the post-publication period (2016-2018), prescriptions remained higher than the pre-publication period at 13.3% [95% CI 11.3%-15.1%] (P<.001). We also observed increases for both potentially low-value and potentially indicated prescriptions. There was no significant difference between the publication (2013-2015) and post-publication periods (2016-2018) for all, potentially low-value, and potentially-indicated prescriptions.

CONCLUSIONS: Antipsychotic prescriptions increased between the periods before and after the initial publication of CW recommendations and held steady in the subsequent post-publication period among community-dwelling older Americans with dementia. The lack of decline in antipsychotic prescriptions continues to pose serious patient safety concerns and suggests that additional interventions, such as electronic clinical decision support tools and financial incentives, are needed to enhance the efforts of professional society recommendations in curbing low-value antipsychotic prescribing for this vulnerable population.

TRENDS IN CO-MORBID DEMENTIA AND CHRONIC KIDNEY DISEASE

Milda R. Saunders¹; Mingyu Qi²; Elbert Huang¹; R Tamara Konetzka². ¹Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Public Health Sciences, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4064669)

BACKGROUND: CKD and ADRD share some demographic, social, lifestyle and clinical risk factors. Shared socio-demographic risks include older age, lower income, and neighborhood disadvantage. Lifestyle and clinical risk factors for both CKD and ADRD include diabetes, hypertension, obesity, smoking, and physical inactivity. Little is known about the population of Medicare beneficiaries with both chronic kidney disease (CKD) and Alzheimer's Disease and Related Dementias (ADRD).

METHODS: Using data from Medicare fee-for-service (FFS) beneficiaries aged 65 and over identified through 2011-2019 Master Beneficiary Summary File (MBSF), we estimated the size, growth, and racial-ethnic characteristics of the ADRD and CKD populations. Individuals were classified as having ADRD and CKD based on CMS Chronic Conditions Data Warehouse (CCW) indicators in the MBSF Chronic Conditions file.

RESULTS: Among FFS beneficiaries, the prevalence of CKD has increased from 13.2% in 2011 to 23% in 2019, and the prevalence of ADRD has been relatively stable over that time 10.58% to 9.9%. The prevalence of individuals with co-morbid ADRD and CKD has risen from 4.4% to 6.3% which represents 1.72 million older adults. Black and Hispanic individuals have the highest prevalence of co-morbid CKD and ADRD, 8.75% and 8.05% respectively, compared to other racial-ethnic groups (<6% all others). In addition, within the ADRD population, the proportion with co-morbid CKD has been steadily increasing from 25.5% in 2011 to 44.4% in 2019. The proportion of individuals with ADRD with co-morbid CKD has increased across all race/ethnicities but is highest in Black and Hispanic patients (56.7 and 51%, respectively in 2019).

CONCLUSIONS: Despite the stable ADRD prevalence, there is a rising number of individuals with CKD who are diagnosed with ADRD and a rising proportion of those with ADRD who also have CKD. Due to shared clinical and demographic risk factors, interventions to reduce CKD progression could also delay ADRD onset. In an aging population, the prevalence of co-morbid CKD and ADRD is increasing, particularly among minoritized groups, and requires a change in prevention, diagnosis, clinical management, and policy.

UNIVERSAL EXPERIENCES OF CAREGIVERS ACROSS DIVERSE CAREGIVING CONTEXTS: A QUALITATIVE EVIDENCE SYNTHESIS

Karen Goldstein^1,2; Molly McFatrich³; Alexa Namestnik³; Nicole Lucas³; Meyra Çoban³; Erin Kent⁴; Abigail Shapiro²; Amy Clark³; Jennifer M. Gierisch^2,3; Sarah Cantrell⁵; Megan E. Shepherd-Banigan^2,3. ¹Division of General Internal Medicine, Duke University School of Medicine, Durham, NC; ²Durham VA Health Care System, Durham, NC; ³Duke University Population Research Institute, Durham, NC; ⁴The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC; ⁵Medical Center Library & Archives, Duke University, Durham, NC. (Control ID #4062014)

BACKGROUND: In 2021, unpaid caregivers provided $600 billion in support for loved ones with serious illnesses in the US. While we observe the benefits of caregiving for patients with chronic illnesses, the burden of caregiving are widely underappreciated and are associated with adverse emotional and physical outcomes for the caregiver. Currently, most caregiver supports are aligned in structured systems siloed according to the condition of the care recipient (e.g., dementia). To inform the development of comprehensive caregiver support systems, it is important to conceptualize the experience of caregiving as a broader phenomenon, agnostic to the care recipient’s condition. We conducted a qualitative evidence synthesis to address how unpaid caregivers experience the process of providing care to individuals across diverse serious illness contexts.

METHODS: We developed an a priori protocol based on current methodologic standards (PROSPERO registration: CRD42022357734). We searched MEDLINE, CINAHL, and PsycINFO databases from 2010-2022 for qualitative literature on informal caregiving experiences lasting at least 6 months. We excluded studies focusing on the physical tasks of provision of care (e.g., medical procedures). We used a maximum variation sampling approach to ensure data from the breadth of caregiving experiences (e.g., adult/child recepients, physical/mental health conditions) and to avoid overrepresentation from higher quantity literature in any one area. We used a thematic synthesis approach with inductive and deductive coding led by experienced qualitative researchers.

RESULTS: We included 40 papers across pre-identified sampling strata covering pediatric/adult recipients with mental health/cognitive impairment, pediatric/adult recipients with physical impairments, and adults with mixed conditions. Five themes were identified: 1) caregivers often fulfill multiple caregiving roles across multigenerational family needs or multiple children simultaneously and experience challenges balancing these demands; 2) caregiving incurs complex cumulative financial, physical, and emotional wear on the caregiver over time; 3) goals of care recipient and caregiver can be at odds, contributing to further caregiver wear; 4) periods of transition in the needs of care recipient can lead to heightened caregiver stress; and 5) support systems and services for caregiving are fractured and difficult to navigate, particularly for caregivers experiencing stigma and bias (e.g., racism, English as a second language).

CONCLUSIONS: Caregiving is a universal experience of the human condition. We found common experiences of caregiving, regardless of recipient condition. General internists should be sensitive to the burden of caregiving among their patients and be prepared to recognize and discuss aspects of caregiving that can take a significant physical and emotional toll. Supporting caregivers is critical and the need for unpaid caregiving is only expected to grow with the aging US population.

UTILITY OF THE PROMIS PHYSICAL FUNCTION MEASURE USING DIFFERENTIAL ITEM FUNCTIONING AMONG INDIVIDUALS WITH COGNITIVE IMPAIRMENT

Rebecca Lovett^1,2; Andrea Russell¹; Abigail Vogeley¹; Morgan Bonham³; Eileen Graham⁴; Daniel Mroczek⁴; Julia Yoshino Benavente⁵; Rachel O'Conor³; Lauren Opsasnick¹; Stephani Batio¹; Michael Wolf¹. 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; ³General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁴Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁵General Internal Medicine, Northwestern University, Chicago, IL. (Control ID #4064453)

BACKGROUND: Impaired physical function, including activities of daily living (ADLs), is a central diagnostic feature of Alzheimer’s disease and related dementias (ADRD). Informant reporting is often relied upon, given concerns surrounding the ability of persons with ADRD to validly self-report symptoms. The objective of this study was to investigate how cognitive impairment severity impacts psychometric properties of a commonly used self-report measure of physical function, the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) scale.

METHODS: Data from 396 older adults participating in a longitudinal cohort study on aging was used for this analysis. Cognitive function was assessed using an extensive neuropsychological battery consisting of 13 tests across 5 cognitive domains (processing speed, working memory, delayed memory, executive function, language); z-scores were calculated for each test. Participants were determined to have mild (-1 to -1.49), moderate (-1.5 to -1.99), or severe (<-2) impairment if performance on two or more tests within at least one cognitive domain met these z-score thresholds. All remaining participants were classified as cognitively normal. Physical function was measured using the PROMIS-PF short-form 10a. Differential item functioning (DIF) analyses were conducted using the lordif package in R with Monte Carlo simulations.

RESULTS: Participants were on average aged 71.2 years (SD 5.3), primarily female (72.0%), white (54.3%), and well-educated (60.0% at least some college). Nearly two-thirds were cognitively normal (72.5%), while 14.4% and 13.4% had a mild and moderate/severe cognitive impairment, respectively. Seven out of 10 PROMIS-SF items were flagged for DIF. Direction of DIF varied; participants with mild impairment exhibited a tendency to underestimate their physical function, while those with moderate/severe impairment were characterized by a tendency to overestimate. McFaddens pseudo R² effect sizes were all below published thresholds of 0.13 (range: 0.01-0.05). Test characteristic curves (TCC) were overlapping between the 3 groups.

CONCLUSIONS: Findings from this study indicate the presence of DIF by cognitive impairment severity on the PROMIS-PF measure. While the magnitude of effect and overlapping TCC curves suggest the observed DIF was negligible, researchers and clinicians should be aware that individuals with a cognitive impairment may respond differently to certain items on this measure. The presence of DIF suggests further study is needed to evaluate measurement bias among patients with cognitive impairment, including ADRD. However, overall, our evidence suggests patients with varying levels of cognitive impairment can provide reliable estimates of physical function using this measure. This has implications for researchers and clinicians seeking to assess functional status among older adults with ADRD, particularly if supplemental reports of functional status are not feasible or readily available.

VARIATION IN TREATMENT OF DIABETES IN THE ELDERLY IN A LARGE INTEGRATED HEALTH SYSTEM

Phuc H. Le¹; Glen B. Taksler²; Ning Guo³; Hamlet Gasoyan⁵; Michael B. Rothberg⁴. ¹Center for Value-based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH; ²Medicine Institute, Cleveland Clinic, Cleveland, OH; ³Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; ⁴Internal Medicine, Cleveland Clinic, Cleveland, OH; ⁵Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH. (Control ID #4064826)

BACKGROUND: Type 2 diabetes (T2D) disproportionately affects older adults, with nearly 30% of those ≥65 years living with the condition. Balancing the benefits of glycemic control with potential harm becomes increasingly important in this population. The American Diabetes Association (ADA) has relaxed the recommended hemoglobin A1c targets for older adults and removed a universal target for those in poor health since 2021. Yet, individualization in glycemic management for older adults with T2D remains challenging.

METHODS: We conducted a cross-sectional analysis of electronic health records (EHRs) from 2019 to 2023 within a large integrated health system in the Midwest. We included patients ≥65 years with T2D on diabetic medication. Patients were categorized into good, intermediate, and poor health groups based on the ADA's Standards of Care. We defined below-goal as A1c >1% lower than targets (7.5%, 8.0%, and 9.0% for good, intermediate, and poor health, respectively) and above-goal as A1c exceeding these targets. We quantified the proportion of patients below/above goal by health status and year and by primary care providers (PCPs). In the provider analysis, we assigned patients to the providers they saw the most each year and excluded providers with <20 patients.

RESULTS: We included 14,869-18,387 patients and 255-309 providers annually. Patients in good health were younger (71 vs 73 vs 75 years) and more likely to be male (59% vs 49% vs 49%) than those in intermediate and poor health while there was no difference in mean A1c across health status (7.10% vs 6.99% vs 7.02%). Among all included patients, the proportion of poor health increased over time (15.7% in 2019 vs 24.1% in 2023). Patients in poor health had more than double the rate of below-goal compared to those in good health (83% vs 36%). In contrast, patients in good health had two to three times higher rates of above-goal than those in poor health (26% vs 7%). Trends over time showed a decrease in below-goal and an increase in above-goal rates for patients in good health but no change for those in intermediate or poor health. Among PCPs, the annual median rate of below-goal was 60% (75% IQR: 54-69) and above-goal 13% (75% IQR: 9-19), which did not change over time.

CONCLUSIONS: Patients in intermediate and poor health were predominantly below goal, while those in good health were equally below and above goal. There was no significant variation in either below- or above-goal rates among PCPs. PCPs were consistent in treating patients below goal more often than above goal, suggesting opportunities for targeted interventions to personalize care for older adults with T2D.

Scientific Abstract - Healthcare Delivery and Redesign

A CLINICAL PHARMACIST AND HEALTH COACH DELIVERED MOBILE HEALTH INTERVENTION FOR TYPE 2 DIABETES IN AFRICAN-AMERICAN AND LATINX POPULATIONS: A RANDOMIZED CONTROLLED TRIAL

Ben Gerber¹; Alana Biggers²; Jessica Tilton²; Daphne Smith Marsh²; Rachel M. Lane²; Dan Mihailescu³; JungAe Lee¹; Lisa Sharp². ¹Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA; ²University of Illinois Chicago, Chicago, IL; ³Cook County Health, Chicago, IL. (Control ID #4038798)

BACKGROUND: African American and Latinx populations with type 2 diabetes experience higher average hemoglobin A1c (HbA1c) than non-Latinx Whites. This study determined whether an intervention involving clinical pharmacists and health coaches using mHealth tools improved HbA1c in these populations.

METHODS: This randomized clinical trial included 221 adult African American or Latinx patients with type 2 diabetes and elevated HbA1c (>= 8%) from an academic medical center in the Midwest. Patients randomized to the intervention group received mHealth diabetes support for 1 year followed by monitored usual diabetes care during a second year (total follow-up duration of 24 months). Those randomized to the waiting list control group received usual diabetes care for 1 year followed by the mHealth diabetes intervention during a second year. The mHealth diabetes intervention included remote support (e.g., review of glucose levels and medication intensification) from clinical pharmacists via a video telehealth platform. Health coach activities (e.g., addressing barriers to medication use and assisting pharmacists in medication reconciliation and telehealth) occurred in person at participant homes and via phone calls and text messaging. Usual diabetes care comprised routine health care from patients’ primary care physicians. Outcomes included HbA1c (primary), blood pressure, cholesterol, body mass index, health-related quality of life, diabetes distress, diabetes self-efficacy, depressive symptoms, social support, medication-taking behavior, and diabetes self-care measured every 6 months. To test group differences in outcomes, we used linear mixed-effects models for repeated measures over time within a 2-group 2-period framework.

RESULTS: Among the 221 participants (mean [SD] age, 55.2 [9.5] years; 154 women [69.7%], 148 African American adults [67.0%], and 73 Latinx adults [33.0%]), the baseline mean (SD) HbA1c level was 9.23% (1.53%). Over the initial 12 months, HbA1c improved by a mean of −0.79 percentage points in the intervention group compared with −0.24 percentage points in the waiting list control group (treatment effect, −0.62; 95% CI, −1.04 to −0.19; p = .005). Over the subsequent 12 months, a significant change in HbA1c was observed in the waiting list control group after they received the same intervention (mean change, −0.57 percentage points; p = .002), while the intervention group maintained benefit (mean change, 0.17 percentage points; p = .35). No between-group differences were found in adjusted models for secondary outcomes.

CONCLUSIONS: In this randomized clinical trial, HbA1c levels improved among African American and Latinx adults with type 2 diabetes. These findings suggest that a clinical pharmacist and health coach–delivered mobile health intervention can improve blood glucose levels in these populations and may help reduce racial and ethnic disparities.

ADHERENCE TO HEART FAILURE MEDICATION USING LINKED EHR PRESCRIPTION AND PHARMACY DISPENSE DATA

Yunan Zhao¹; Xiyue Li¹; Samrachana Adhikari¹; Ian Kronish²; Saul Blecker¹. ¹Population Health, New York University, New York, NY; ²Medicine, Columbia University Irving Medical Center, New York, NY. (Control ID #4062806)

BACKGROUND: Nearly half of heart failure (HF) patients exhibit poor adherence to guideline-directed medical therapy (GDMT), emphasizing the need for practical methods to accurately identify nonadherent patients who could benefit from adherence interventions. Currently, adherence is commonly calculated using the proportion of days covered (PDC) based on medication fills, typically from insurance claims data. However, this PDC assessment lacks the incorporation of critical information from prescription data, e.g., when medications are initially prescribed or discontinued. In recent years, many electronic health records (EHRs) have prescription and pharmacy dispensation data available, enabling enhanced PDC assessment that can be utilized in routine clinical care. This study aimed to compare PDC estimates using linked EHR prescription and pharmacy dispense data with dispense-only data estimates.

METHODS: We performed a retrospective cohort study using EHR data from a large health system in New York City. We included patients over 18 years who had diagnosis of heart failure, at least one clinical encounter between April 2021 and October 2022, and an active prescription for at least one GDMT. PDC is the ratio of the number of days of medication supplied over a specified period. We calculated PDC using two approaches: 1) using linked prescription and dispense data, in which the specified period was days of an active prescription up to 180 days, and 2) using dispense-only data, in which the specified period was days between the first and last fills up to 180 days. We compared the mean PDC, the percentage of non-adherent patients, defined as PDC<0.8, and the average length of specified periods using the two approaches.

RESULTS: We identified 32,379 patients in the linked prescription and dispense data. Of these patients, 2136 (6.6%) were not recorded in dispense-only data, as they never filled any prescriptions. Among the 30,243 patients in both datasets, the mean PDC using linked prescription and dispense data was 0.84 (SD 0.23), while using dispense-only data was 0.93 (SD 0.12; p<0.001). The linked prescription and dispense approach identified 10,796 (33.3%) patients with PDC<0.8, while the dispense-only approach identified 3023 (10.0%) patients with PDC<0.8. The average specified period using linked prescription and dispense data was 163.8 (SD 39.2) days and 156.4 (SD 44.4) days using dispense-only data.

CONCLUSIONS: PDC based on Linked prescription and dispense data identified 6.6% of patients who did not fill their prescriptions, a group overlooked by PDC reliant on dispense-only data. Furthermore, by lacking information on the initial start date or end date of a medication, dispense-only data overestimated adherence as compared to linked prescription and dispense data. Linking prescription and dispense data has the potential to identify more patients for adherence interventions in clinical encounters compared to the conventional approach that relies on pharmacy fill data only.

A MIXED METHODS EVALUATION OF A REGIONAL PRIMARY CARE REMOTE BLOOD PRESSURE MONITORING PILOT

Sana Tehal¹; Sai Priyanka Kodam^2,1; Jesse Rokicki-Parashar¹; Yingjie Weng³; Anuradha Phadke⁴. ¹PRIMARY CARE AND POPULATION HEALTH, Stanford University, Stanford, CA; ²Texas Tech University Health Sciences Center El Paso, El Paso, TX; ³MED/QUANTITATIVE SCIENCES UNIT, Stanford University, Palo Alto, CA; ⁴Stanford Health Care, Stanford, CA. (Control ID #4029564)

BACKGROUND: Remote blood pressure monitoring (RBPM) can improve blood pressure control among patients with hypertension (HTN). RBPM program impact depends on the protocol and patient population. We present an evaluation of a pilot institutional primary care RBPM program.

METHODS: We conducted a mixed-methods evaluation that included a prospective cohort observational study alongside patient and care team surveys. Care teams at 10 regional primary care clinics (9 academic, 1 community) in California invited patients with hypertension and uncontrolled blood pressure (BP) per an electronic medical record registry to participate. Participants received a Withings Bluetooth-enabled BP cuff, training materials on use, and provider or pharmacist telemedicine follow up visits. As our primary objective, we evaluated the systolic and diastolic blood pressure among participants over 6 months. We used a general mixed effects model to adjust for patient and provider characteristics. As a secondary objective, we assessed the number of patients submitting blood pressure readings per week. Through patient and care team surveys 6 months after pilot start, we assessed patient experience, care team experience, patient behavioral change, and opportunities for improvement.

RESULTS: Among the 150 patients (mean age 57 years, 65% male) who participated, mean baseline home systolic blood pressure (SBP) was 134 mmHg (SD=17) and diastolic blood pressure (DBP) was 84 mmHg (SD=13). In our primary objective, we observed an adjusted reduction in SBP by 1.08 mmHg per month (95% CI, -1.24 to - 0.91) and DBP by 0.88 mmHg per month (95% CI, -0.99 to -0.77). In our secondary objective, we found that the number of patients contributing home blood pressure readings declined over 6 months from 121 initially to 22 at study end.

In survey responses from 60/150 patients, over 80% of respondents were comfortable with the technology and found HTN care guidance helpful. 35% reported increased exercise and 28% had improved diet. Improvement suggestions focused primarily on device set-up, including recommending dedicated staff for set-up and automating the technical elements of the set-up process.

Care team survey respondents (n=23) agreed it was easy to review BP readings but cited technology set-up and sustaining patient engagement as barriers.

CONCLUSIONS: This RBPM pilot study observed a significant, albeit modest BP reduction over 6 months among 121 patients. Despite patients flagging as having BP potentially >140/90 mmHg, home readings revealed an average BP in the 130s/80s mmHg, limiting improvement opportunities.

Survey evaluation found RBPM and telehealth facilitated hypertension control and lifestyle improvements. Key improvement opportunities for future implementations include enhanced support for technology set-up and engaging patients in sustaining BP reporting.

A MULTIDISCIPLINARY CLINIC FOR ADULTS WITH MEDICAL COMPLEXITY: UNDERSTANDING THE CHALLENGES OF HOSPITAL COURSES FOR PATIENTS NAVIGATING HEALTHCARE TRANSITION

Margaret Rosenthal¹; Betsy Hopson²; Madeline Eckenrode³; Carlie Stein². ¹Department of Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; ²Medicine, UAB, BIrmingham, AL; ³Internal Medicine/Pediatrics, UAB, Birmingham, AL. (Control ID #4063634)

BACKGROUND: Patients with medical complexity and disabilities are often marginalized within healthcare systems. In particular, young adults with complex medical conditions of childhood face unique challenges as they transition from pediatric to adult healthcare. The “Staging Transition for Every Patient” (STEP) program at an academic medical center in the Southern region is a multidisciplinary clinic designed to address difficulties patients face transitioning from pediatric to adult healthcare. In addition to outpatient care, the STEP program works to mitigate patient fear of emergency department use and hospitalizations during the transition process by establishing emergency care plans and deliberate hospital co-management. A critical next step in reducing hospitalizations and length of stay is to review hospitalization courses in our patients and then to launch an inpatient consult service to address gaps in care.

METHODS: We performed retrospective chart review of all hospitalizations from September 2020 to June 2023 that patients had after they established care at the STEP clinic. We reviewed electronic medical records of 56 patients with 112 total hospitalizations, collecting data on hospital course and conducting descriptive analysis.

RESULTS: The majority of STEP patients requiring hospitalizations were young adults, with a mean age of 24 years. 69.6% of hospitalized patients had technology dependence, including wheelchair use, CNS shunt, feeding tubes, and tracheostomy/noninvasive positive-pressure ventilation. Ten patients had 3 or more hospitalizations during the study period. During the hospitalizations, 5/56 (9%) patients died, while 2 additional patients in this cohort died at home. The hospital courses of patients were a median length of four days (range 1 – 97 days) and were often complicated, with 21.4% of hospitalizations involving 3 or more consulting services assisting in the multidisciplinary management of complex conditions. Follow up STEP clinic appointments within 2 weeks of hospital discharge were attended after 19.6% of all hospitalizations.

CONCLUSIONS: We understand that our patients who are hospitalized have a similar degree of technology dependence compared to the overall clinic population, are older (mean age in clinic is 22.1), and that a small number of patients used significant hospital resources, with 3 or more stays within our study period. Patients were also unlikely to follow-up immediately following their hospitalization. In response to this data review, policy changes informed by complex hospitalizations have included the development of an “emergency room passport” to alert providers about critical health issues, the creation of a vulnerable patient task force, and an inpatient complex care consultation service. Based on these data, we have identified two areas for improvement: post-hospital care planning and multidisciplinary pre-hospital management of our most frequently admitted patients.

A NEW EQUILIBRIUM FOR TELEMEDICINE: PREVALENCE OF IN-PERSON, VIDEO, AND TELEPHONE-BASED CARE IN THE VETERANS HEALTH ADMINISTRATION 2019-2023

Jacqueline Ferguson¹; Charlie Wray^3,2; Cindie Slightam¹; James Van Campen¹; Donna Zulman⁴. ¹Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA; ²Medicine, University of California San Francisco, San Francisco, CA; ³Section of Hospital Medicine, San Francisco VA Health Care System, San Francisco, CA; ⁴Medicine, Stanford University, Stanford, CA. (Control ID #4062325)

BACKGROUND: The rapid uptake of telemedicine (e.g., encounters via telephone or video) in the early phases of the COVID-19 pandemic is well-documented, yet, there is little known about the redistribution of in-person and telemedicine encounters as US healthcare systems enter a post-pandemic phase. In this evaluation, we provide an updated timeline of the fluctuations in use of in-person care and telemedicine within the US. Department of Veterans Affairs (VA) healthcare system.

METHODS: We retrospectively identified 277,348,286 outpatient encounters occurring between 1/1/2019 and 8/31/2023, that took place in-person, by telephone, and by video before (pre-March 11, 2020), during (3/11/2020 – 5/10/2023), and after the pandemic (post-5/11/2023, defined by the end of the Federal COVID-19 Public Health Emergency declaration). We tabulated the number monthly encounters, and calculated the monthly percentage of encounters delivered via each modality (i.e., in-person, telephone, video) by care service (i.e., primary care, mental health, subspecialty care).

RESULTS: At the start of the pandemic, across all services, in-person encounters sharply decreased. Among primary care and mental health services, decreases in in-person care were offset by a compensatory increase in telephone- and video-based encounters and phone-based care became the dominant modality. Among subspecialty care, total encounters decreased and phone-based care was only briefly more common than in-person care.

In January 2021, in-person care once again became the dominant modality among primary care services and the pandemic-related decrease among all in-person – and concomitant surge in video and telephone encounters -- reversed. Across all services, telephone and video-based care decreased from a peak of 79.6% of care in April 2020 to 36.7% in April 2023. This decrease was driven by fewer telephone encounters, while the proportion of video visits remained close to peak levels at 11-13%. By August 2023, video-based encounters accounted for 34.5% of mental health, 3.7% of subspecialty, and 3.5% of primary care, while phone encounters accounted for 20.3%, 34.8%, and 16.7%, respectively.

CONCLUSIONS: A new equilibrium has emerged in which telephone-based care has largely returned to pre-pandemic levels, while video-based care accounts for 11-12% of outpatient care. The majority of mental healthcare is provided via telemedicine, likely due its easy adaptation to virtual platforms. While primary care and subspecialty telemedicine is often limited by the need for in-person evaluations, about 10% of in-person primary and subspecialty care has converted to telemedicine. The observed patterns suggest that telemedicine rates stabilized around May 2021, although telephone visits continue to decrease across all services and mental health video visits increase. Notably, this stabilization occurred when vaccines were widely available—two-years prior to the end of the Federal Emergency Declaration.

A NOVEL NURSE-DRIVEN HYPERTENSION MANAGEMENT PATHWAY IMPROVED BLOOD PRESSURE CONTROL AMONG VETERANS WITH HYPERTENSION

Stefanie A. Deeds¹; John Geyer¹; Linnaea C. Schuttner¹; Anders Chen^2,1; Chelle Wheat³; Jorge Rojas Jr.³; Eric Gunnink³; Karin Nelson^1,4; Ashok Reddy^1,4. ¹General Medical Services, US Department of Veterans Affairs, Washington, DC; ²Internal Medicine, University of Washington, Seattle, WA; ³Primary Care Analytics Team, Veterans Health Administration, Seattle, WA; ⁴Medicine, University of Washington, Seattle, WA. (Control ID #4062688)

BACKGROUND: Blood pressure (BP) control is a key indicator of quality at the Veterans Health Administration (VA). Prior COVID-19, only in-clinic blood pressures were included in quality monitoring and management was predominantly clinician-led.

During the pandemic, hypertension performance waned largely due to declines in in-person measures for quality metrics. In response, patient-reported blood pressures were added to performance monitoring in 2022.

To leverage remote care and patient-reported blood pressure monitoring, we sought to create and test a novel nurse-driven hypertension pathway. The pathway consists of 3 main components: 1) a dashboard used to identify patients (missing annual blood pressure or blood pressure >140/90 mmHg) 2) a care-protocol which included nurse outreach and/or virtual visit, 3) an EHR note template, used to capture home BP readings, exclude inappropriate patients (e.g., managed outside VA), and track referrals (e.g., to pharmacists for escalated care). Documented actions and BP data update the corresponding dashboard.

METHODS: We evaluated this pathway in a non-randomized difference-in-difference trial at two comparable VA sites. We included veterans aged 18-85 with hypertension diagnosis in the prior year with data available for the study period.

Nurses were trained on the pathway from May to Nov, 2022. Data collection was through November 2023.

Our primary outcome was the proportion of patients with controlled blood pressure (BP, <140/90 mmHg) at the most recent outpatient visit (past year) at the pathway VA (vs. control site).

An interrupted time series tested for change in outcome before vs. after intervention, as well as change in slope comparing pathway and control sites, adjusted for patient demographics from the month prior to rollout.

RESULTS: 2970 patients were included (n=2208, pathway; n=762, control). Baseline demographics varied slightly between sites (pathway, mean age 65y (SD=11), 9% female, 58% non-Hispanic White, 64% controlled BP; control, 66y (SD=10), 14% female, 81% non-Hispanic White, 55% controlled BP).

May to Nov 2022, pathway site increased BP template use 370% (502 to 2360), vs. 36% at control site (368 to 503).

In the adjusted analysis, BP control increased at the pathway site from 59% to 67% of patients (pre- vs. post) compared to the control site which increased from 53% to 55% of patients.

CONCLUSIONS: We found that a nurse-driven hypertension pathway improved BP control among veterans with hypertension. Successes include developing novel tools adapted to existing nurse workflows at the VA. Additionally, we developed training for nurses to support virtual care management for chronic disease, which can serve as a model for ongoing population health efforts. The hypertension pathway is being adopted at other regional VA sites.

A NOVEL SHORT-TERM STAFFING AND TELEHEALTH PROGRAM IN A POST-COVID-19 PANDEMIC WORLD

Amy M. O'Shea¹; Bjarni Haraldsson¹; Peter J. Kaboli²; Ariana Shahnazi³; Matthew R. Augustine⁴. ¹Research, Iowa City VA Healthcare System, Iowa City, IA; ²Internal Medicine, Iowa City VAMC, Iowa City, IA; ³CADRE, Iowa City VA Medical Center, Iowa City, IA; ⁴Health Services Research & Development, VA Puget Sound Health Care System, New York, NY. (Control ID #4062717)

BACKGROUND: The Clinical Resource Hub (CRH) is a Veterans Health Administration (VHA) program implemented to mitigate clinical staffing deficits using telemedicine. The COVID19 pandemic dramatically impacted primary care (PC) clinic operations and patient access due to staff turnover, in-person restrictions and shift to video visits. Our objective was to determine if CRH after the start of the COVID-19 pandemic successfully provided staffing gap coverage impacted patient access to primary care.

METHODS: This retrospective observational cohort study defined VHA PC clinics as CRH users when they had at least 10 PC CRH visits per month for two consecutive months. Clinics were stratified as small, medium, or large (i.e., 450-2,399, 2,400-9,999, and ≥10,000 unique patients), and as rural or urban. PC provider gaps were calculated using a clinic’s average monthly gap staffing metric (i.e., ratio of maximum clinic capacity divided by patients assigned) and classified as under- (<1.0), marginally- (1.0-1.2), or fully- staffed (>1.2). Associations between CRH user status and the gap metric were stratified by clinic size and rurality and tested with a chi-square test. We used linear regression to test the relationship between PC staffing gaps and 4 outcomes at CRH user sites: established and new patient wait times, timely care, and third next available appointment. Control clinics are those that have never had a PC CRH encounter.

RESULTS: Over the 30-month study period (October 2020 – March 2023), 347 (51.8%) of 670 clinics were identified as CRH users. Compared to controls, CRH users were less likely to be understaffed (0.9% vs 9.1%; Χ²=9.7; p<0.01) among rural clinics, marginally staffed (23.9% vs 37.1%; Χ²=8.3; p=0.02) among urban clinics, and marginally staffed (27.8% vs. 39.9%; Χ²=7.7; p=0.02) among medium-sized clinics. Among CRH user clinics, new patient wait times increased by 8.3 days/month (95% CI=[3.6,13.0]) and 2.8 days/month (95% CI=[0.7, 4.9]) for clinics that were under- or marginally-staffed compared to fully staffed. The time to the third next available appointment was also longer for clinics that were identified as under- vs. fully staffed (4.1 days/month, 95% CI=[0.5, 7.8]). No significant associations were noted by PC staffing gap status for established patient wait time or timely care.

CONCLUSIONS: Although both CRH user and control clinics experienced PC provider staffing gaps, rural control clinics were most likely to be understaffed. Among CRH clinics we saw longer new patient wait times when that clinic was under- or marginally-staffed, while we only saw longer times to third next available appointment among understaffed clinics. Further evaluation is needed to determine how quickly the CRH program can be implemented when provider gaps are identified.

APPLYING EXPERIENCE-BASED CO-DESIGN IN THE DEVELOPMENT OF CULTURALLY AND GLYCEMIC RISK-ADAPTED INVITATIONS TO REACH AND ENGAGE PATIENTS IN DIABETES SCREENING

Leilani Dodgen³; Cristian Vargas³; Brittany Ajoku³; Patricia M. Chen²; Molly McGuire¹; Timothy P. Hogan²; Michael E. Bowen^1,2. ¹Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ²School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX; ³Health and Wellness Center, Baylor Scott & White Health, Dallas, TX. (Control ID #4062136)

BACKGROUND: Despite existing guidelines, high rates of undiagnosed dysglycemia (Type 2 diabetes (T2D) and prediabetes (PDM)) disproportionately impact minoritized communities. Proactive, population health outreach strategies designed to reach and engage diverse communities are needed to enhance existing screening rates.

METHODS: In partnership with primary care clinics within an integrated, safety-net health system, we applied principles of Experience-Based Co-Design (EBCD), a methodological approach that reflects the values of patient-centered care and stakeholder engagement, to develop culturally and glycemic risk-adapted invitation (CGRI) letters to address differences in race/ethnicity and acculturation (Hispanic, English-speaking; Hispanic, Spanish-speaking; non-Hispanic (NH) Black; and NH White), and glycemic risk status (known prediabetes or at-risk/elevated glucose). CGRI invitations aim to improve screening response rates as part of a larger population health diabetes screening intervention. Our phased EBCD approach included: 1) consultation with a community advisory panel to gather baseline insights on CGRIs for T2D screening; 2) formative, semi-structured interviews with clinical staff (n=8) and patients (n=25) informed by the Health Belief Model to elicit perceptions of diabetes risk, attitudes and barriers toward T2D screening, potential CGRI content, and formatting; and 3) a series of focus groups (n=8) comprised of patients and clinical staff, organized by race/ethnicity and glycemic risk, and structured to support review and refinement of invitation drafts.

RESULTS: Across our racial/ethnic communities, the phased EBCD approach resulted in 4 invitation letters for patients at risk of diabetes and 4 letters for patients with prediabetes. Each letter includes cross-cutting themes identified by all groups and targeted themes that also emerged across groups, but varied in how each group preferred those themes to be expressed for better cultural alignment in the invitation. Cross-cutting themes included the importance of 1) facilitating understanding & knowledge of diabetes; 2) testing logistics; 3) diabetes risk & screening follow-up; and 4) trust in one’s healthcare team & the healthcare system. Targeted themes included the importance of: 1) diabetes prevalence statistics; 2) risk factors; 3) the impact of diabetes on the body; 4) the benefits of screening; overcoming screening fears; and 5) respecting patient screening barriers.

CONCLUSIONS: The principles of EBCD can provide an effective lattice to structure the gathering and incorporation of stakeholder feedback when creating interventions. Our EBCD work yielded 8 invitation letters reflective of what matters most to the diverse communities of patients most in need of diabetes screening. As a next step, CGRI letters will be tested in a randomized trial to assess their potential at addressing persistent disparities in diabetes screening.

ASSESSING THE IMPLEMENTATION OF CLINICAL PHARMACIST OUTREACH FOR MEDICATION TITRATION IN A REMOTE PATIENT MONITORING PROGRAM FOR HYPERTENSION

Helen H. Shi¹; Allison Stark²; Aloke Maity⁴; Abhishek Shah²; Joseph Manganelli²; Paula Baichoo²; Svetlana Korchevsky²; Pooja Suthar²; Sharon Rikin³. ¹Albert Einstein College of Medicine, Bronx, NY; ²Care Management Organization, Montefiore Health System, Bronx, NY; ³Internal Medicine, Montefiore Medical Center, Brooklyn, NY; ⁴Montefiore Medical Center, New York, NY. (Control ID #4063670)

BACKGROUND: Uncontrolled hypertension (HTN) is driven by clinical inertia for medication titration. While remote patient monitoring (RPM) programs using team-based care are encouraged for HTN management, there is insufficient research on which components of RPM programs in a real-world setting are associated with BP control and overcoming barriers to medication titration. We developed an RPM-HTN program in the Bronx, consisting of out-of-office BP measurements collected via an online RPM portal, coupled with clinical pharmacist telephonic outreach for medication titration. We aimed to assess the implementation of RPM-HTN’s intervention components and their association with BP improvement.

METHODS: This is a retrospective cohort implementation study of primary care patients enrolled in RPM-HTN from January 1, 2022 – June 30, 2023. We identified patients enrolled for ≥3 months with uncontrolled HTN. We evaluated the implementation of the RPM-HTN program using implementation outcome measures: (1) the proportion of enrolled patients with uncontrolled HTN that received clinical pharmacist outreach and (2) the proportion that received antihypertensive medication titration (by the clinical pharmacist or any other clinician). We analyzed how these outcomes correlated with the effectiveness outcome of BP control defined as a reduction in average (SBP) by >5 mmHg within 3 and 6 months. Medication and clinical encounter data were extracted from electronic medical records and BP data from the RPM portal. Relative risk (RR) and chi-square analysis were used to assess associations between receiving clinical pharmacist outreach and medication titration at 3 and 6 months, and each of these variables with reduction of SBP at 3 and 6 months.

RESULTS: Among 830 RPM-HTN patients, 385 (46%) had uncontrolled HTN in the first month. Within 3 months, 51% of patients completed clinical pharmacist telephone visits, 51% had medication changes, and 53% achieved SBP reduction. Within 6 months, this increased to 62%, 72%, and 80% respectively. Medication titration was positively associated with SBP reduction at 3 months (RR 1.60, p <0.001) and 6 months (RR 1.43, p<0.001). Clinical pharmacist outreach was positively associated with SBP reduction at 3 months (RR 1.24, p = 0.04) but not at 6 months (RR 1.03, p = 0.79). Pharmacist outreach was positively associated with medication titration at 3 months (RR 1.59, p<0.001) and 6 months (RR 1.52, p<0.001).

CONCLUSIONS: We found that not all participants in the RPM-HTN program received the intended intervention components, which highlights opportunities for RPM-HTN delivery improvement. Although pharmacist outreach did not significantly impact BP control, it was associated with instigating medication changes. Because medication change is important to achieving BP control, we need to focus on strategies for PCPs and specialists who manage HTN to overcome clinical inertia for medication titration and improve medication adherence amongst patients.

A STRATEGIC MODEL FOR POST-PANDEMIC TELEHEALTH IN THE VETERANS HEALTH ADMINISTRATION

Colin T. Purmal^1,2; Tanvir Hussain^3,2. ¹Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, San Francisco VA Health Care System, San Francisco, CA; ³Medicine, University of California System, Oakland, CA. (Control ID #4062880)

BACKGROUND: Telehealth surged early in the COVID-19 pandemic but then decreased with resumption of in-person care, stabilizing in 2021 to higher than pre-pandemic values. In contrast, the Veterans Health Administration (VHA) Sierra Pacific Region, or VISN 21, has witnessed a continued increase in telehealth encounters from 2020 through 2023.

METHODS: The VISN 21 regional telehealth program serves Veterans from seven healthcare facilities across California, Nevada, and the Pacific Islands. Encounter and patient demographic data for the program were obtained from the VHA Corporate Data Warehouse for fiscal years (FYs) 2021 through 2023 (October 1, 2020, to September 30, 2023).

RESULTS: Within this regional telehealth program, encounters increased by 76.8% between FY2021 and FY2022, and 80.8% between FY2022 and FY2023. The increase was driven by both development of new services and greater adoption of the services already present. Of 202,364 encounters FY2021 to FY2023, 41.0% were delivered to Veterans in non-urban communities.

CONCLUSIONS: This regional telehealth program experienced increased utilization by Veterans since the pandemic likely due to strategic development of programs that complement, rather than compete, with in-person care. The following four strategies have guided program development:

1. Gap coverage: telehealth clinicians available to cover local system vacancies.

2. Immediate Demand Services: direct on-demand primary, urgent, and emergency care available to Veterans.

3. Population Services: clinical programs infrequently used at a single facility but appreciable at a regional scale.

4. Asynchronous Telehealth: clinical studies stored remotely and then interpreted by telehealth providers.

Telehealth also still serves as a critical post-pandemic access strategy for non-urban communities which experience geographic barriers to accessing healthcare in the Sierra Pacific Region.

A SYSTEMATIC REVIEW OF COORDINATED CARE IN CARDIOVASCULAR-KIDNEY-METABOLIC (CKM) CONDITIONS

O. Kenrik Duru¹; Muthiah Vaduganathan²; Katherine R. Tuttle³; Wendy St. Peter⁴; Glenda Roberts³; Janani Rangaswami⁵; Susanne Nicholas⁶; Joshua J. Neumiller⁷; Roy O. Mathew⁸; Patrick O. Gee⁹; Radica Alicic³. ¹GIM/HSR, UCLA, Los Angeles, CA; ²Brigham and Women's Hospital, Boston, MA; ³Kidney Research Institute, Seattle, WA; ⁴Regents of the University of Minnesota, Minneapolis, MN; ⁵The George Washington University, Washington, DC; ⁶University of California Los Angeles, Los Angeles, CA; ⁷Washington State University, Pullman, WA; ⁸Loma Linda VA Health Care System, Loma Linda, CA; ⁹P Gee Consulting, Greater Richmond Region, VA. (Control ID #4060609)

BACKGROUND: Type 2 diabetes (T2D), chronic kidney disease (CKD) and cardiovascular disease (CVD) share common risk factors and frequently coexist and drive high rates of death, adverse heart and kidney outcomes, and poor quality of life. Coexistance of T2D, CKD and CVD is described as a CKM syndrome. Breakthrough therapies including sodium glucose co-transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists significantly reduce mortality, and improve kidney and cardiovascular outcomes. Thus, there is a need for improved treatment delivery. This systematic review assessed coordinated care programs for CKMs, including program types, components, outcomes, and challenges in implementation.

METHODS: We searched Embase and Medline for studies from Jan 2015–Mar 2023, and congress abstracts from Jan 2021–Mar 2023. Studies must have patients with ≥2 CKMs for inclusion; the coordinated-care program must address all 3 CKM, either through treatment, monitoring or risk reduction.

RESULTS: A total of 22 international studies met our inclusion criteria; interventions included patient visits to multidisciplinary team (MDT) care clinics (n=9), pharmacist integration (n=5), patient engagement and education (n=6), or MDT/multispecialty team meetings (n=2). Three studies included patients with all 3 CKMs, 3 included patients with any of the 3 CKMs, and 16 focused on 1 CKM but also monitored the other 2 CKM. Overall, results showed: 1) greater patient satisfaction with coordinated-care programs vs usual care, 2) decreased number of health-related problems, 3) increased attendance rates for virtual consultations, and 4) decreased healthcare costs with further reductions for telehealth.

CONCLUSIONS: There are a diverse set of coordinated care approaches delivering CKM care. These models suggest improvements in patient satisfaction and cost savings, yet there is a paucity of large-scale studies evaluating clinical outcomes related to these approaches.

AUTOMATED TEXT MESSAGE-BASED PROGRAM TO MANAGE UNCONTROLLED BLOOD PRESSURE IN PRIMARY CARE PATIENTS: A RANDOMIZED CLINICAL TRIAL

Klea Profka¹; Kayla R. Clark¹; Laura Norton¹; Katy Mahraj³; Leslie Reid-Bey¹; Zakiya Walker¹; Anthony Girard¹; Lin Xu¹; Charles Rareshide¹; Jingsan Zhu¹; Michael Josephs³; Aileen John⁴; Kevin G. Volpp¹; Eric Bressman²; Anna U. Morgan². ¹Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; ²Internal Medicine, University of Pennsylvania Department of Medicine, Philadelphia, PA; ³Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia, PA; ⁴Penn Medicine, Philadelphia, PA. (Control ID #4039537)

BACKGROUND: Although evidence-based treatments for hypertension are widely available, uptake can be limited by reliance on conventional office visits. We developed and tested an automated, bidirectional text-messaging program with a human backend to support longitudinal, remote blood pressure (BP) management in primary care patients with uncontrolled hypertension. We hypothesized that an automated program could improve BP by offering a higher intensity, more incremental approach and a lower friction medium to engage with the clinical team.

METHODS: Patients at two primary care clinics were randomized 1:1. Eligibility criteria were: uncontrolled hypertension (two BPs > 140/90 mmHg in the last 12 months, including most recent) and use of ≥1 anti-hypertensive. The control arm received usual care at their PCP’s discretion. Patients assigned to the intervention received an SMS invitation into the study; those who did not respond received a call from a study coordinator. Patients who agreed to participate were mailed a cuff and received weekly SMS requesting a BP reading. An RN and APP reviewed BP trends, and contacted patients and adjusted medications as needed. At the end of the trial, all patients were offered a $95 incentive to complete an in-office BP check at their primary care clinic. The primary outcome was change in SBP at 6 months. Secondary outcomes were the change in SBP at 3 months post randomization; change in DBP at 3 months and 6 months; and the proportion of patients who achieved BP control (<140/90).

RESULTS: The mean (SD) age (n=300) was 63 (±12.2) years; 133 (44.3%) were male; 154 (51.5%) identified as Black, and 120 (40.1%) as White; 119 (39.7%) were insured by Medicare and 41 (13.7%) by Medicaid. Of 150 patients in the intervention, 97 agreed to participate and 84 sent in at least one BP reading. Of those who completed the visit (n=99), the starting SBP was higher in the intervention (153.74) than control arm (148.80). The change in SBP at 6 months was greater in the intervention (14.66) than control arm (10.87), but this was not statistically significant. There was no difference when including those with non-study visit (EHR) measurements at 6 months. Those in the intervention arm experienced a greater decrease in SBP and DBP at 3 months.

CONCLUSIONS: In this randomized clinical trial of a 6-month automated text message-based hypertension management program, the improvement in BP was not significantly different between arms. The study was limited in part by uptake of the end-of-study measure. Future study may be directed at staff and patient experiences with this centralized, connected health-enabled model of care.

BARRIERS AND FACILITATORS TO IMPLEMENTATION OF A PHARMACIST-LED TELEHEALTH INTERVENTION TO OPTIMIZE PAIN MANAGEMENT FOR PATIENTS PRESCRIBED LONG-TERM OPIOID THERAPY

Danielle Wesolowicz^1,2; Jennifer Snow¹; Sara Edmond³; Anne C. Black^4,1; Joseph W. Frank⁵; William Becker^6,1. ¹Research, VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; ²Psychiatry, Yale School of Medicine, New Haven, CT; ³PRIME, VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; ⁴Internal Medicine, Yale School of Medicine, New Haven, CT; ⁵Medicine, University of Colorado School of Medicine, Aurora, CO; ⁶Internal Medicine, VA Connecticut Healthcare System, West Haven, CT. (Control ID #4064442)

BACKGROUND: The provision of guideline-concordant care for patients with chronic pain on long-term opioid therapy can be particularly challenging for primary care providers (PCPs) due to limited time, resources, and training. Telemedicine Collaborative Management (TCM) is a pharmacist-led telehealth intervention embedded in primary care whereby a pharmacist in consultation with a physician leads the assessment of the benefits and risk of continued long-term opioid therapy and supports optimization of medication management (e.g., opioid taper or switch to buprenorphine when indicated, trialing of non-opioid analgesics) with return of pain medication management to PCPs once stable. In a recent VHA clinical trial, the TCM model was effective in reducing pain interference, initiating buprenorphine regimens, and reducing opioid dose. The goal of this formative evaluation was to better understand potential barriers and facilitators of the TCM model to support and evaluate a real-world implementation study of TCM.

METHODS: Semi-structured qualitative interviews informed by the RE-AIM framework were conducted in focus groups with key informants (including pharmacists, collaborating physicians, primary care providers, and clinical administrators) at ten participating VHA medical centers. In these interviews, we sought to elicit informants’ perceptions of TCM implementation and how it might be tailored to each site’s contexts with regard to informant knowledge, attitudes, organizational structure, motivation and fit of the TCM model. Rapid qualitative analysis was used to summarize findings.

RESULTS: Identified barriers to TCM implementation included low comfort in re-assuming opioid prescribing among PCPs, inflexibility in pain management clinic structures, lack of administrative support, and anticipatory concerns among providers that patients would be resistant to changing medication regimens. Facilitators included adapting intervention protocols to existing facility procedures and integration of an expert pharmacist on pain care teams to improve provider comfort in managing opioid regimens. Suggested strategies to optimize TCM implementation included provision of ongoing training, identifying points of contact for TCM implementation, and facilitation of ongoing clinical contact between pharmacists and primary care teams.

CONCLUSIONS: These findings will inform implementation facilitation strategies tailored to each participating medical center as part of a larger clinical trial that will examine the effectiveness of implementation facilitation of TCM and the impact of TCM, alone or combined with a cognitive-behavioral therapy-based pain self-management intervention, on chronic pain opioid-related harms.

BURNOUT AMONG PRIMARY CARE PROVIDERS AND STAFF IN VA CLINICS UTILIZING VIRTUAL CONTINGENCY STAFFING

Eric A. Apaydin^1,2; Caroline Yoo^1,3; Nicholas Jackson⁴; Susan E. Stockdale^1,5; Danielle Rose¹. ¹Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²RAND Corporation, Santa Monica, CA; ³Department of Health Policy and Management, University of California Los Angeles Jonathan and Karin Fielding School of Public Health, Los Angeles, CA; ⁴Division of General Internal Medicine-Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4024468)

BACKGROUND: Primary care team members in clinics experiencing staffing shortages report higher rates of burnout, likely due to higher workloads. Introducing contingency primary care providers (PCPs) into clinics experiencing PCP shortages may reduce the burnout associated with higher workloads, but may also necessitate reconfiguring workflows, thereby exacerbating burnout. In this analysis, we model rates of burnout among VA primary care providers and staff who worked in clinics that vary by staffing levels and utilization of temporary virtual providers.

METHODS: Using annual, repeated cross-sectional VA employee survey data from 2018-2022, we examined the relationships between staffing gaps and burnout among 122,755 providers and staff in 139 healthcare systems, before and after implementation of a national contingency staffing program using virtual PCPs. We performed a multi-level, piece-wise logistic regression to estimate the effect of healthcare system-level PCP staffing gaps on individual-level burnout before and after implementation of the contingency PCP program. An interaction term tested the impact of program use in healthcare systems with PCP staffing gaps, controlling for other provider and healthcare system characteristics. Predicted marginal means of burnout were calculated from model results.

RESULTS: From 2018-2022, 34-44% of PCPs and staff were burned out, and contingency PCP visits ranged from 0 to 776 per 1000 patients at the healthcare system-level post program implementation. In predictions derived from our full model (Figure 1), the probability of burnout was higher in clinics with staffing gaps before program implementation (36%, 95% CI 35-37% v. 34%, 33-35%), and in the lowest tercile of contingency provider visits (40%, 38-42% v. 37%, 36-38%). However, the staffing gap effect was mitigated at higher levels of contingency provider visits.

CONCLUSIONS: We found that the impact of staffing gaps on burnout was mitigated at higher levels of contingency provider program use, suggesting that contingency providers may alleviate high workload in short-staffed clinics. Further refinement to the program may be needed to ensure higher uptake and to reduce burnout at all VA primary care clinics experiencing PCP shortages.

CARING FOR THE UNINSURED: A HEALTH CARE ACCESS PROGRAM IN AN URBAN SAFETY NET SYSTEM IN THE MID-ATLANTIC

Kerry Meltzer^1,2; Kevin Chen^4,3; Christine Zhang⁴; Susan Zhou⁴; Theodore G. Long^4,5; Jonathan Jimenez^4,6. ¹National Clinician Scholars Program at University of Pennsylvania, Philadelphia, PA; ²Primary Care, Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA; ³Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, NY; ⁴Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY; ⁵Population Health, New York University Grossman School of Medicine, New York, NY; ⁶Family Medicine & Community Health, Duke University School of Medicine, Durham, NC. (Control ID #4058802)

BACKGROUND: It is well known that individuals without health insurance have worse access to care and poorer health outcomes. In the US, undocumented adults have uninsured rates as high as 50% and while some may qualify for employer-sponsored insurance, they are not allowed to purchase insurance through the Affordable Care Act Marketplace and do not have access to federally-funded public health insurance plans. Because of this, there is little known about how undocumented individuals engage with health care. In 2019, a new health care access program (“HP”) was established and offered to those who do not qualify for insurance—most of whom are undocumented. To date, there has been no comprehensive evaluation of the patients enrolled or how they are using the health care system.

METHODS: We conducted a cross-sectional analysis of adults age >18 years enrolled in HP or Medicaid as of January 1, 2022 at an urban safety net system in the Mid-Atlantic. Patients were included if they had at least one visit in the previous year. We collected data on sociodemographic characteristics as well as health care utilization and basic chronic disease quality measures for those with diabetes mellitus (DM) or hypertension for patients seen in 2022. Outcomes were compared using chi squared tests for categorical variables and Kruskall-Wallis tests for comparing medians or two-tailed analysis of variance for comparing means.

RESULTS: Our study consisted of 83,003 HP patients and 512,012 Medicaid patients. Compared with Medicaid patients, HP patients were older (47.7 vs 38.3 years), more likely to be Hispanic (66.8% vs 32.9%) with Spanish as their preferred language (61.9%), whereas the majority of Medicaid patients had English as their preferred language (74.2%). Based on the Elixhauser comorbidity count, HP patients had more comorbidities with 51.2% having at least one to three compared with Medicaid patients where 60.3% had none. While HP patients had higher rates of DM (23.5% vs 9.2%), hypertension (32.3% vs 15.4%), and obesity (21.0% vs 9.2%), Medicaid patients were more likely to have a diagnosis of pulmonary disease (8.9% vs 5.5%), psychosis (4.1% vs 0.8%), or a substance use disorder (9.3% vs 4.2%). HP patients were found to have more primary care visits (2.4 vs 0.7) and specialty visits (3.9 vs 1.2) but had similar rates of Emergency Department (ED) visits (0.5) and hospitalizations (0.1). For those with DM, the average A1c was similar across both groups (7.6%). For those with hypertension, the mean blood pressure for HP patients was 132.0/76.2 vs 132.8/77.9 for Medicaid patients.

CONCLUSIONS: HP patients had higher rates of outpatient utilization—including both primary care and specialty visits—compared with Medicaid patients, but had similar rates of ED visits and hospitalizations. The HP program was effective in enrolling a large number of patients who did not qualify for health insurance and offers an alternative solution to providing care to uninsured individuals through a health care access program.

CHANGES IN MEDICARE REIMBURSEMENT FOR CANCER SCREENING FROM 2013 TO 2021

Simar S. Bajaj^1,2; Jaejeong Kim²; Anthony Zhong³; Chi-Fu J. Yang². ¹Harvard University, Cambridge, MA; ²Surgery, Massachusetts General Hospital, Boston, MA; ³Department of Medicine, Harvard Medical School, Boston, MA. (Control ID #4063298)

BACKGROUND: Early detection is critical to improving cancer outcomes. However, less than 5% of eligible patients get screened for lung cancer, and uptake rates have stalled for breast, colorectal, and cervical cancer screening in recent years. Inadequate payment may be partially responsible. In this study, we examined trends in Medicare reimbursement for cancer screening.

METHODS: Cancer screening codes were identified from the Medicare Coverage Database, while reimbursement rates and volumes were queried from the Medicare Physician & Other Practitioners by Geography and Service dataset from 2013-2021. Codes were excluded if they were not reimbursed in 2021. The compound annual growth rate (CAGR) and total percentage change were calculated with data adjusted to January 2021 dollars using the US Bureau of Labor Statistics’ inflation calculator. Average reimbursement changes were weighted by screening volumes, and the Kruskal Wallis test was used to compare reimbursement rates between cancer sites.

RESULTS: Across nearly all screening services, reimbursement rates declined (Figure), with the average CAGR decreasing by 2.09%, 2.10%, and 2.22% for breast, colorectal, and cervical cancer screening but by 9.20% for lung cancer screening (p<0.0001). Between 2013 and 2021, average reimbursement decreased by 13.42%, or $12.70, for breast cancer screening; 14.73%, or $21.23, for colorectal cancer screening; and 15.73%, or $6.36, for cervical cancer screening. However, for lung cancer screening, average reimbursement decreased by a significantly greater amount: 42.49%, or $61.61, between 2015, when Medicare coverage began for this service, and 2021 (p<0.0001).

CONCLUSIONS: Cancer screening reimbursement rates have substantially declined over the past 8 years, with lung cancer the most devalued. Given the White House Cancer Moonshot’s goal to halve cancer mortality in the next 25 years, screening should be further incentivized to promote early treatment and improve patient outcomes.

COMMUNITY CARE VISITS FOR PRIMARY CARE IN THE VETERANS HEALTH ADMINISTRATION (VHA) IN THE PRESENCE OF A SHORT-TERM PROVIDER STAFFING PROGRAM

Matthew R. Augustine¹; Kailey Mulligan²; Peter J. Kaboli³; Bjarni Haraldsson⁴; Ariana Shahnazi⁵; Amy M. O'Shea⁶. ¹Health Services Research & Development, VA Puget Sound Health Care System, New York, NY; ²University of Iowa Health Care, Iowa City, IA; ³Internal Medicine, Iowa City VAMC, Iowa City, IA; ⁴Research, Veterans Health Administration, Washington, DC; ⁵CADRE, Iowa City VA Medical Center, Iowa City, IA; ⁶Research, Iowa City VA Healthcare System, Iowa City, IA. (Control ID #4063722)

BACKGROUND: The 2018 Mission Act allowed veterans to receive VHA-reimbursed care from a non-VHA community provider (community care, CC) when their drive time to or visit wait time exceeded a set threshold at their closest VHA clinic. In October 2020, the VHA launched the Clinical Resource Hub (CRH). CRH is a telehealth program to improve patient access during provider staffing gaps. The goal of this work is to examine whether the CRH substituted primary care otherwise provided in the community.

METHODS: This observational cohort study used VHA administrative data to identify primary visits across VHA facilities delivered via CRH or CC from October 2020 thru March 2023. We identified clinics with at least 10 CRH visits in 2 consecutive months and stratified CRH use into low, medium, and higher tertiles based on average monthly CRH visit rate. Clinics that used CRH but did not meet the CRH user definition were excluded. The primary analysis examined the average monthly CC visit rates among CRH clinics in the high versus low tertiles. The number of CC visits, unique veterans served by CC, and visit rates among CC users are provided among high and low CRH user clinics. CC visit rates by clinic type, size, and rurality are compared by chi-square test.

RESULTS: During the 30-month study period, 15 million primary care visits occurred at 709 clinics, of which 450,590 (3.0%) were delivered by CRH, and 65,162 (0.4%) by CC. CRH user clinics had, on average, a higher monthly CC visit rate than never-users (5.7 vs. 3.4 per 1,000 visits; p=0.074). Further results are in Table.

CONCLUSIONS: Monthly CC visit rates were higher, on average, among CRH user clinics than never users. Compared to low CRH user clinics, rural and smaller high CRH user clinics were more likely to refer care to the community. However, no evidence of a substitution effect was detected. Further study is needed to determine if the CRH program has not yet met the threshold to reduce CC or that CC may be complementary to other care modalities. Barriers to obtaining care for rural and smaller primary care clinics within the VHA system, including by the CRH program, should also be further evaluated.

CONNECTIONS BETWEEN PERSONAL VALUES AND HEALTHCARE AMONG HIGH-RISK PATIENTS WITH MULTIMORBIDITY

Linnaea C. Schuttner^1,2; Jonathan A. Staloff^1,2; Mariah A. Theis¹; James D. Ralston^3,4; Ann-Marie Rosland^6,5; Karin Nelson^1,2; Laura Coyle⁷; Scott Hagan^1,2; Tamara Schult⁸; Traci Solt^7,9; Katherine C. Ritchey¹⁰; George G. Sayre^1,4. ¹Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA; ²Dept of Medicine, University of Washington, Seattle, WA; ³Kaiser Permanente Washington Health Research Institute, Seattle, WA; ⁴Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA; ⁵Internal Medicine, University of Pittsburgh, Pittsburgh, PA; ⁶VA Pittsburgh Healthcare System, Pittsburgh, PA; ⁷Office of Primary Care, US Department of Veterans Affairs, Washington, DC; ⁸Office of Patient Centered Care and Cultural Transformation, Veterans Health Administration, Washington, DC; ⁹Office of Assistant Under Secretary for Health for Integrated Veterans Care, US Department of Veterans Affairs, Washington, DC; ¹⁰Geriatrics/GRECC, VA Puget Sound Geriatric Research Education and Clinical Center, Seattle, WA. (Control ID #4059502)

BACKGROUND: Delivering patient-centered healthcare requires a foundational understanding of what is most important in life to patients, i.e., personal values. Incorporating patient personal values into healthcare planning, particularly for patients with multimorbidity, is being operationalized at many levels in healthcare including within the Veterans Health Administration (VHA). However, it is not clear what are the contexts and circumstances where patients perceive connections between their personal values and health, healthcare, and healthcare decisions. It is also not clear how these topics may be mediated by psychosocial complexity, which may affect a patient’s ability to link these topics. To address this, we examined how high-risk patients with multimorbidity in the VHA make these connections using qualitative interviews.

METHODS: We performed qualitative individual semi-structured telephone interviews with high-risk adults engaged in VHA primary care. Participants were ≥ 75th-percentile risk of hospitalization or mortality using the validated Care Assessment Need (CAN) risk prediction score, with ≥ 2 diagnoses among depression, hypertension, chronic kidney disease, or diabetes. Interviews were analyzed using inductive and deductive content analysis. We performed a subgroup analysis of patients meeting an a priori definition of high-complexity, based on responses to interview screening questions (recent hospitalization, feeling overwhelmed by care, or fair or poor perceived health status).

RESULTS: Participating patients (n=23) were on average 68 years old, 17 (74%) were male, eight (35%) were high complexity. Three main themes emerged: 1) personal values were rarely discussed in healthcare settings or reflected in healthcare decision-making, many times due to patients perceiving clinicians not having time for these topics or due to perceived lower relevance by patients; 2) when personal values were perceived as affecting health decisions, it was within specific contexts or circumstances, such as deciding on surgery, while in other circumstances personal values were never considered, such as starting a routine daily medication; 3) eliciting personal values in healthcare settings could have positive or negative consequences, as some patients felt disclosure resulted in more personalized care, but others felt uncomfortable with disclosure and would disengage if pressed. No major differences were found when comparing findings among individuals by complexity level.

CONCLUSIONS: High-risk patients with multimorbidity have differing perspectives on the relevance of personal values to healthcare and healthcare decisions. Incorporating patient preferences for disclosure, and selection of appropriate healthcare contexts, may be important considerations when integrating patient personal values in healthcare planning or decision-making.

EFFECTIVENESS OF HOSPITAL-TO-HOME IN REDUCING PATIENT READMISSION RATE

Sandra J. Ng Kar Kwan²; Chong Yau Ong¹. ¹Sengkang General Hospital, Singapore, Singapore; ²Lee Kong Chian School of Medicine, Singapore, Singapore. (Control ID #4023686)

BACKGROUND: As the healthcare landscape in Singapore grapples with a rapidly ageing population, fewer caregivers, acute public hospital bed shortages and insufficient intermediate and long-term care capacity, the importance of effective transitional care becomes increasingly evident. This study aims to examine the effectiveness of the Hospital-to-Home (H2H) program in improving patient outcomes in a tertiary hospital setting in the North-East of Singapore.

METHODS: We performed a quasi-experimental study using a pre-post design to evaluate the effectiveness of the H2H program in reducing hospital utilization by reducing readmissions, Emergency Department (ED) reattendances, and to shorten the length of stay in hospital. The program involves an interdisciplinary team of doctors, nurses, and allied health professionals who follow-up with patients post-discharge over phone calls or home visits. The number of ED visits and inpatient admissions three months before enrolment, during enrolment and three months after discharge from the program were recorded for each enrolment case. The number of ED visits and inpatient admissions were calculated per enrolment and compared between the three periods. All comparisons were made using the Wilcoxon Signed-Rank test.

RESULTS: We analysed 2004 enrolments from 1679 patients. There was a significant decrease in the number of ED visits and inpatient admissions from pre-enrolment to during enrolment to post-enrolment (all p <0.001). There was no difference in the mean length of stay from the pre-enrolment to post-enrolment period (p=0.23).

CONCLUSIONS: Our study shows that the H2H program is effective in reducing the rates of readmission, both in terms of ED visits as well as inpatient admissions.

EFFECT OF LAYPERSON-DELIVERED EMPATHY-FOCUSED TELEPHONE PROGRAM ON GLYCEMIC MANAGEMENT FOR FQHC PATIENTS WITH UNMANAGED DIABETES: A RANDOMIZED TRIAL.

Maninder Kahlon¹; Nazan Aksan¹; Nicole Clark¹; Maria Cowley-Morillo¹; Rhonda Aubrey¹; Julia M. Guerra Cantu¹; David A. Pereira¹; Melissa R. Valdez². ¹The Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, TX; ²Lone Star Circle of Care, Georgetown, TX. (Control ID #4030332)

BACKGROUND: Mental health is frequently comorbid with and can exacerbate diabetes management. However, the shortage of mental health professionals is a barrier to care. We previously tested a layperson-delivered telephone-based program, “Empathy in Action” (EIA), that improved depressive symptoms. Here we assessed the program’s effects on glycemic management for patients with unmanaged diabetes.

METHODS: 260 patients were recruited from an FQHC in Austin, Texas from 02/22-04/23 to talk about “life with diabetes”. Inclusion criteria: 21-70 years old, and at least one clinic measurement of Hemoglobin A1C (A1C) in the prior year above 8.0 (>=7.5 at baseline). Stratified randomization of patients with PHQ-9>=5 or <5 into intervention (INT) and usual care control (UC) arms ensured a balanced distribution of depression risk.

INT participants received the EIA program and were assigned to callers recruited from the community for part-time work (e.g. retired school teacher, recent mother/musician). Callers called 3X p wk in the first 4 wks and 1X p wk in the following 22 wks with options to alter frequency. Callers used empathetic conversational skills to build a relationship based on the participant's interests in their life with diabetes. INT participants also received a step tracker or smart scale (launch) and two gifts selected by their caller (<$25 each).

Measurements were collected at baseline, 13 and 26 weeks: (1) A1C and blood pressure by study staff masked to arm and (2) diabetes affective measures and mental health by self-report on tablets. Linear mixed effect regressions with random person intercepts and time coded as days elapsed since baseline at each measurement point were carried out. The models included the stratifier and the grouping variable in addition to the effect of interest which was the two-way interaction of time and group.

RESULTS: Participants were 62.6% female, 75.8% Hispanic/Latino, 67.7% had annual income below $40,000. During the program, 6 participants withdrew consent, 80% completed assessments at 26 weeks (86% INT, 74% UC). For INT, from base to 26 weeks, A1C improved relative to UC by -0.56 ((mean (SE)), INT base 9.98 (0.15), 26 weeks 9.31 (0.18), UC base 9.84 (0.14), 26 weeks 9.73 (0.23)) (time x group p=0.011). For those with PHQ9 >= 5 at base, for INT relative to UC, (i) A1c improved by -1.29 (INT base 10.08 (0.26), 26 weeks 8.86 (0.28), UC base 10.13 (0.24), 26 weeks 10.21 (0.46), p = 0.007) and (ii) a composite metric of diabetes affective measures (self-efficacy, perception of self-management, distress and medication adherence) also improved (p <.05). The reduction in A1C was significantly correlated with total number of connected calls, r(195) = -.17, p <.05. There was no improvement relative to controls in systolic or diastolic BP.

CONCLUSIONS: Patients with diabetes and low-income showed clinically-relevant improvements in glycemic control relative to usual care through a program of layperson-delivered empathetic engagement over the telephone.

ELECTRONIC HEALTH RECORD TIME AND TEAM EFFICIENCY AMONG PRIMARY CARE PHYSICIANS: A NATIONWIDE, LONGITUDINAL STUDY

Lisa Rotenstein^1,2; Nathaniel Hendrix³; Robert Phillips³; Julia Adler-Milstein². ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²University of California San Francisco, San Francisco, CA; ³American Board of Family Medicine Inc, Lexington, KY. (Control ID #4064127)

BACKGROUND: There are known associations between time on the EHR and primary care physician (PCP) burnout. The COVID-19 pandemic has created new pressures for PCPs, including an increased volume of EHR-based work and pandemic-related staffing pressures. Given this context, we to characterize the role of EHR-related experiences and interventions in modulating burnout.

METHODS: The study population for this analysis was composed of PCPs who provided direct patient care and sought recertification through the American Board of Family Medicine from 2017 to 2022. Physicians seeking recertification must complete the Continuous Certification Questionnaire (CCQ); thus, this questionnaire has a 100% response rate.

After descriptively analyzing the sample and quantifying the prevalence of burnout, team efficiency, and perceived home EHR time, we built three models: first, a multivariable logistic regression model to assess the associations of team efficiency and home EHR time with burnout; second, a model of burnout over time including interaction terms of team efficiency and home EHR time with the year; third, multivariable logistic regression models to assess factors associated with high team efficiency and low home EHR time.

RESULTS: The sample consisted of 43,875 physicians who answered the CCQ from 2017 to 2022. More than half (55.4%) were employees, and 69.5% practiced in a setting with 2-19 providers.

Burnout increased over time, with 37.9% of physicians meeting the criteria for burnout in 2017 vs. 42.8% in 2022. The prevalence of perceived team efficiency ranged from 60.2% in 2022 to 68.4% in 2019. The prevalence of high home EHR time ranged from 62.9% in 2021 to 65.5% in 2019.

Across the study period, high home EHR use was associated with 2.5 (95% CI: 2.2, 2.7) times the odds of burnout, while high team efficiency was associated with 0.44 (95% CI: 0.39, 0.49) times the odds of burnout. High home EHR use was associated with increasing odds of burnout over time (β for interaction=0.08, p=0.01) With each subsequent year, high team efficiency was associated with a nonsignificant trend of decreased odds of burnout (β for interaction=0.06, p=0.06).

In multivariable models, full or partial practice ownership, collaboration with a nurse or care coordinator, and participation in value-based care initiatives were associated with greater odds of high team efficiency. Collaboration with a physician assistant was associated with significantly greater odds of low home EHR time. Finally, collaboration with a nurse was associated with significantly greater odds of reporting both high team efficiency and low home EHR time.

CONCLUSIONS: In this nationwide, longitudinal study, we demonstrate that among PCPs, high team efficiency is associated with lower odds of burnout, while high home EHR time is associated with higher odds of burnout. Our findings highlight potentially modifiable practice factors to enhance team efficiency, home EHR time, and ultimately, the PCP experience.

ENGAGING PATIENT AND CLINICAL STAKEHOLDERS THROUGH HUMAN-CENTERED DESIGN SESSIONS TO REFINE PHOTO+CARE, A PATIENT-CLINICIAN PHOTO-BASED COMMUNICATION INTERVENTION FOR OLDER ADULTS WITH MULTIPLE CHRONIC CONDITIONS

Tiffany Chinn, Isabella Hoang, Hannah Pan, Eric Chu, Jane Jih. Division of General Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4062699)

BACKGROUND: Human-centered design (HCD) is a process that integrates stakeholders’ perspectives and feedback into every step of intervention development. We are refining Photo+Care (P+C), a patient-centered patient-clinician photo-based intervention, where patients with multiple chronic conditions (MCC) share photos of contextual factors (domains: medication use, food experience, home environment) important to MCC care to their primary care clinician in a clinic visit to enhance patient-clinician communication to inform patient-centered care plans. We used HCD sessions to incorporate input from patients, clinicians, clinic team members, and clinic leaders to optimize P+C for primary care.

METHODS: We recruited a convenience sample of patients age 65+ with at least 2 chronic conditions, primary care clinicians (physicians and nurse practitioners (NPs)), clinic team members (registered/licensed vocational nurses, medical assistants, practice coordinators), and clinic leaders (practice/nurse managers) from a multisite primary care practice at an academic medical center in the California-Hawaii region. Two trained researchers facilitated recorded individual and group HCD sessions focused on design, implementation, and integration by presenting scenarios to learn users’ needs, anticipate barriers, and gather feedback on intervention components and processes. Two coders used thematic analysis to code transcripts within 1 week of the session with the intervention protocol iteratively refined before subsequent sessions.

RESULTS: We have completed individual and group HCD sessions with 6 patients, 5 physicians, 2 NPs, 5 clinic team members, and 3 clinic leaders. Patients were all age 70+ with an average of 5 chronic conditions and 10 daily medications. All participants voiced that the intervention could support delivery of patient-centered care despite potential impacts to existing workflows for clinician and clinic team members. Identified areas of refinement to optimize integration into primary care delivery included uploading photos shared during a clinic visit in the electronic health record (EHR) with patient tech training and support to upload photos via the EHR patient portal, clear parameters on the number and domains of photos shared during a clinic visit, and and standardized workflows, training and documentation tools for clinicians and clinic team members (Table 1).

CONCLUSIONS: Involving patient feedback and multidisciplinary perspectives through HCD approaches in the design and refinement of a primary care-based patient-centered intervention is important to account for and address real-world challenges for integration and adoption.

EVALUATION OF EQUITY AND INCLUSIVITY OF PATIENT ENGAGEMENT IN A REMOTE PATIENT MONITORING FOR HYPERTENSION PROGRAM

Ashley A. Berlot¹; Rakin Islam¹; Allison Stark²; Aloke Maity¹; Sharon Rikin³. ¹Medicine, Albert Einstein College of Medicine, Bronx, NY; ²Care Management Organization, Montefiore Health System, Bronx, NY; ³Internal Medicine, Montefiore Medical Center, Brooklyn, NY. (Control ID #4062544)

BACKGROUND: Remote patient monitoring (RPM) is effective for blood pressure (BP) improvement. Whether it is an equitable and inclusive method to improve BP in a real world setting with diverse and complex patients is unknown. The objectives of this study were to evaluate which patient characteristics impact RPM engagement and determine if RPM engagement was associated with BP control at three months.

METHODS: We performed a secondary analysis of clinical and demographic data collected from the electronic medical record for adult patients enrolled in an RPM for hypertension program from 1/1/2022 to 8/31/2023 at primary care clinics within an academic medical center in the Mid-Atlantic Region. Participants received a cellular enabled BP device and were instructed to measure their BP twice daily. A team consisting of nurses, community health workers, and clinical pharmacists performed telephone visits, using interpreter services as needed, at least monthly to review BP data with patients and make medication changes as needed until BP control was maintained for at least one month. The primary objective was to determine if the RPM program was equitable by examining whether or not patient characteristics were associated with level of engagement using bivariate logistic regression. Level of engagement was defined as high if participants recorded their BP for more than half the days enrolled in a calendar month. The secondary objective was to determine whether level of engagement was important for BP control (defined as <140/90 mmHg at three months) using logistic regression adjusted for patient characteristics. Significance was set as two-tailed p<0.05.

RESULTS: Participants (N=983) were, on average, 63 + 14-years-old, mostly female (68.1%), most preferred English (76.4%) as their language, and identified as Hispanic (42.5%) or non-Hispanic Black (40.9%). The average baseline systolic BP was 140 + 15 mmHg. Patient characteristics associated with high (N=623) versus low engagement (N=360) were older age (OR=1.02 [95% CI 1.01, 1.03]), lower average baseline systolic BP (OR=0.98 [95% CI 0.98, 0.99]), and non-Hispanic Black (OR=1.37 [95% CI 1.03, 1.82]) compared to Hispanic participants. The relationship with race/ethnicity was attenuated when stratified on preferred language (English vs. other). Patients with high engagement were 91% more likely to achieve BP control at three months than those with low engagement when adjusted for age, gender, race/ethnicity, preferred language, hypertension associated comorbidity, and baseline average systolic BP (OR=1.91 [95% CI 1.31, 2.78]).

CONCLUSIONS: Engagement in RPM was generalizable to a diverse population. We found a strong association of high engagement with BP improvement. Programs should focus on designing care teams and processes to meet the needs of patients for factors where differential engagement was found, such as preferred language other than English, younger age, and higher starting BP.

EXPLORING PRIMARY CARE PROVIDERS’ PERSPECTIVES ON PATIENT EDUCATION AND SHARED DECISION-MAKING IN MANAGING HYPERTENSION AND MEDICATION NONADHERENCE

Lawrence Kwong¹; Laura Gingras¹; Elizabeth Baquero¹; Meena Seetharaman¹; Celine Sabbagh¹; Sanjai Sinha¹; Keith Roach¹; Alfred Leong³; Monika M. Safford². ¹Medicine, Weill Cornell Medicine, New York, NY; ²Department of Medicine, Weill Cornell Medical College, New York, NY; ³NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY. (Control ID #4064721)

BACKGROUND: Control of cardiovascular risk factors such as hypertension is a major challenge in primary care. For example, only about half of U.S. adults with hypertension achieve blood pressure control (BP< 140/90), despite the availability of effective low-cost medications. The reasons for this are complex – including societal, health system, clinician, and patient-level factors. One major contributor is the high prevalence of medication nonadherence, with 25-55% of hypertensive patients taking < 80% of prescribed doses. Nonadherence is a multifaceted problem without straightforward solutions, but it is clear that patient understanding and beliefs about hypertension, concerns about side effects, and engagement in shared decision-making (SDM) play a role. In this study we explored the perspectives of primary care providers (PCPs) on this problem - specifically, their experiences and practices, as well as barriers and facilitators, in engaging in patient education and SDM in hypertension.

METHODS: In-depth focus groups were conducted with 22 PCPs from three clinical sites (one tertiary academic center, one community hospital, and one Federally Qualified Health Center) in a large Northeastern U.S. city. A thematic analysis approach was used to inductively identify themes and categories, using Nvivo software. Multiple coders were used to identify themes and differences were reconciled by discussion.

RESULTS: Participants were diverse (64% non-white, 64% female), with a range of years of primary care experience (36% < 10 yrs, 64% > 10 yrs). All care for patients with hypertension and have experience with nonadherence. Analysis revealed the following: 1) PCPs see patient education as central to their role, but also fear that providing “too much” information about side effects may do harm by inducing nocebo effects and decreasing adherence. 2) PCPs believe in the importance of shared decision-making (SDM) around treatment decisions but struggle to apply SDM in the hypertension context, particularly when the “right” decision seems obvious to them. 3) Time constraints and competing medical issues are a major barrier to comprehensive patient education and engagement in SDM. 4) PCPs welcome assistance from non-physician team members in providing education. 5) PCPs do not currently use, but are open to using, web or mobile-based tools to assist in patient education and SDM, as long as these tools are easy to use and integrated into existing systems.

CONCLUSIONS: PCPs face barriers to providing patient education and shared decision-making in hypertension, including time constraints and PCP perceptions about harms of “too much” information about side effects. Interventions are needed to assist PCPs in providing education and SDM in a way that does not exacerbate the nocebo effect and minimizes time burden. PCPs are open to the use of non-physician staff (e.g. nurses, pharmacists, or peer coaches) and the use of web or mobile tools in these efforts.

FEASIBILITY, ACCEPTABILITY, AND PRELIMINARY EFFECTIVENESS OF A DIGITALLY- ENABLED CHW INTERVENTION FOR PATIENTS WITH HEART FAILURE: A CLINICAL TRIAL

Jocelyn A. Carter¹; Natalia Swack¹; Eric M. Isselbacher²; Karen Donelan³; Anne N. Thorndike¹. ¹Medicine, Massachusetts General Hospital, Boston, MA; ²Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA; ³Brandeis University Heller School for Social Policy and Management, Waltham, MA. (Control ID #4015387)

BACKGROUND: Heart failure (HF) hospital readmissions are a leading cause of US 30-day hospital readmissions. Factors related to clinical complexity and unmet social needs are among the key drivers associated with poor HF clinical outcomes. Digital platforms have shown promise in improving HF outcomes but limitations like patient lack of familiarity with technology and unmet social needs continue to limit implementation and adoption. Hypothesis: An intervention pairing HF patients with a digital platform and a community health worker (CHW) for 30 days post-hospital discharge is (a) feasible, (b) acceptable, and (c) preliminarily effective in improving clinical outcomes.

METHODS: Adult inpatients at risk for readmission were enrolled in a RCT 12/2022 - 6/2023 (N=50). The 30-day intervention used a digital platform within a mobile phone application including a daily symptom questionnaire and HF educational videos connected to a biometric sensor (tracking heart rate, oxygenation, steps taken), a digital weight scale, and a digital BP monitor. All patients were paired with a CHW with dashboard access to the digital platform. CHWs were trained in platform orientation, resolution of technical issues, and monitoring the dashboard with the use of a color-coded schematic associated with a daily score indicating if patients were at or moving away from clinical baselines. Feasibility (use of the platform and CHW), acceptability (willingness to use the intervention again), and preliminary effectiveness outcomes (30-day readmissions, emergency department (ED) visits, and missed PCP/specialty appointments) were analyzed.

RESULTS: Analysis demonstrated intervention feasibility with participant wear of the sensor 11.1 hrs/day, use of the digital blood pressure (1.0 times/day; SD=0.22) and weight scale (1.1 times/day (SD=0.18) . The symptom questionnaire was completed on 78% of study days and ≥2 CHW interactions occurred for 76% of participants. Acceptability was shown with 91% of participants indicating willingness to use the intervention again. A ~15% absolute reduction in 30-day readmissions was noted (14% vs. 29%), with a reduction in missed appointments (0% vs. 3%) in the digitally-enabled CHW vs. CHW enhanced usual care arm. No reduction in ED visits was seen. The most common CHW-patient interactions included healthcare coaching (23%).

CONCLUSIONS: This trial demonstrates the feasibility, acceptability, and preliminary effectiveness of a digitally-enabled CHW intervention for patients with HF in a pilot trial. Though this was a small study inadequately powered to assess clinical outcomes or true effectiveness, the novel intervention demonstrates promise and seeks to enhance clinical care by re-enforcing clinical care plans, addressing unmet needs, providing biometric data to care teams to detect clinical decline earlier, and potentially prevent readmission. A larger randomized controlled trial is needed to establish the effectiveness of this intervention on clinical outcomes like 30-day readmission.

FEASIBILITY AND ACCEPTABILITY OF A PRIMARY CARE TOOL FOR PANEL MANAGEMENT OF COMPLEX HIGH-RISK PATIENT GROUPS

Linnaea C. Schuttner^1,2; Karin Daniels³; Karley Atchison³; Rebecca Piegari⁴; Ann-Marie Rosland⁵. ¹Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA; ²Dept of Medicine, University of Washington, Seattle, WA; ³Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; ⁴Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC; ⁵Internal Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4059562)

BACKGROUND: Patients at high-risk for adverse health outcomes have complex, heterogenous health needs. Primary care teams are challenged to meet these needs effectively and efficiently. Models segmenting high-risk patients using EHR data can identify groups with similar health profiles, but have not been incorporated into primary care tools or interventions. We pilot tested a novel clinical informatics tool (VET-PATHS) among frontline primary care teams.

METHODS: The VET-PATHS tool displays high-risk patients in subgroups based on condition profile via previously validated models, and offers tailored suggestions for actionable risk-reduction strategies (‘care steps’), based on health-record data and clinical guidelines. VET-PATHS includes VHA patients with a predicted ≥10%/year hospitalization risk. Initial VET-PATHS prototypes were iterated via human-centered design with primary care clinician-users. In this current phase, 4 primary care teams at 2 VHA sites tested the tool and accompanying workflows in facilitated weekly huddles. Feasibility, acceptability, care plan changes, and perceived impacts on care quality were assessed via direct huddle observation and rapid analysis of individual qualitative interviews at baseline and exit.

RESULTS: Four primary care teams participated: two general (panel size n=476-862), two focused teams (advanced renal disease, n=103; women with substance use disorders, n=112). Of these, 11% (91/862) to 59% (61/103) of total patients per panel were assigned by the tool to a high-risk subgroup: cardiometabolic (n=119/300, 40%), liver (n=58/300, 19%), mental health (n=46/300, 15%), or substance use disorder (n=77/300, 26%). Team huddles typically incorporated primary care providers, nurses, and administrative staff. Over 4-8 weekly huddles, teams reviewed 44%-96% of subgroup-assigned patients (total N=230). The tool suggested a mean of 3.8 care steps/patient reviewed (SD=3.2). Teams discussed a mean of 2.7 care steps/patient reviewed (SD=0.9) and made a care plan change 1 time for every 3 patients reviewed (mean=0.3, SD=0.2). General teams made changes more often than focused teams (0.5 vs. 0.2 times). Tool acceptability was greater among general teams, with perceived positive potential impact on care quality related to addressing care gaps and efficiency in thinking about patients by subgroup (“It focused our efforts on care that […] maybe we have neglected.” PCP03, general team).

CONCLUSIONS: Effective tools for primary care of complex high-risk patients are critically needed, but require user-informed development. This pilot study of an informatics tool for panel management of high-risk patients demonstrated acceptability and feasibility particularly for general primary care teams, with observed changes in team huddle processes and patient care plans and perceived improvements in efficiency of addressing patient needs. Tool updates will be pilot tested among additional teams in early 2024.

FEASIBILITY AND ACCEPTABILITY OF SHARED MEDICAL VISITS TO IMPROVE LONELINESS IN THE HIGH-NEED POPULATION: A PILOT STUDY

Francis Balucan¹; Michael D. McCann¹; Taina Ovchinokov¹; Christy A. Claiborne¹; Merranda Holmes¹; Scott S. Lee¹; Yaping Shi¹; Benjamin French¹; Eduard E. Vasilevskis². ¹Medicine, Vanderbilt University Medical Center, Nashville, TN; ²Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4063768)

BACKGROUND: High-need patients are characterized by medical complexity, increased acute care utilization and disproportionate costs. In a recent unpublished cross-sectional analysis, we showed that 73% of this population suffered from either moderate or severe loneliness. We hypothesized that repeating longitudinal shared medical visits conducted by a multidisciplinary group to provide education and address loneliness for the high-need population would be feasible and acceptable.

METHODS: In this small two-arm pilot randomized intent-to-treat control trial, we aimed to enroll 30 high-need patients who are part of a comprehensive interdisciplinary care program at a tertiary care academic center. The intervention arm underwent three 120-minute shared medical visits over a 9-month period led by an interprofessional team. The visits included medical encounters, disease-related education, mindfulness exercises and coping skill development. Afterwards, loneliness and acceptability were measured. Feasibility (attendance), acceptability (Net Promoter Score (NPS); scaled from 0-10 and obtained by subtracting the percentage of detractors (0-6) from the percentage of promoters (9-10) and scored from -100 to 100), and loneliness (De Jong Gierveld Loneliness Scale: 0-3 as not lonely; 3-8 as moderately lonely; score greater than 8 as severely lonely) were measured. Intervention effects on outcomes were measured and assessed using the appropriate regression methods and mixed effects procedures for repeated measures.

RESULTS: Patients enrolled in the interdisciplinary comprehensive care program were eligible for enrollment. With the goal to enroll 30 patients, 27 were enrolled by direct communication. 13 were enrolled in usual care while 14 were enrolled into the shared medical visit intervention arm. The intervention group underwent three 120-minute shared medical visits over a 9-month period, occurring every 3 months. With regards to feasibility, 50% (7) attended the first event, 21% (3) attended the second event, and 36% (5) attended the 3rd visit. In measuring acceptability, the median NPS increased from median of 7.0 (6.5-9.0) on first visit to 9.0 (IQR 9.0, 10.0) on third visit. The NPS of each visit was 0, 100, and 100, respectively. This small pilot was not powered to adequately evaluate the effects on loneliness; there was no statistical difference between the two groups.

CONCLUSIONS: Loneliness is associated with poor outcomes in the general population and is prevalent in the high-need population. We conducted shared medical visits as planned, though we note a significant drop out in attendance. Future investigations should address the large drop out in participants, though difficult in this comorbid population. We demonstrated that shared medical visits are acceptable to high-need patients; increased benefit was seen over time. Qualitative comments further provided support of the acceptability. Future, larger studies need to understand the effects of group visits on loneliness.

FRAMEWORKS FOR ASSESSING HEALTHCARE QUALITY AND DISPARITIES: A SCOPING REVIEW

Diana Zhang¹; Feifei Ye²; Steven Martino²; Marc Elliott²; Sangita Taxi²; Sachi Yagyu¹; Aneesa Motala¹; Susanne Hempel¹. ¹University of Southern California Keck School of Medicine, Los Angeles, CA; ²RAND Corporation, Santa Monica, CA. (Control ID #4013795)

BACKGROUND: Selecting a framework for quality of care and healthcare disparities has implications for how care is delivered and healthcare organizations are evaluated. The aim of the present study is to identify and appraise existing frameworks for healthcare delivery settings.

METHODS: The scoping review identified existing quality of care and disparities frameworks in the scientific and grey literature. We searched the databases PubMed, CINAHL, PsycINFO, Social Work, Cochrane Database of Systematic Reviews, Campbell Collaboration, and PROSPERO. We also reviewed the website of health services research organizations, funders of research, federal agencies charged with monitoring or improving quality of care and/or those that address health disparities. In addition, we reference-mined existing reviews and consulted with content experts. Included studies met the following criteria: Publications that 1) address quality of care indicators, criteria, or benchmarks, 2) include a figure or detailed description of a framework, and 3) are applicable to healthcare context. Citation screening was supported by machine learning, and two independent reviewers screened publications. Data abstraction and critical appraisal used an abstractor-checker model.

RESULTS: We identified 76 relevant frameworks proposed by a variety of healthcare organizations and federal agencies. Summary tables and figures document the existing area of interest. A comprehensive evidence table documents all eligible frameworks, including the geographic regions of the existing international literature. Frameworks varied in the complexity of included framework domains, some restricting to healthcare processes, others incorporating health and drivers of health. The most frequently occurring elements were effectiveness, efficiency, safety, and access. The scoping review shows framework components together with definitions domains and the conceptualization of equity to facilitate comparisons across frameworks, as well as applications of the framework, context and any translations into concrete quality of care and disparities measures. Quality of care frameworks varied in their inclusion of components of disparities and the role of health equity. Critical appraisal showed 54% of frameworks documented the involvement of stakeholders, and for 9% stakeholder involvement was unclear and not mentioned. In total, 92% of frameworks were evidence-based and reported data contributing to the development or validation of the framework. All frameworks defined the population the framework aimed to depict, and 57% of frameworks reported validity testing.

CONCLUSIONS: The scoping review provides an overview of the currently available models of quality of healthcare. The work documents the lack of integration of disparities and equity in existing models. The synthesis compares and contrasts existing models and provides recommendations to advance the conceptualization of quality of care in the U.S.

HIGHER LEVEL OF MORBIDITY AMONG OLDER VETERANS WITH DIABETES RECEIVING TELEHEALTH VS IN-PERSON ONLY SERVICES IN THE VETERANS HEALTH ADMINISTRATION

Quratulain Syed^2,1; Gerald McGwin^3,4; Theodore Johnson^2,1; Mary K. Rhee^1,2; Lawrence S. Phillips^1,2; Katharina V. Echt^1,2; Camille Vaughan^2,1. ¹Medicine, Emory University School of Medicine, Atlanta, GA; ²Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, GA; ³The University of Alabama at Birmingham, Birmingham, AL; ⁴VA Clinic Birmingham, Birmingham, AL. (Control ID #4062009)

BACKGROUND: The Veterans Health Administration (VA) led the telehealth revolution in healthcare and expedited expansion of telehealth services during the pandemic. The study aims include analyzing clinical metrics including glycemic control and utilization of care metrics for older Veterans with Diabetes receiving care at the VA. The abstract reports initial data comparing clinical measures in 2021 of Veterans with Diabetes age 70 or older who received care via both telehealth and in-person encounters with those who received in-person care only, in primary care or endocrinology clinics in the VA healthcare system during 2019.

METHODS: Patients eligible for inclusion were age 70 years or older and had clinical encounters with physicians, nurse practitioners, physician assistants and clinical pharmacists at primary care and endocrinology clinics in the VA healthcare systems during 2019 and 2021, as identified in the VA Clinical Data Warehouse. Patients were categorized by encounter types, determined by CPT and stop codes as: 1) hybrid, if patient had in-person and telehealth (either audio or video) encounters 2) in-person (F2F) if patient only had F2F encounters during the year. Clinical characteristics in 2021 were studied for groups stratified by encounter type in 2019 to study long term clinical outcomes related to encounter modality. We omitted data related to 2020 due to the impact of early pandemic on F2F clinical encounters across the VA healthcare system. Logistic regression was utilized to estimate the association between HbA1c levels and encounter types. Mean A1c readings from 2021 were calculated for both groups while adjusting for 2019 HbA1c measurements. Poisson regression was utilized to estimate the rate ratio (RR) for the association between ED and hospital visits in 2021 and encounter type, adjusted for 2019 visits.

RESULTS: A total 410,640 patients had hybrid or F2F only clinical encounters in both 2019 and 2021. A total 24,834 patients (6%) in the cohort were in the 95th percentile group of the Care Assessment Need (CAN) claims-based risk score (which is a predictor of hospitalization and mortality) in 2019; 84% of these received hybrid care and 16% received F2F care that year. Mean Elixhauser Comorbidity Index score was higher in hybrid group (12; SD 10.2), compared to F2F group (7.6; SD 8.1) p-value <0.0001. The hybrid group had higher mean HbA1c (7.22) compared to F2F group (7.17) p-value <0.001. The hybrid group also had higher odds of having a HbA1c test performed compared to the F2F group (OR 1.198 95% CI 1.17-1.22). Patients who used hybrid care in 2019 had approximately 2x higher incidence of having a hospital or emergency room encounter in 2021 than those who received F2F care in 2019.

CONCLUSIONS: Older veterans with diabetes who receive hybrid care have higher level of morbidity compared to those who received F2F only care. Further analyses are needed to compare hybrid encounter intervention with F2F only among the high-risk population.

HIGH TOUCH VS LOW TOUCH STRATEGY FOR IMPLEMENTING A COLORECTAL CANCER SCREENING DIGITAL HEALTH INTERVENTION IN PRIMARY CARE PRACTICES: A HYBRID RANDOMIZED IMPLEMENTATION TRIAL

David P. Miller^1,2; Ajay Dharod^2,1; Anna Snavely⁴; Mark Dignan³; Elena Wright¹; Aliza Randazzo¹; Kristie Foley¹. ¹Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC; ²Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; ³University of Kentucky College of Medicine, Lexington, KY; ⁴Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC. (Control ID #4064092)

BACKGROUND: Primary care clinicians face time constraints in addressing colorectal cancer (CRC) screening. Digital health interventions could help by identifying eligible patients, educating them about options, and enabling screening requests. However, optimal strategies for implementing apps in busy primary care settings are unclear.

METHODS: We conducted a hybrid Type III implementation pragmatic trial of the mPATH tablet app for CRC screening that was previously found to double CRC screening rates in a randomized clinical trial. Based on feedback from clinical staff, we divided mPATH in two parts: 1) mPATH-CheckIn that includes routine screening for depression, fall risk, and intimate partner violence, and 2) mPATH-CRC that displays a brief informed decision-making video about CRC screening and allows patients to request screening via the program. We randomized 18 community-based primary care practices, stratified by size, to either: 1) a “low touch” implementation strategy (n=8) consisting of on-site training and as needed technical support, or 2) a “high touch” strategy (n=10) consisting of the same elements plus at-elbow launch support, a clinic champion, audit and feedback, and regular coaching calls. We instructed front desk staff to give all adult patients the mPATH-CheckIn tablet for use in the waiting room. If screening was needed, nursing staff gave the patient the mPATH-CRC tablet for them to use while waiting in the exam room. Our primary implementation outcome was the proportion of eligible patients who completed mPATH-CRC in the 6th month post-implementation, with proportions compared using logistic mixed models accounting for clustering within practices.

RESULTS: In the first 6 months post-implementation, 50,176 patients aged 18 and older were seen in the 18 randomized practices (33,435 High Touch, 16,741 Low Touch). Most patients were female (59%), white (81%), and had commercial insurance (51%) or Medicare (36%). In the first month following launch, the mPATH-CheckIn app was used in 46.5% of High Touch patient encounters and 40.2% of Low Touch encounters (p=0.46), and use decreased to 18.6% and 14.0% respectively in the 6th month (p=0.09). mPATH-CRC app use started at 5.8% (High Touch) and 5.3% (Low Touch) in the first month (p=0.55), and decreased to 0.9% and 1.0% respectively in the 6th month (p=0.93). In multivariable models examining use over all 6 months, High Touch clinics had non-statistically significant higher use of mPATH-CheckIn (OR 2.8; 95% CI 0.86 – 9.0) and mPATH-CRC (OR 1.7; 95% CI 0.95 – 3.0).

CONCLUSIONS: Compared to a low touch strategy, a high touch strategy yielded similar modest usage rates of a patient-facing digital health app, and usage decreased substantially over time. Potential barriers to program use include clinical staff turnover, post-pandemic change fatigue, and competing time demands. Qualitative interviews with key informants will explore further the barriers and facilitators of implementation.

HOME-DEVELOPED FIT AS A COLON CANCER SCREENING OPTION IN A SAFETY NET HEALTHCARE SYSTEM

Brian R. Hughes¹; Abigail Braun¹; Jing Zhou Wang²; Jason Gilbert¹; Donald Kirkpatrick². ¹Internal Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO; ²Gastroenterology, University of Colorado System, Denver, CO. (Control ID #4045817)

BACKGROUND: Colon cancer has a high prevalence and burden of disease, but only 65% of eligible patients undergo screening. In a safety net system, this number is lower. Currently, there are two Tier 1 screening tests recommended by the US Multi-Society Task Force on Colorectal Cancer: colonoscopy and fecal immunochemical testing (FIT). The COVID pandemic made home-developed testing with results immediately available to consumers common. A home FIT that can be developed for the consumer exists, but is not yet FDA approved in part because of concerns that a positive test might not subsequently lead to a colonoscopy. To address this concern, we surveyed patients in our primary care and gastroenterology specialty clinics regarding their preference for colon cancer screening including an option for a home-developed FIT, as well as their expected action in response to a positive FIT.

METHODS: Colon cancer screening eligible patients in primary care and gastroenterology specialty clinics in a safety net system were surveyed to determine preferences for colon cancer screening. The survey included options for colonoscopy, standard FIT, and a home-developed FIT. The survey also included whether a positive FIT (standard or home-developed) would prompt them to seek a colonoscopy.

RESULTS: In an ongoing IRB approved study, the first 50 patient surveys were included in this analysis. 66% of patients (29/44) preferred any form of FIT to colonoscopy, with 6 patients indicating no preference. 36% of patients (18/50) indicated that a home developed FIT would be their preferred method of screening for colorectal cancer. 100% of patients (50/50) indicated that they would contact their health care provider to undergo a colonoscopy if they had a positive home FIT.

CONCLUSIONS: In preliminary data of an ongoing study, greater than one third of patients surveyed preferred a home-developed FIT to screen for colorectal cancer. All patients surveyed indicated that they would follow up with their healthcare provider to schedule a colonoscopy if their home-developed FIT was positive. Our early results suggest that there is patient interest in a home-developed FIT option for colon cancer screening. Home based FIT testing could further decrease barriers to colon cancer screening, increasing overall participation in colorectal screening within our safety net patient population.

HOSPITAL AT HOME NATIONAL PRACTICE STANDARDS

David Levine¹; Gabrielle Schiller³; Peter Read²; Albert Siu³; Linda DeCherrie⁵; Bruce Leff⁴. ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Carle Health Methodist Hospital, Peoria, IL; ³Icahn School of Medicine at Mount Sinai, New York, NY; ⁴Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ⁵Medically Home Group Inc, Boston, MA. (Control ID #4065110)

BACKGROUND: Hospital at home (HaH) is the delivery of hospital-level services at home traditionally available in a bricks-and-mortar hospital setting. In November 2020 the Centers for Medicare and Medicaid Services (CMS) created the Acute Hospital Care at Home Waiver, creating a national payment and regulatory framework. Over 300 hospitals in 37 states have cared for over 12,000 acutely ill patients at home. Despite the large increase in this care model, no national practice standards and unknown standardization across programs exist. The HaH Users Group (HaHUG) is a national body of HaH programs that developed practice standards and surveyed programs to identify the current state of practice nationwide.

METHODS: In 2019 the HaHUG assembled experts from its membership with experience developing practice standards. The 21-person workgroup first assembled all existing international standards, gray literature, and any existing guidance documents from active programs. Through multiple iterations the workgroup developed the categories, individual standards, and each standards’ associated items. A program met a standard if it had half the associated items functioning. Programs exceeded the standard if they had more than half and did not meet the standard if they had less. In 2021, the HaHUG had an open comment period for all members. In 2022, the workgroup finalized the standards accounting for community feedback. In 2023, HaHUG member programs voluntarily self-assessed their programs using the practice standards. Responses were anonymous. We describe the program standards and the percent that met, exceeded, and did not meet the standards.

RESULTS: HaH practice standards were 8 categories and 31 total standards. Categories included leadership, education and training, human resources management, quality and quality improvement, safe practice and environment, and clinical standards and protocols. Individual standards included protocols for the role of family caregivers or for emergency response operations, for example. Of HaHUG’s 75 programs representing 189 hospitals, 26 programs (35%) and 55 hospitals (29%) completed a self-assessment. On average across all standards, hospitals self-assessed they exceeded 57% of the standards, met 39%, and did not meet 4%. Hospitals performed best in the information systems and management category (100% met or exceeded) and quality and quality improvement category (98% met or exceeded). The leadership category (93% met or exceeded) and safe practice and environment category (93% met or exceeded) had the most room for improvement.

CONCLUSIONS: A novel set of practice standards were crafted for HaH. Reassuringly, the vast majority of programs met these standards nationally, yet across the country there are clear areas of strength and room for improvement as the country standardizes its practices.

HOSPITALISTS’ ATTITUDES AND EXPERIENCES WITH POST-HOSPITALIZATION CARE TRANSITIONS FOR PATIENTS WITH SUBSTANCE USE DISORDERS: A CROSS-SECTIONAL ANALYSIS

Michael A. Incze²; Sophia Huebler²; David Chen²; Andrea Stofko²; Chaorong Wu²; Jacob D. Baylis²; Chesley Wells¹; Danielle Babbel². ¹Intermountain Healthcare, Salt Lake City, UT; ²Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4046846)

BACKGROUND: Hospitalizations for medical complications of substance use are common and represent opportunities to engage with individuals who have substance use disorders (SUD) and offer treatment. Post-hospitalization transitions of care are integral to providing full-spectrum inpatient SUD care; however, little is known about hospitalists’ experiences with post-discharge care transitions.

METHODS: We conducted a cross-sectional study surveying hospitalists across two large health systems in the Mountain West to assess current practices, barriers, facilitators, and perceptions towards post-hospitalization care transitions for patients with SUD. We used Wilcoxon signed-rank tests to identify the most impactful barriers and facilitators among all respondents. We used logistic regression models to explore the influence of various individual and environmental characteristics on perceived barriers and facilitators.

RESULTS: The survey was distributed to 429 individuals across 15 hospitals. Eighty-two respondents met inclusion criteria. Most respondents frequently cared for hospitalized patients with SUD (n=63, 77%) and prescribed medications for SUD (n=44, 56%). Four (5%) respondents felt patients received adequate support during care transitions. Lack of social support (p<.001) and social factors such as lack of transportation (p<.001) were perceived as the largest barriers to successful care transitions. Conversely, a partnering outpatient clinic/clinician (p<.001) and outpatient-based care coordination (p<.001) were perceived as the strongest facilitators. Respondent characteristics and attitudes towards people with SUD had a modest effect on perceived barriers and facilitators.

CONCLUSIONS: Hospitalists perceived increased outpatient SUD treatment infrastructure and transitional care supports as most important in facilitating post-hospitalization care transitions for patients with SUD. While our study was limited by potential selection bias among respondents, a single state, and a small sample size, we believe that our results nonetheless have important implications for health systems to design and study interventions to improve care transitions for this vulnerable population.

HOSPITAL-LEVEL CARE AT HOME FOR ACUTELY ILL ADULTS IN RURAL SETTINGS: A RANDOMIZED CONTROLLED TRIAL

David Levine^1,3; Meghna Desai³; Stephanie Blitzer³; Sarah Findeisen³; Rachel Moyal-Smith⁴; Abby Ow²; Stuart Lipsitz^2,1. ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Science and Technology, Ariadne Labs, Boston, MA; ³Home Hospital, Ariadne Labs, Boston, MA; ⁴Implementation, Ariadne Labs, Boston, MA. (Control ID #4063476)

BACKGROUND: One in five Americans live in a rural setting, limiting their access to high-quality healthcare. Hospital-level care at home has been successfully implemented as a substitute to acute hospital care and has demonstrated cost reductions, fewer readmissions and improved safety and care. However, little, if any, evidence exists evaluating home hospital in rural settings. We present preliminary data on the world’s first randomized controlled trial of rural home hospital.

METHODS: Adult patients were recruited at two rural hospitals in the US. Eligible patients met criteria for inpatient-level care, specific home hospital criteria, and did not require critical care. Patients were randomized to usual care in the hospital or to the home hospital. Home patients were visited once daily by a remote physician and twice daily in person by a nurse. They received intravenous medications, remote monitoring, video communication, and point-of-care testing. We present preliminary unadjusted patient characteristics, mortality, readmission, and the need for escalation of care.

RESULTS: We randomized 129 patients (64 home; 65 control). In our preliminary unadjusted analysis we found no clinically significant differences between groups. Patients had a mean age of 64 years (SD, 15). Most patients were of White race (96%), lived with someone else (74%), completed high school (55%), and were not smokers (61%). Around half were retired (47%) and married/had a life partner (47%). Medicare was the most common insurance (50%), followed by Medicaid (25%), dual-eligible (18%), and commercial (7%).

The most common diagnoses were chronic obstructive pulmonary disease exacerbation (21%), pneumonia (19%), other infections (16%), cellulitis (15%), complicated urinary tract infection/pyelonephritis (12%), and heart failure exacerbation (12%).

Mean length of stay for the entire hospitalization was 6.4 days (SD, 5.0) for home patients and 4.7 days (SD, 3.7) for control patients. No deaths were reported during admission or within 30 days after hospital discharge in either group. Unplanned 30-day readmission occurred in 13% of home patients and 17% of control patients. Five home patients were escalated back to the general hospital ward while one control patient was escalated to the intensive care unit.

CONCLUSIONS: In this unadjusted analysis of the first randomized controlled trial of rural home hospital, preliminary results suggest that quality and safety were not compromised during home hospital care. Further analysis, including of the primary outcome cost, is needed to confirm these results and to make more definitive conclusions about acute hospital level care at home in rural settings.

IMPACT OF A THEORY-INFORMED IMPLEMENTATION STRATEGY ON CLINICIAN BARRIERS TO OUT-OF-OFFICE BLOOD PRESSURE MONITORING FOR PATIENTS WITH NEW HYPERTENSION: FINDINGS FROM THE EMBRACE TRIAL

Nadia Liyanage-Don^2,1; Nathalie Moise^2,3; Erica Phillips⁴; Eileen Carter⁵; Carmela Alcantara⁶; Maria Serafini²; Joseph Schwartz²; Ian Kronish^2,1. ¹Medicine, Columbia University Irving Medical Center, New York, NY; ²Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, NY; ³Medicine, Columbia University Irving Medical Center, New York, NY; ⁴Medicine, Weill Cornell Medicine, New York, NY; ⁵Nursing, University of Connecticut, Storrs, CT; ⁶Social Work, Columbia University, New York, NY. (Control ID #4064562)

BACKGROUND: Little is known about the best way to increase out-of-office blood pressure (BP) monitoring in patients with newly elevated office BP, in line with hypertension screening guidelines. In the EMBRACE trial, a multistakeholder team used the Behavior Change Wheel framework to design an implementation strategy for increasing out-of-office BP monitoring in such patients. Key components included linking primary care practices to ambulatory BP monitoring (ABPM) testing services, creating EHR tools to prompt test ordering, and delivering one-time educational presentations and quarterly reminder emails. Implementing this strategy modestly increased ABPM but not home BP monitoring (HBPM) compared with usual care. We aimed to understand why the theory-informed implementation strategy had only modest benefits.

METHODS: We surveyed primary care clinicians from the 4 intervention and 4 control practices participating in the EMBRACE trial to compare perceived barriers to out-of-office BP monitoring 1 year after delivering the implementation strategy. The survey assessed clinician determinants of out-of-office BP monitoring that had been identified via focus groups prior to implementation. Responses were rated on a 5-point Likert scale. Recall of receiving implementation strategy components was also assessed. Multilevel models to account for clustering of clinicians within practices were used to analyze survey results. We then conducted interviews with intervention clinicians and coded transcripts using thematic content analysis to better understand their experiences.

RESULTS: Of 142 eligible clinicians, 89 (63%) completed surveys (53 from intervention practices, 36 from control practices; 68.5% women; 49.4% trainees). In adjusted analyses, there was a trend (p<0.2) toward intervention clinicians being more likely to remember to order out-of-office BP monitoring, being aware of ABPM testing availability, knowing how to order and interpret ABPM, and perceiving ABPM to be affordable. Between-group differences in perceived barriers to ABPM were larger when trainees were excluded from the analyses. There was no trend for differences in barriers to HBPM. The most commonly recalled implementation strategy components were the accessible ABPM testing service and reminder emails, recalled by 59% and 48% of clinicians respectively. Key themes that emerged during interviews included limited recall of multiple strategies (particularly by trainees with limited time in busy clinics), perceptions that an Epic Best Practice Advisory intended to prompt test ordering was easily ignored, and logistic challenges referring to offsite ABPM testing for some practices.

CONCLUSIONS: More frequent delivery of implementation strategies may be needed to ensure clinicians recall receiving education on how and why to order out-of-office BP monitoring. Locally available ABPM testing and better designed EHR tools may also be needed to substantially increase out-of-office BP monitoring for patients with newly elevated office BP.

IMPACT OF REGULAR HOME DELIVERY OF HIV SELF-TESTING AND COUNSELING ON HIV TESTING AND PREVENTION OUTCOMES IN GAY AND BISEXUAL MEN WHO TEST INFREQUENTLY: A PRAGMATIC, VIRTUAL RANDOMIZED CONTROLLED TRIAL

Erik Ocean¹; Siddhi Nadkarni^2,1; Tyler Wray¹. ¹CAAS, Brown University, Providence, RI; ²Yale School of Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4044379)

BACKGROUND: HIV self-testing (HST) could be an important tool that helps encourage more frequent testing than clinic-based testing alone. However, some have raised concerns that those who use HST may be less likely to obtain necessary follow-up care when needed, such as confirmatory testing, testing for other sexually transmitted infections (STIs), and pre-exposure prophylaxis (PrEP). In this study, we tested whether delivering HST at regular intervals encouraged more regular testing versus clinic testing and whether providing timely follow-up counseling alongside HST increased receipt of other care services, such as STI testing and PrEP care.

METHODS: Gay and bisexual men at high-risk for HIV in the US who tested infrequently were randomized to receive one of the following every three months for a year: (1) text reminders to seek HIV testing at a local clinic (control), (2) mailed HST kits with access to a free 24-hour helpline (standard HST), or (3) mailed HST kits equipped with technology that enabled timely follow-up phone counseling after the test was used (eTest). Online surveys were collected semi-quarterly over 12 months to assess differences in rates of HIV and other STI testing, PrEP uptake, and high-risk sexual behavior. Analyses were performed in Stata SE 16 (College Station, TX).

RESULTS: 811 participants were randomized to a condition. About 1% of study participants were ultimately diagnosed with HIV during the study period, all but one were diagnosed through an HST. Of those who reported reactive results on study-provided HSTs, over 70% reported negative results on follow-up testing. The odds that a participant who received quarterly HSTs tested for HIV at any time over the 12-month period were 7-8 times that of those who were only reminded to get tested at a local clinic. Likewise, the odds that a participant tested more than once in a year with HST were 8-9 times higher than with clinic-based testing. However, the probability of testing for HIV in any given follow-up period declined by 7-8% across the study period among those receiving HST, compared to about 2% among control participants. Monitoring HST use and providing follow-up phone counseling and basic PrEP education did not significantly increase rates of STI testing or PrEP uptake. However, eTest participants who received risk reduction counseling reported an average of 27-28% fewer high-risk condomless anal sex events relative to control and standard group participants.

CONCLUSIONS: HST vastly increased HIV testing and encouraged more regular testing among individuals at high-risk for HIV who previously tested infrequently, indicating its potential roles in prevention and reducing time to diagnosis. Future research is needed to explore providers’ roles in supporting HST and counseling alongside or within traditional healthcare.

IMPLEMENTING CONTEXTUALIZED HEPATITIS C TREATMENT PROTOCOLS FOR HIGH-RISK, VULNERABLE POPULATIONS: THE ERASE HEP C STUDY

Anmol Desai¹; Kia Reinis¹; Lauren O'Neal¹; Patrick Chang¹; Cristal Brown^1,2; Deepak Agrawal^1,2; Michael Stefanowicz^1,2; Audrey Kuang^1,2; Darlene Bhavnani¹; Tim Mercer^1,2. ¹The University of Texas at Austin Dell Medical School, Austin, TX; ²CommUnityCare, Austin, TX. (Control ID #4058735)

BACKGROUND: Hepatitis C virus (HCV) is a leading cause of liver-related morbidity and mortality. HCV treatment is now more effective given direct acting antivirals with a >95% cure rate and an evidence-based simplified treatment algorithm. Yet for vulnerable populations, such as people experiencing homelessness (PEH) and people who inject drugs (PWID), HCV treatment access remains limited. The objective of this study was to expand HCV treatment access in clinics serving PEH and PWID by addressing in-clinic barriers via locally contextualized simplified HCV treatment protocols.

METHODS: We conducted a prospective single-arm clinical trial on the implementation and effectiveness of the locally contextualized, simplified HCV treatment protocols that were implemented at clinics in August 2022. Adult patients who were 18 years or older, diagnosed with chronic hepatitis C, and enrolled in care at one of our clinical study sites were determined eligible for the trial and were enrolled from September 2022 to March 2023. We used the intent-to-treat approach and included all enrolled patients in our denominators. We used a Bayesian random effects probit model to generate cluster-adjusted estimates and 95% credible intervals (95CrI) of our clinical endpoints: treatment initiation, completion, and cure.

RESULTS: Of 62 patients, 39% were currently homeless with 89% having ever experienced homelessness. 69% were currently using at least one substance; 94% had ever used a substance. 60% had at least one chronic medical condition while 81% had at least one mental health condition, with 58% experiencing comorbid current substance use and a mental health condition. An estimated 45% (CrI 20.5%, 65.4%) initiated treatment, 38% (CrI 19.7%, 58.3%) completed treatment, and 9.8% (CrI 1.8%, 34.6%) achieved cure.

CONCLUSIONS: We identified two main intervals of drop off along the HCV care cascade: 1) enrolled to initiated treatment and 2) completed treatment to achieving cure. In this highly vulnerable population, clinic adapted protocols were insufficient to engage patients across the HCV care cascade. Novel approaches, such as outreach, patient navigation, and test-and-treat protocols, will be necessary to eliminate HCV.

IMPLEMENTING PATIENT-CENTERED CARE BEYOND PRIMARY CARE SETTINGS: THE CASE OF HIV SPECIALTY CARE

Sonia Rupcic¹; Allen Gifford²; Gemmae Fix¹. ¹CHOIR, VA Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; ²Veterans Affairs Boston Healthcare System, Boston, MA. (Control ID #4063735)

BACKGROUND: Healthcare systems are increasingly embracing models of patient-centered care (PCC) predicated on patient-provider interactions in which patients’ values, goals and preferences shape decision-making. Veterans Health Administration (VHA) Primary Care has been at the vanguard, instituting a “Whole Health” (WH) system of care, which realigns clinical encounters around the principles of PCC. VHA is now expanding WH to specialty settings. HIV Clinics offer important insights into WH implementation in specialty care settings. Many patients with HIV receive specialty and primary care consolidated in infectious disease clinics, potentially limiting their exposure to and benefits from WH. We researched HIV providers’ understandings of WH and identified strategies to implement WH in HIV specialty care.

METHODS: We used a qualitative study design to examine provider perspectives on WH. We recruited HIV care providers and WH leaders from 18 VA Medical Centers, where WH is being tested in primary care. Semi-structured interviews were audio-recorded and transcribed. We independently analyzed transcriptions using a multi-step inductive and deductive coding process. This began with initial thematic analysis in which transcripts were reviewed and notated with open codes. Themes were then mapped onto constructs from the 2022 Consolidated Framework for Implementation Research (CFIR), a well-established framework used to assess and tailor interventions. Data were then organized into a matrix. Throughout the process, we met to iteratively discuss findings.

RESULTS: We interviewed physicians, psychologists, nurses, and leadership (N=15) from 4 geographically diverse VA Medical Centers. Participants expressed a commitment to the ideals of PCC, though were less aware of the institutional manifestations of WH. In thinking through how WH (CFIR Domain: innovation) might be implemented in HIV care settings (inner setting), providers (individuals) focused on issues rooted in the history of HIV (outer setting). Participants situated their care practices in relation to “20 years ago,” “back in the day,” and “shift[s] over time,” describing entangled histories of HIV stigmatization and drug development that jointly shaped the organization of HIV care. Participants suggested HIV providers, who daily confront the serious effects stigma has on medication adherence, are uniquely attuned to the social needs of patients (process). They reflected that this orientation well qualified them to deliver PCC.

CONCLUSIONS: HIV Clinics offer an ideal setting to expand VA’s WH system of care within specialty care. Though WH is a new model of care, some providers have adopted PCC practices in response to the unique history of their specialties. As healthcare systems deepen their commitment to PCC, it is vital systems should attend to these histories as a first step in inventorying the resources available and needed to provide PCC.

IMPLEMENTING THE 3 WISHES PROJECT IN SAFETY-NET HOSPITALS: ENGAGING STAKEHOLDERS TO TAILOR AN IMPLEMENTATION STRATEGY

Michelle Wan¹; Kamya Bijawat²; Carolyn J. Marentes Ruiz⁴; Anne Walling^2,10; Derjung M. Tarn⁹; Brian Mittman¹¹; Neil Wenger²; Hope Cassano⁸; Emily Beers⁵; Rucha Gadgil^12,6; Nader Kamangar⁷; Nancy Blake³; Dong Chang⁶; Thanh H. Neville⁴. ¹Medicine, UCLA Medical Center Olive View, Sylmar, CA; ²Medicine, University of California Los Angeles, Los Angeles, CA; ³Nursing, Los Angeles General Medical Center, Los Angeles, CA; ⁴Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California Los Angeles, Los Angeles, CA; ⁵Palliative Care, Los Angeles General Medical Center, Los Angeles, CA; ⁶Division of Pulmonary and Critical Care Medicine, Department of Medicine, Los Angeles General Medical Center, Los Angeles, CA; ⁷Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, UCLA Medical Center Olive View, Sylmar, CA; ⁸Palliative Care, Harbor-UCLA Medical Center, Torrance, CA; ⁹Family Medicine, University of California Los Angeles, Los Angeles, CA; ¹⁰Greater Los Angeles Veterans Research and Education Foundation, Los Angeles, CA; ¹¹Research and Evaluation, Kaiser Foundation Hospitals, Pasadena, CA; ¹²Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, CA. (Control ID #4061238)

BACKGROUND: Stakeholder engagement in implementation research decreases implementation barriers, increases relevance to local participants, and promotes adoption. We engaged stakeholders in the early phase of a type 2 hybrid effectiveness-implementation study to implement the 3 Wishes Project (3WP) in 3 safety-net hospitals (SNHs). The 3WP aims to improve end-of-life care for patients dying in intensive care units (ICU) by fulfilling small meaningful wishes for patients and/or families. We describe how we engaged stakeholders to tailor the implementation strategy to local settings.

METHODS: Stakeholders at each hospital were identified by the site lead investigator and invited to individual or focus group semi-structured interviews. At each interview, the principal investigator described the core functions (primary goals) and customizable forms (how each function could be operationalized) of the proposed 3WP implementation approach. Core functions were (#1) obtaining initial engagement and providing training, (#2) facilitating bedside wish elicitation and fulfillment, (#3) tracking and documentation, and (#4) sustaining unit-level engagement. Stakeholders were asked to suggest forms specific to their SNH. Four members of the research team (the PI, two residents, and a research coordinator) listened to recordings of the interviews and independently performed content analysis to identify all forms suggested by participants. The researchers discussed findings and produced a complete core function/form matrix that will guide implementation.

RESULTS: Thirty stakeholders participated: 4 unit directors, 11 charge nurses, 3 nurse educators, 7 physicians, 1 palliative care nurse, and 4 bedside ICU nurses. To obtain initial engagement and provide training (core function #1), stakeholders suggested unit-specific meetings where 3WP can be promoted (and more formal training provided when appropriate), such as monthly staff meetings, daily shift change huddles, and multidisciplinary rounds. To facilitate bedside wish elicitation (#2a), stakeholders recommended badge buddies and a script for nurses to reference, and informational brochures written in patient-preferred languages. To facilitate wish fulfillment (#2b), sites recommended establishing an inventory of items to meet the cultural and spiritual needs of a majority Catholic patient population (e.g. rosaries, flameless candles). Methods of documenting 3WP participation (#3) included the electronic medical record and HIPAA-compliant clouds. Unit bulletin boards, health system-wide monthly newsletters, and computer screensavers were identified as spaces to recognize 3WP achievements and sustain unit engagement (#4).

CONCLUSIONS: Recommendations from stakeholders will be incorporated into the 3WP implementation strategy for each of the 3 SNHs. Ongoing engagement will inform future tailoring as needed. The recommendations address local barriers and patient needs, highlighting the value of stakeholder engagement in implementation research.

IMPROVING RATES OF CARDIAC STRESS TEST COMPLETION THROUGH SCHEDULING INTERVENTIONS

Maelys Amat¹; Scot B. Sternberg²; Anjala Tess¹; James Benneyan⁶; Mark D. Aronson³; Gordon Schiff⁵; Russell Phillips⁴. ¹Internal Medicine, Beth Israel Deaconess Medical Center, Somerville, MA; ²Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ³Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ⁴Center for Primary Care, Harvard Medical School, Boston, MA; ⁵Brigham and Women's Hospital, Boston, MA; ⁶Northeastern University, Boston, MA. (Control ID #4060981)

BACKGROUND: 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 the initial evaluation of cardiac symptoms, our institution, along with others, has noted high rates of incomplete tests or delays to test completion. In this context, we aimed to increase completion of cardiac stress tests through a scheduling intervention.

METHODS: We performed an intervention study using a nonrandomized pre-post study design at one large urban hospital-based primary care clinic in Boston, MA. We included all cardiac stress test orders September 1st, 2022 and September 31^st, 2023 and compared these to a baseline cohort of orders from May 1^st, 2022 to August 31^st, 2022. For the intervention cohort, all patients were enrolled in the intervention if they had not scheduled their stress test within 4 weeks of test order date. The first intervention consisted of proactive outreach phone calls for scheduling of the cardiac stress test. A second intervention ran from January 1^st, 2023 to July 31^st, 2023 and consisted of interviews designed to learn more about reasons that patients did not schedule and educate patients on the importance of stress test completion. Our primary outcome was completion of the cardiac stress test. Secondary outcomes included time to test completion, rates of test scheduling and rates of canceled or unkept tests.

RESULTS: We identified a total of 699 cardiac stress tests, of which 160 were ordered during the baseline timeframe and 549 were ordered during the intervention timeframe. Patients in the intervention cohort were slightly more likely to be female, Hispanic, Black, non-English speaking and be on Medicaid insurance, and less likely to be under 40 years of age. During the baseline timeframe, 98 (61.3%) of the 160 ordered tests were completed. During the intervention timeframe, 443 (80.7%) of the 549 ordered tests were completed. Of all tests in the intervention cohort, 320 (58.3%) did not receive the intervention, 207 (37.7%) received the first intervention only and 22 (4.0%) received the first and second intervention. Of all patients scheduled for a cardiac stress test, completion rates were 90.7 % for those who did not receive an intervention, 88.4% for those who received the first intervention only and 77.8% for those who received both interventions. There was a slightly higher rate of unkept tests for patients who received both interventions (22.2%) when compared to the no intervention (9.3%) or first intervention only (11.6%) cohorts.

CONCLUSIONS: A tiered scheduling intervention for cardiac stress test was successful in yielding increased rates of test completion. Further studies should deepen our understanding of the effect of patient interviews on test completion and evaluate the impact of scheduling interventions on unkept tests.

IMPROVING RISK ADJUSTMENT TO PREDICT PRIMARY CARE SPENDING: SUPPORTING A LARGE STATE INSURER IN RISK ADJUSTMENT MODEL CREATION

Aidan P. Crowley^1,2; Lin Yang¹; Maura Boughter-Dornfeld¹; David Pagnotti³; Jingsan Zhu¹; Amol S. Navathe^4,2. ¹Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Health Care Management and Economics, University of Pennsylvania Wharton School, Philadelphia, PA; ³Perelman School of Medicine, Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; ⁴Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA. (Control ID #4058647)

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) is preparing to launch a new capitated payment model for primary care, Making Care Primary. Capitated payment requires accurate and comprehensible risk adjustment to compensate primary care providers (PCPs) and reduce patient selection. To risk-adjust for Medicare beneficiaries, CMS currently uses Hierarchical Condition Categories (HCCs), a set of 115 conditions weighted by contribution to total spending. However, HCCs may not accurately predict primary care spending, especially in non-Medicare populations. Our research question was to examine (1) how well HCCs predict primary care spending, (2) whether re-training the model improves predictions, and (3) how to deal with unstable HCCs. We worked with a statewide insurer to re-train the CMS-HCC model on primary care data across multiple lines of business (LOB): Medicare Advantage (MA), Medicaid Managed Care (MMC), and commercial.

METHODS: We utilized claims data from 2015 and 2019. Our population included all beneficiaries over 18 years old attributed to a PCP. We created linear regression models for PCP spend accounting for LOB, age group, and gender. We compared three models: (1) continuous HCC score calibrated on total spend, (2) continuous HCC score calibrated on primary care spend, and (3) all 115 HCCs as categorial variables with additional conditions such as hypertension. We ran a fourth model testing cutoffs for inclusion of HCCs, as the consistency of some HCC predictions varied across years. We defined stability as a statistically significant coefficient and tested cutoffs for a difference in predicted spend of less than $25, $50, $75, or $100 between years.

RESULTS: Our sample included 223,750 commercial, 26,656 MA, and 33,755 MMC beneficiaries. The categorical model predicted primary care spending best compared to observed spending while also increasing transparency for PCPs about how each condition contributes to payment. With a cutoff of a $50 difference between model years, 62 HCCs met our definition of stability among commercial beneficiaries, 52 among MA, and 27 among MMC. Mean predicted spend for commercial members remained constant at $262.60 in 2015 and $236.90 in 2019 regardless of cutoff for HCC inclusion (Table 1).

CONCLUSIONS: Our findings suggest that a risk adjustment model trained on primary care data with the most stable HCCs predicts primary care spending well. Excluding unstable HCCs had little effect on mean predicted spend yet improved clarity for PCPs. This work demonstrates the ability to collaborate with a large insurer to test and adapt a risk adjustment model to align with PCP and payer priorities.

LONGITUDINAL TRENDS IN BURNOUT AMONG PRIMARY CARE PRACTICES PARTICIPATING IN A NATIONAL QUALITY IMPROVEMENT INITIATIVE

Lisa Rotenstein^1,2; Deborah Cohen³; Miguel Marino⁴; David W. Bates⁵; Samuel Edwards³. ¹Medicine, Brigham and Women's Hospital, Boston, MA; ²University of California San Francisco, San Francisco, CA; ³Oregon Health & Science University, Portland, OR; ⁴Family Medicine, Oregon Health & Science University, Portland, OR; ⁵General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #4064137)

BACKGROUND: Burnout is prevalent among clinicians and staff in primary care practices. While previous research has identified practice characteristics associated with burnout at specific timepoints, it is less understood how burnout changes over time in primary care practices undertaking targeted quality improvement (QI) efforts, and practice level factors associated with burnout trajectories.

METHODS: We studied practices that participated in the AHRQ-funded EvidenceNOW study focused on increasing implementation of cardiovascular preventive care among small-to-medium-size primary care practices from 2015-2019. Practices received several types of QI support, including practice facilitation, learning collaboratives, health information technology support and expert consultation. We included practices who reported burnout for their clinicians and staff pre-intervention, post-intervention, and 1-year after intervention completion and had complete information on the hours and duration of the QI intervention. After quantifying the proportion of clinicians and staff who met the criteria for burnout at each timepoint, we built a linear mixed model to identify whether levels and the trajectory of practice-level burnout over time differed by practice characteristics or by hours or duration of the QI intervention.

RESULTS: The study sample consisted of 773 practices. More than one-third of practices (39.1%) were clinician owned, one-fifth (19.8%) were solo practices, and most were in an urban area (60.4%). 43.6% were participating in an accountable care organization (ACO) pre-intervention.

Across practices, the mean (SD) burnout prevalence was 19.3% (21.8%) pre-intervention, 22.5% (23.1%) post-intervention, and 21.3% (23.4%) 1-year post-intervention, representing a significant increase across timepoints (p = 0.02). In multivariable linear mixed models, burnout levels differed by practice ownership (p=0.009) and trajectories of burnout differed by ACO participation (p=0.002). Across the study period, burnout was higher at baseline among practices part of a hospital/health system/HMO and lower among those part of a federal system. Burnout remained stable over the study period in ACO-participating practices, while rising in those not part of an ACO. Burnout levels and trajectories did not differ with hours or duration of QI intervention, practice size, practice location, or demonstration program participation.

CONCLUSIONS: In this nationwide, longitudinal study, we demonstrate that the prevalence of burnout rose slightly among clinicians and staff in primary care practices after implementation of a QI intervention, and plateaued post-intervention. Levels of burnout varied by practice ownership across the study period. Trajectories of burnout differed by ACO status, but not by hours or duration of the intervention. These findings demonstrate the feasibility of intensive QI interventions from an experience standpoint, while highlighting practice features that may influence burnout levels and trends.

OUTPATIENT TRENDS IN OPIOID PRESCRIPTION FILLS BY PRESCRIBER SPECIALTY FOR ACUTE AND CHRONIC PAIN EPISODES, 2010-2022.

Michele Buonora⁴; Joseph S. Ross¹; Molly M. Jeffery^2,3. ¹Internal Medicine, Yale School of Medicine, New Haven, CT; ²Department of Emergency Medicine, Mayo Clinic Minnesota, Rochester, MN; ³Department of Health Services Research, Mayo Clinic Minnesota, Rochester, MN; ⁴Department of Medicine, Montefiore Medical Center, New York, NY. (Control ID #4063594)

BACKGROUND: Outpatient opioid prescribing has declined nationally since the 2010s, acceleratingly since 2016. Little is known about how overall declines in prescribing vary by prescriber specialty and pain episode type (acute vs chronic). We characterize opioid prescribing trends from 2010-2022 by prescriber specialty, analyzing acute and chronic pain episodes separately.

METHODS: We identified all opioid prescription fills between 1/1/2010 and 8/25/2023 for adult enrollees (>18 years) in OptumLabs Data Warehouse, which contains pharmacy and medical claims data for commercial insurance and Medicare Advantage (aged Medicare, disabled Medicare) enrollees in the United States. Opioid use episodes were classified as: (1) acute: <90 days; (2) chronic: >90 days and including 120+ days’ supply or 10+ fills; and (3) episodic: all other. We grouped prescriber specialties into 10 categories, combining anesthesiology and physical medicine/rehabilitation to capture pain medicine specialists. Daily doses were standardized to morphine milligram equivalents (MME). We describe trends in fill rates and prescription characteristics stratified by insurance population.

RESULTS: We identified 94,396,165 eligible opioid fills by 13,239,830 patients between 2010 and 2022. Across the study period, the fill rate per 100 person-years of enrollment declined in both acute and chronic episodes in all three populations (commercial: 67%, aged Medicare: 33%, disabled Medicare: 39%). Fills in chronic episodes declined more than fills in acute episodes in commercial and disabled Medicare populations (commercial: 72% in chronic, 62% in acute; disabled Medicare: 40% in chronic, 32% in acute). The median daily dose decreased in both acute and chronic episodes; days’ supply increased in chronic episodes, but decreased in acute. The distribution of prescriber specialties among fills in acute and chronic episodes varied. Chronic episodes were increasingly concentrated in pain medicine specialists (from 19.2% to 26.2% in commercial, 19.6% to 29.3% in disabled Medicare), with decreasing proportions from surgical, dental, and emergency medicine specialists; the proportion written by primary care was stable (and above 47% in all populations) during the study period. In acute episodes, the proportion of fills written by primary care decreased during the study period (from 27.8% to 19.3% in commercial, 44.5% to 37.9% in disabled Medicare); fewer than 7% of fills in acute episodes were written by pain medicine specialists in all years.

CONCLUSIONS: Between 2010 and 2022, opioid prescription fills for commercially insured and Medicare Advantage enrollees in the United States decreased substantially, with the greatest declines in chronic episodes. Chronic opioid prescribing was increasingly concentrated among pain medicine specialists, while acute opioid prescribing became less concentrated in primary care. Assessing whether people with chronic pain maintained access to care as opioid prescribing declined is a priority for future work.

PATIENT ATTRITION SIGNIFICANTLY IMPACTS ESTIMATES OF PRIMARY CARE PROVIDER WORKLOAD

Michael F. Mayo-Smith^1,2; Vikrant Vaze⁴; Rachel Weber⁵; Hari Balasubramanian³. ¹Medicine, White River Junction VA Medical Center, White River Junction, VT; ²Dartmouth College Geisel School of Medicine, Hanover, NH; ³Mechanical and Industrial Engineering, University of Massachusetts Amherst, Amherst, MA; ⁴Dartmouth Thayer School of Engineering, Hanover, NH; ⁵Healthcare IE LLC, Mission Viejo, CA. (Control ID #4060593)

BACKGROUND: Using panel size as a measure of primary care (PC) provider (PCP) workload has become standard and “PC panel size” has in common parlance come to mean the number of patients assigned to a PCP. Because practices experience a steady flow of patients in and out of the practice, organizations develop rules to include/exclude patients from panel lists. These vary but commonly include a “lookback” period of up to 36 months; if a patient has not had any visit in the lookback period, the patient is excluded from the panel list. Because of this lookback, panel lists include many patients who have left the practice and are no longer generating workload. In contrast to this definition, in most studies modeling PC workload “panel” is defined as a set number (commonly 2500) of patients, all receiving comprehensive care from their assigned PCP throughout the year. Using this definition these studies have consistently found time needed to provide guideline recommended care excessive. Our aim was to determine the impact on expected workload if modeling studies used the same definition of “panel size” as healthcare organizations, recognizing existence of patient attrition and presence of inactive patients on panels.

METHODS: We developed a mathematical model to estimate workload generated from a given panel size when attrition is considered. We used data from Medical Expenditure Panel Survey and National Ambulatory Medical Care Survey to generate estimate of monthly attrition in PC of 1.5%. We assumed monthly 1.5% of patients leave the practice but remain on panel lists until removed at the end of the lookback period of 36 months. We assumed practices add new patients at the same rate as patients are removed from panel lists.

RESULTS: Using panel list of 2500 patients in an organization using a 36-month lookback, we calculated 36 months x 1.5% attrition per month = 54% of patients (1350) would be inactive (still on panel list but no longer actively seeking care or generating workload for PCP). Of 2500 patients on panel list, only 1150 (46%) would be active.

CONCLUSIONS: Failure to account for attrition when defining PC panel leads to significant overestimation of workload for a given panel size. PC is a $600 billion enterprise; more accurate approaches to modeling PC workload are needed.

PATIENTS’ VIEWS ON BEING BILLED FOR SECURE MEDICAL ADVICE MESSAGES

Elizabeth R. Pfoh¹; Michael B. Rothberg⁴; Victoria Criswell¹; Maria C. Tang⁶; Sandra Hong²; Robert Saper⁶; Eric Yudelevich³; Jordan Alpert⁵. ¹Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ²Cleveland Clinic, Cleveland, OH; ³General Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; ⁴Internal Medicine, Cleveland Clinic, Cleveland, OH; ⁵Center for Value-Based Care Research, Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; ⁶Cleveland Clinic, Cleveland, OH. (Control ID #4064411)

BACKGROUND: Secure messaging (SM) enables patients to ask physicians questions asynchronously. This work is often uncompensated. Health systems are beginning to bill if the SM requires medical knowledge and >5 minutes of a physician’s time. The fee acknowledges the medical knowledge needed to answer the question and obtains compensation for the physician’s time. Our objective was to identify patients’ feelings and intended actions after our institution initiated a fee for SMs that required medical knowledge.

METHODS: In the summer of 2023, we surveyed adult primary care patients at a Midwest integrated health system who sent at least one medical advice SM after December 1, 2022. Eligible patients received an SM with a link to the survey.

We used a literature review, physician input, and informal interviews with patients to derive the survey questions and refined them using input from a patient focus group. We asked about awareness of the fee-based policy, preferences in receiving medical advice, anticipated changes in behavior and expectations, and basic demographic information. We also included two exclusion questions to ensure the patient remembered sending an SM. We used Stata 16.0 for the descriptive analysis. The local IRB approved this study.

RESULTS: We had 229 respondents. Median age was 59 years (IQR: 47-70), 65% were female, 86% were White, 42% had private insurance, and 52% lived 11-25 minutes away from their doctor.

Most patients (63%) were unsure whether their SM for medical advice would meet the threshold for billing, and 38% said they would send fewer messages. Patients had divided opinions on whether they would mind paying if the question required medical knowledge (42% agreed, 26% were neutral, and 34% disagreed). Similarly, one-third agreed that billing for medical advice was appropriate, 24% were neutral, and 42% disagreed. Almost half of respondents expected a more complete (54%) or faster (49%) response in exchange for being billed. Over half (59%) did not agree that sending a message was equivalent to an in-person visit. Yet, 54% agreed SM is a better way to get answers to medical questions than making an in-person appointment, and only 27% would call the office instead of sending a message for a minor medical problem. Patients differed on whether payment for answering messages acknowledges the care physicians’ provide (39% agree, 28% disagree).

CONCLUSIONS: Patients plan to send fewer SMs due to the fee, but a substantial portion do not agree they should be charged for SMs. If required to pay a fee, patients want a higher quality of service. Given that primary care visits are often “free” to patients with insurance, billing for a service that patients feel is not equivalent to an in-office visit may require additional clarification.

PILOT DEMONSTRATION FOR PHYSICIAN COMPENSATION INCENTIVES TO IMPROVE DIAGNOSTIC SPECIFICITY IN CLINICAL DOCUMENTATION

Musburger G. Brooke²; David S. Burstein¹; Bichun Ouyang⁵; Michael Hanak⁴; Laura J. Zimmermann¹; Ali Keshavarzian³. ¹Internal Medicine, Rush University Medical Center, Chicago, IL; ²Rush University Rush Medical College, Chicago, IL; ³Gastroenterology, Rush University Medical Center, Chicago, IL; ⁴Family & Preventive Medicine, Rush University Medical Center, Chicago, IL; ⁵Rush University Medical Center, Chicago, IL. (Control ID #4045928)

BACKGROUND: Clinical documentation is a primary means by which physicians communicate medical information. Omissions in clinical documentation can lead to diagnostic delays and medical errors. Physician behaviors are influenced by compensation incentives, especially when measures are controlled by clinicians and of value to patients. This pilot assessed whether compensation incentives can improve the specificity of free text documentation to improve the diagnostic process and reduce medical errors.

METHODS: We identified six common medical diagnoses which often have significant omissions in documentation: DVT/PE, CVA, CKD, CHF, COPD, and smoking. For each diagnosis, we identified 2-3 clinically significant details via literature review and expert discussion (e.g., GOLD Criteria and oxygen use for COPD). We disbursed a $20,000 compensation incentive pool among primary care clinicians for each medical diagnosis documented in outpatient progress notes that included all clinically significant details for that diagnosis. We enrolled clinicians from purposively sampled office locations via practice meetings and emails with an option to opt-out. We used ICD10 codes to extract progress notes during a 12-week incentivized period (Sep 26 to Dec 16 2022) and a preceding 6-week baseline, unincentivized period (Aug 15 to Sep 25). Progress notes were reviewed and scored by blinded research assistants using pre-specified criteria (interrater reliability assessed with Cronbach’s alpha; k=0.72). We analyzed performance as the proportion of documented diagnoses that included all clinically significant details (numerator) when the diagnosis was addressed during the visit (denominator). We performed descriptive statistics of clinician characteristics and performance. We performed a paired t-test to compare baseline and incentivized performance. We then used a generalized linear mixed model with binomial distribution to compare baseline and incentivized performance with adjustment for clinicians’ years in practice and office location.

RESULTS: From eight office locations, all 32 eligible clinicians participated (25 MD/DO, 7 NP/PA; 21 IM, 11 FM). Average years in practice was 17.8 (SD 9.9) and average clinical FTE was 0.87 (SD 0.14). There were 12,991 visits during the incentivized period and 6,401 baseline visits. There were 673 diagnoses with all clinically significant details documented during the incentivized period (56/week; $29 incentive paid per diagnosis) compared to 200 at baseline (33/week). Incentivized performance (mean proportion±SD) was 46.5%±23.6% compared to 32%±20.7% at baseline (p=0.01). In our adjusted analysis, incentivized performance was 48.2% and baseline performance was 35.6% (p<0.0001).

CONCLUSIONS: Compensation incentives produced a modest improvement in clinicians’ free text documentation of clinically significant medical information. Incentivizing free text documentation may be apt for indicating medical complexity while also improving the diagnostic process and reducing medical error.

PRELIMINARY ASSESSMENT OF THE GREENHOUSE GAS EMISSIONS OF INHALED MEDICATIONS IN A NATIONAL HEALTHCARE SYSTEM

William G. Weppner^1,2; Joanne Bernstein^3,4; Brian Chesebro⁵; Hardeep Singh^6,7. ¹Department of Medicine, University of Washington, Boise, ID; ²Boise VA Medical Center, Boise, ID; ³General Medicine, Medical College of Wisconsin, Whitefish Bay, WI; ⁴VA Milwaukee Healthcare System, Milwaukee, WI; ⁵Environmental Stewardship, Providence Portland Medical Center, Portland, OR; ⁶Baylor College of Medicine, Houston, TX; ⁷Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX. (Control ID #4064789)

BACKGROUND: The majority of metered dose inhalers (MDIs) currently use hydroalkylflouranes (HFAs) as a propellant. Unfortunately, HFA’s have an outsized carbon footprint that is 1300-3350 times more potent than equivalent volumes of carbon dioxide (CO₂e). MDIs contribute to the greenhouse gas (GHG) emissions for health care systems; this is estimated to be 4% of England’s National Health Service footprint. GHG emissions due to inhaler use is unknown in the Veterans Administration (VA) heath care system. Measurement of this would allow comparisons across VA facilities, provide national data on the GHG emissions burden from inhaled medications, and provide a methodology to evaluate interventions to reduce carbon footprints of MDIs.

METHODS: Cross-sectional analysis of purchasing information from VA pharmacy data for the 2022 calendar year describing the total number of active inhaler orders. Medication data included quantities of 3 types of inhaled medications prescribed - MDIs, dry powder inhalers (DPIs), and soft mist inhalers (SMIs). The latter two delivery systems do not include HFAs and are more environmentally preferable. Inhalers were identified by a specific VA drug identification code, which allowed description of weight, delivery device, propellant, and relevant additives. GHG emissions were calculated by converting the volume of HFA propellant to kilograms of CO2 equivalents (kgCO2e). For each drug class and formulation, these emissions were normalized by clinical dose. Calculations of societal costs were based on estimates of comparable CO2e generation by cars, as well as the recently approved monetary cost provided by the EPA.

RESULTS: Preliminary analysis focused on albuterol MDIs, the most-commonly prescribed inhaled medication. During 2022, eight different formulations of albuterol hand-held delivery inhalers were prescribed in the national VA pharmacy system. Six of the eight formulations contained HFA-134a, a high-global warming potential propellant estimated to be 1300 times that of an equivalent amount of C02. 3.57 million albuterol hand-held inhalers were provided in the VA system in 2022, of which 94.2% contained the HFA-134a propellant. This represents a total of 648,138,640 potential doses with a high global warming propellent. Using published equivalents for HFA-134a containing inhalers, this equates to 34,625,004 kgCO2e produced in one year by HFA-containing MDIs in the VA.

CONCLUSIONS: Preliminary analysis of GHG impact of MDIs in the VA suggests a relatively large carbon footprint, equivalent the CO2 generation of more than 7,500 cars in the United States in one year. Using recently updated EPA guidance on the social cost of GHG emissions, this indicates an additional annual cost of $6.5 milllion due to future climate impacts. To address the high global warming potential of inhaled medications, additional measurements at patient, clinic and hospital levels are needed to identify potential opportunities to transition to more environmentally preferable inhalers.

QUALITATIVE STUDY EXPLORING PATIENT, PROVIDER, AND PAYER PERSPECTIVES ON OBESITY MANAGEMENT

Timothy M. Bober²; Flor d. Cameron²; Sam Richardson²; Lane Alexander²; José Giovanni Luiggi-Hernández²; David Rometo¹; Linda-Marie Lavenburg²; Haley Grant⁴; Autumn Boyer²; Kathleen M. McTigue³; Julie Gouveia-Pisano⁵; Avani Patel⁵; Lisa Tarasenko⁵; Jannette Escobar⁵; Allison Brenner⁵; Megan Hamm². ¹Endocrinology and Metabolism, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh, Pittsburgh, PA; ³Medicine, University of Pittsburgh, Pittsburgh, PA; ⁴Biostatistics, University of Pittsburgh, Pittsburgh, PA; ⁵Pfizer Inc, New York, NY. (Control ID #4062704)

BACKGROUND: The prevalence of obesity among US adults is rising despite extensive medical and public health attention. In addition to bariatric surgery and behavioral weight management, several effective anti-obesity medications emerged in the last ten years with benefits even outside of weight loss. Despite the indication and availability of pharmacological and non-pharmacological obesity treatments, multiple studies found that conversations between patients and providers about obesity management are infrequent. Furthermore, when obesity counseling does occur, discussions often elicit mutual emotional discomfort, are not solution-oriented, or do not align with patient priorities. The reasons for these perceptions are multifactorial, including: patient-provider relationship dynamics; differing preferences and perspectives of obesity and its implications; differing conversational techniques; perceived stigma among patients; and known provider anti-fat bias. Building on this evidence base, the goal of this study is to explore patient, provider, and payer perspectives on obesity management.

METHODS: Semi-structured interviews will be conducted with 40 patients, 30 providers, and 10 payers. Patient and provider interview guides cover experiences with patient-provider conversations on weight, and attitudes toward and beliefs about obesity and its treatment options. Payer interview guides focus on the logic of coverage decisions for obesity treatment. Interviews are transcribed and coded according to a codebook developed inductively from the content of the interviews, and conventional content and thematic analyses are planned. Preliminary results identified themes presented below.

RESULTS: In this ongoing study, 28/40 patient interviews, 11/30 provider interviews, and 2/10 payer interviews are complete. All participant groups regard obesity as a disease, but note stigma associated with it. Patients want to discuss/treat obesity in medical settings, but only if conversations are non-stigmatizing and are personalized. They desire individualized treatment plans that go beyond general advice, and regard medication treatment for obesity as unnecessary unless also treating comorbidities. Providers describe willingness to address obesity, noting that their patients often initiate conversations about it, but report lack of training in obesity management. While lifestyle modification plus medication is more effective than lifestyle advice alone, they describe that approach as the least affordable for their patients. Both patients and providers describe financial barriers to obesity treatment. Payers report reluctance to cover obesity management in the absence of other comorbidities.

CONCLUSIONS: This ongoing study of the obesity treatment landscape has identified themes of stakeholder willingness to address obesity in medical contexts, while stigma, lack of knowledge, and lack of affordability serve as barriers to discussing or initiating obesity treatments.

RANDOMIZED CONTROLLED TRIAL OF FECAL IMMUNOCHEMICAL TEST (FIT)-BASED MAILED OUTREACH OFFERING ACTIVE CHOICE VS. SEQUENTIAL CHOICE FOR COLORECTAL CANCER SCREENING

Uri Ladabaum¹; Anuradha Phadke¹; Jimmy Dang²; Yingjie Weng¹; Ajitha Mannalithara¹; Manisha Desai¹. ¹Medicine, Stanford University School if Medicine, Palo Alto , CA; ²Stanford Medicine, Stanford, CA. (Control ID #4064681)

BACKGROUND: Screening decreases colorectal cancer (CRC) incidence and mortality, but many persons remain unscreened. Offering FIT to those who decline colonoscopy improves screening participation. Offering colonoscopy in a FIT-based program has not been studied systematically. Our aim was to compare FIT-based mailed outreach with Active Choice (FIT or colonoscopy up-front) vs. Sequential Choice (initial FIT; colonoscopy only to FIT non-participants)

METHODS: We performed a randomized controlled trial of CRC screen-eligible persons in eight academic medical center primary care clinics. All mailed outreach included a FIT kit and a first letter with basic information on CRC and screening. The Active Choice letter also included a graphic comparing FIT and colonoscopy attributes, and an invitation to return the FIT kit or schedule a colonoscopy using a dedicated phone number. The Sequential Choice letter also included a graphic showing only FIT attributes and an invitation to return the FIT kit. Text reminders were sent at 6 weeks. Second letters were sent at 3 months. The Active Choice letter reminded patients to return the FIT kit or schedule a colonoscopy. The Sequential Choice letter introduced colonoscopy for the first time, included the graphic comparing FIT and colonoscopy attributes, and an invitation to return the FIT kit or schedule a colonoscopy using the dedicated phone number. The primary outcome was screening completion.

RESULTS: The Sequential Choice arm included 2,035 persons and the Active Choice arm included 2,047 persons, with comparable demographics (55% women; median age 58.4 [IQR 53-66] years; 44% White, 27% Asian, 10% Hispanic, 3.4% Black, 15% Other/Unknown; prior CRC screening 36%).

Screening completion rates were comparable in the Sequential vs. Active Choice arms: at 3 months, 566/2,035 (28%) vs. 531/2,047 (26%), Odds ratio (OR) 1.10 (95% CI 0.96-1.26), p=0.2; at 9 months, 850/2,035 (42%) vs. 839/2,047 (41%), Odds ratio (OR) 1.03 (95% CI 0.91-1.17), p=0.6.

Screening modalities were comparable between Sequential vs. Active Choice arms at 9 months: 67% FIT, 29% colonoscopy, 1.5% FOBT, 2.4% MT-sDNA vs. 73% FIT, 25% colonoscopy, 0.5% FOBT, 1.7% MT-sDNA, p=NS.

Of the 1,180 patients screened by FIT, results were available for 1,165, and 54 (4.6%) were positive, with no difference by arm. Of the 54 FIT+ patients, 28 (52%) had a colonoscopy (14 per arm), with median time between FIT+ and colonoscopy of 40.5 [IQR 21-61] days.

CONCLUSIONS: FIT-based mailed outreach achieved similar overall screening participation rates with Active or Sequential Choice, with comparable patient preference rates for FIT vs. colonoscopy. Our results may not apply to our entire clinic populations, because those with past colonoscopy within 10 years were not eligible. High follow-up colonoscopy rates in FIT+ patients were not achieved. Colonoscopy for FIT+ patients must be ensured in any outreach program.

RURAL VETERAN PERCEPTIONS OF A VIRTUAL HEALTH RESOURCE CENTER IN A COMMUNITY-BASED SETTING

Leah M. Marcotte¹; Mariah A. Theis²; John Geyer¹; George G. Sayre²; Kelvin Pho²; Eric Gunnink²; Ashok Reddy³. ¹Medicine, University of Washington, Seattle, WA; ²HSR&D, US Department of Veterans Affairs, Washington, DC; ³Medicine, University of Washington School of Medicine, Seattle, WA. (Control ID #4063702)

BACKGROUND: Rural Veterans are more likely to rely on care through the Veterans Health Administration (VA) than urban Veterans; yet rural Veterans often face barriers to care (e.g., travel distances). Virtual care (VC) services such as video visits and secure messaging may help address some barriers. Yet, limited digital access prevents many rural Veterans from using VC services. The VA Virtual Health Resource Centers (VHRCs) provide in-person technology support for Veterans to support increased digital access. However, most of these Centers are located at urban VA Medical Centers. VA Puget Sound proposed a novel implementation of VHRC in a rural, community-based setting. Our objective was to understand facilitators/barriers to a planned implementation of a VHRC to support VC services among rural Veterans.

METHODS: We conducted rapid qualitative analysis among rural Veterans in Lewis County, WA. We abstracted data from the VA Corporate Data Warehouse to create a recruitment sample. We randomly sampled 200 Veterans, half of whom had ≥ 1 video visit within the last year to compare groups across VC use. We oversampled for diverse characteristics (i.e., race/ethnicity, gender). We developed a semi-structured interview guide using pre-determined constructs from an adapted conceptual model for healthcare access. We conducted and transcribed interviews virtually. We analyzed data using template analysis and created a matrix for data visualization to compare data among and between the two groups.

RESULTS: We interviewed 28 Veterans; 52% interviewed had used video visits, 11% lived in highly rural (vs. rural) settings, 27% identified as a race/ethnicity other than non-Hispanic White (vs. 15% of the eligible population), and 26% identified as female (vs. 9% of the eligible population). The most cited facilitator to video visits was avoiding driving/travel (n=16). The most cited barrier was the perception that many visits were not medically appropriate over video (n=11). Regarding implementation, almost all Veterans interviewed said that the proposed site was easy to get to and most viewed the proposed program favorably. We identified 2 emergent themes. First, several Veterans interviewed cited needs of highly rural Veterans as different from rural Veterans (e.g., due to higher transportation barriers to care). Second, several Veterans interviewed discussed a recently closed VA clinic in the town of the planned implementation. The VHRC project was perceived as a replacement for services lost (which was viewed favorably by some Veterans and inadequate by others).

CONCLUSIONS: Our study findings highlight VC facilitators and barriers among rural Veterans and found overall favorable perceptions of a VHRC in a rural, community-based location. Our results are relevant for VA operational leaders as they may help inform rural VHRC implementations, mobile VHRC models, and strategic planning of digital access services in locations where VA clinics close.

SOCIAL NORMING AND PHARMACIST E-CONSULT INTERVENTIONS TO REDUCE CLINICAL INERTIA IN THE TREATMENT OF HYPERTENSION: A RANDOMIZED CONTROLLED TRIAL

Nancy Haff^1,3; Sushama K. Sreedhara¹; Wendy Wood²; Elad Yom-Tov⁴; Daniel M. Horn^5,3; Melissa Hoover⁶; Greg Low⁶; Julie Lauffenburger⁷; Alexander Chaitoff^7,3; Massimilano Russo^1,3; Kaitlin Hanken⁷; Katherine L. Crum⁸; Constance P. Fontanet⁹; Niteesh K. Choudhry^1,3. ¹Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital Department of Medicine, Boston, MA; ²Department of Psychology, University of Southern California Marshall School of Business, Los Angeles, CA; ³Harvard Medical School, Boston, MA; ⁴Computer Science, Bar-Ilan University, Ramat Gan, Tel Aviv, Israel; ⁵Medicine, Massachusetts General Hospital, Boston, MA; ⁶Mass General Physicians Organization, Massachusetts General Hospital, Boston, MA; ⁷Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; ⁸Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA; ⁹Dartmouth College Geisel School of Medicine, Hanover, NH. (Control ID #4057642)

BACKGROUND: Clinical inertia, or failure to intensify treatment when indicated, contributes to suboptimal blood pressure (BP) control. Interventions to overcome inertia and increase appropriate antihypertensive prescribing are needed.

METHODS: This three-arm, randomized trial tested the effectiveness of 2 interventions to reduce clinical inertia in hypertension care. Primary care providers (PCPs) caring for patients in need of antihypertensive intensification were randomized to one of 3 arms: 1) Pharmacist e-consult, 2) Social norming dashboards, or 3) Usual care. Patients aged 18-79 with an opportunity for treatment intensification at their upcoming PCP visit were eligible if, based on electronic health record data: (1) their most recent outpatient BP ≥140/90 mmHg (if age 18-59) or ≥150/90 mmHg (age 60-79) and (2) they had no treatment intensification since that time. In the e-consult intervention, a pharmacist reviewed patients’ charts and sent electronic health record messages with individualized recommendations to modify antihypertensive treatment to PCPs 1-3 days in advance of patients’ visits. Social norming dashboards were sent by email once weekly to PCPs and contained a list of eligible patients with upcoming visits and, every 3^rd week, a report displaying the PCP’s hypertension control rates compared to their peers. In the usual care arm, eligible patients were identified for outcome assessment, but PCPs did not receive any intervention. The primary outcome was the rate of intensification of hypertension treatment at the targeted visit among all eligible patients in each intervention arm compared to usual care. A sensitivity analysis assessed intensification among the subset of patients with a BP >130/80 mmHg at the targeted visit.

RESULTS: Forty-five primary care providers and 466 of their patients were included in the study. Patients had a mean age of 64 years, 47% were female, and 73% were white; 209 (44.8%) had a BP >130/80 mmHg at the targeted visit. The primary outcome occurred for 19 patients (12.7%) in the usual care arm, 21 (12.1%) in the social norming dashboard arm, and 23 (16.1%) in the pharmacist e-consult arm, with no statistically significant difference between arms (Table). Among patients with BP >130/80 mmHg at the index visit, intensification occurred more often in the pharmacist e-consult arm compared to usual care (OR 2.39 [1.69-3.37]). There were no other differences between arms (Table).

CONCLUSIONS: Pharmacist e-consults improved intensification of antihypertensive medications among patients with elevated blood pressures during the targeted visit but not among allcomers. A social norming dashboard did not increase intensification. This could have been due to the intervention timing, trusted source (pharmacist), delivery through the EHR, or other factors.

SYMPTOM TRACKING IN PRIMARY CARE: CREATING AND TESTING A SAFETY-NET SYSTEM

Talya Salant¹; James Benneyan²; Gordon Schiff³; Jasper Su²; Molly Hodsden²; Seth A. Berkowitz¹; Russell Phillips⁴. ¹Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Northeastern University, Boston, MA; ³Medicine, Brigham and Women's Hospital, Boston, MA; ⁴Center for Primary Care, Harvard Medical School, Boston, MA. (Control ID #4064749)

BACKGROUND: Tracking of worrisome symptoms in primary care can provide a valuable safety-net for preventing missed or delayed diagnoses. However, few reliable symptom tracking systems exist within primary care, leading to potential patient harm and provider burnout. We combined systems engineering and user-based design to create and test a worrisome symptom tracking system at a community-based primary care practice in Boston.

METHODS: Chart reviews of 86 patients established baseline rates of worrisome symptom follow-up in usual primary care. Based on findings from the chart review and input from a PCP survey, a team of systems engineers, PCPs, nurses, and software engineers met over a period of four months to iterate a semi-automated symptom tracking system prototype and to ensure feasibility within a busy primary care practice. The system was designed to provide a structured “test of time” through a referral template, timed nurse-led outreach, reminder flags, and communication back to the PCP. Work is ongoing to further automate the outreach through texting and embedding the system within the EHR.

RESULTS: In usual care, only 60.5% of worrisome symptoms are followed up to diagnosis or resolution (i.e. diagnostic loop closed). Over a period of 10 months (1/10/2023-11/10/2023), 46 patients were referred by eight providers for worrisome symptom monitoring. Of these, 85% were successfully followed up (“closed”) and 33.3% required additional evaluation. The average time to documented resolution of symptoms using the symptom tracking system was 20 days compared to 103 days in usual care.

CONCLUSIONS: A symptom tracking system is feasible and highly effective in improving the rate of symptom follow-up and in reducing the time to symptom follow-up within a community-based primary care practice. Broader implementation and study of symptom tracking systems in diverse clinical settings is needed to further demonstrate their benefit as operationalized “tests of time”.

TELEMEDICINE ADOPTION AND LOW-VALUE CARE USE AMONG OLDER ADULTS IN TRADITIONAL MEDICARE: A DIFFERENCE-IN-DIFFERENCES ANALYSIS

Ishani Ganguli¹; Christopher Lim²; Nicholas Daley¹; David Cutler²; Meredith Rosenthal³; Ateev Mehrotra⁴. ¹Division of General Medicine and Primary Care, Brigham and Women's Hospital, Chestnut Hill, MA; ²Harvard University Faculty of Arts and Sciences, Cambridge, MA; ³Harvard University T H Chan School of Public Health, Boston, MA; ⁴Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #4064419)

BACKGROUND: Low-value care is a persistent, costly problem. The post-pandemic rise in telemedicine adoption may reduce low-value care use by introducing barriers to completing these services at given visits, and/or may increase opportunities for low-value care use by contributing to higher visit volumes, but there are no studies examining this. We used a quasi-experimental approach to assess the impact of telemedicine adoption on low-value testing among Medicare beneficiaries.

METHODS: We used 2019-2022 100% Medicare FFS claims data and difference-in-differences (DiD) analysis to compare beneficiaries who were continuously enrolled and alive through December 31, 2022 and attributed pre-pandemic (2019) to systems in the top vs. bottom quartile of telemedicine adoption during the pandemic. This approach accounted for baseline quality differences in health systems and minimized selection bias in that patients attributed to systems in 2019 could not have chosen them based on their future adoption of telemedicine. We used beneficiary-level linear regression to assess differences in total visits (including in-person and telemedicine) and receipt of 4 low-value screening and acute diagnostic services (binary) in 2022 vs 2019 among those in high vs. low telemedicine systems, clustering results at the Hospital Referral Region level.

RESULTS: We examined 5,624,278 attributed beneficiaries, including 1,383,509 in high telemedicine systems and 999,351 in low telemedicine systems. In 2019, those in high telemedicine systems had more visits per beneficiary (10.90 vs 9.39) and were at lower baseline risk of low-value PSA testing (30.17% vs. 31.93%) and low-value imaging for syncope (5.58% vs. 5.76%) and higher baseline risk of low-value Papanicolaou smears (4.32% vs. 3.13%) and low-value imaging for uncomplicated low back pain (12.26% vs 11.45%) than those in low telemedicine systems. Post-telemedicine adoption, those in high telemedicine systems had a larger differential rise in total visits (diff in diff 0.12 visits per beneficiary, 95%CI 0.09-0.15). Those in high telemedicine systems also had a larger differential rise in PSA testing (DiD 0.77%points(95%CI 0.26,1.29)), a smaller differential rise in Papanicolaou smears (DiD -0.44%points(95%CI -0.53,-0.35)) and back imaging (DiD -0.78%points(95%CI -0.92,-0.63)), and no difference in imaging for syncope (DiD 0.097%points(95%CI -0.009,0.203)).

CONCLUSIONS: Older adults exposed to high telemedicine health systems had differentially more visits overall, lower risk of low-value Pap smears and back imaging, and higher risk of PSA tests. This pattern suggests the possibility that for screening services, telemedicine adoption may deter low-value Pap smears (which must be done during office visits); whereas for PSA tests (which can be ordered virtually and completed after a visit), exposure to higher visit volumes may outweigh barriers at given visits. These results can inform ongoing policy debate and imminent decisions on how to reimburse telemedicine visits.

THE CHRONIC PAIN MARATHON: PRIMARY CARE PERSPECTIVES ON SERVING DIVERSE POPULATIONS

Ryan E. Pascua¹; Edgar Valazquez¹; Jessica Ristau¹; E. B. Schwarz²; Jason Satterfield¹. ¹Division of General Internal Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4027805)

BACKGROUND: Chronic pain results in considerable personal and health system costs, disproportionately impacting marginalized communities. Nonpharmacologic interventions have demonstrated benefits in pain management but are rarely available or accessible.

METHODS: To understand challenges in managing chronic pain and ways to increase access to nonpharmacologic interventions including physical therapy, cognitive behavioral therapy (CBT), mindfulness, and health coaching for chronic pain, we conducted semi-structured interviews with 13 PCPs and 5 staff serving patients with chronic pain. Interviews were transcribed and analyzed using thematic analysis.

RESULTS: Participants identified four major themes in addressing chronic pain: 1) limited access to services, 2) lack of attention to psychosocial factors, 3) lack of culturally concordant care, and 4) the need for team-based approaches. As one participant elaborated, “Numerous barriers hinder patients from obtaining access or appointments, including long wait times, unresponsive phone lines, and high costs.” Participants expressed hopes that new technology, such as a mobile app may enhance access to nonpharmacologic therapies including cognitive behavioral therapy or physical therapy. Participants expressed the need for holistic approaches, while recognizing that they often fall short of this ideal. One participant stated, “the toolkit extends far beyond standard Western medicine prescriptions. It encompasses approaches such as addressing trauma, employing acupuncture, chiropractic care, massage, and a multimodal strategy, many of which my patients lack access to.” PCPs emphasized the critical importance of providing linguistically and culturally concordant care, noting that psychosocial components of chronic pain are sometimes under-recognized in patients from underrepresented backgrounds. In addition, “services with language and cultural concordance can enhance access and may have a ripple effect on other aspects of patients' healthcare including housing, food, medications, and other medical conditions.” Several participants expressed a need for team-based approaches, particularly given visit time constraints. As one PCP aptly put it, “Managing chronic pain is not a sprint; it's a marathon.” Participants also shared enthusiasm for expanding clinical teams with community health coaches with nonpharmacologic pain management skills that promote and support the use of the mobile app.

CONCLUSIONS: Primary care providers have an urgent need for additional support in managing chronic pain. Innovations in health policy, digital health and clinical team structures are needed to reduce disparities in pain management. Many PCPs feel that digital tools and partnerships with culturally concordant pain coaches would increase the feasibility of offering nonpharmacologic pain management strategies in safety-net settings.

THE IMPORTANCE OF ADHERENCE IN ATTAINING BLOOD PRESSURE CONTROL BASED ON THE NEW GUIDELINES

Paul Sabharwal²; Michael B. Rothberg^3,1; Elizabeth R. Pfoh¹. ¹Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ²Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; ³Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4064317)

BACKGROUND: While trying to improve blood pressure (BP) control, health systems often focus on medication intensification. Past studies suggest that intensification is effective regardless of adherence. The objective of this study is to identify the importance of adherence versus intensification in attaining new, lower BP targets.

METHODS: Our cohort study included patients with hypertension at a large health system in the Midwest in 2021. We defined BP control using the 2017 guidelines (<130/80 mmHg). We used prescription fill data to determine adherence by dividing the number of days filled over prescribed days. We defined intensification as a new prescription at a higher dose or with an additional class ≤7 days after an uncontrolled reading. To study the impact of intensification vs. adherence, we excluded patients without a subsequent visit or an uncontrolled BP in the first half of the year. We used a multilevel logistic regression to find the probability that a patient’s last BP was controlled based on their medication adherence rate, intensification status intensification (yes vs no), and their interaction term. We controlled for age, sex, race, and first uncontrolled systolic BP as fixed variables and physician as a random variable.

RESULTS: Of 150,405 patients with hypertension, 54% had an elevated BP in the first six months, of which 75% had a subsequent visit. Of those patients, the mean age was 69 years, 55% were female, and 75% were White. The mean adherence rate was 87%. A quarter of patients received ≥1 medication intensification. Only 34% of patients had controlled BP at their last reading. Adherence was associated with higher probability of control among patients without intensification. (p<0.01)(Figure). Intensification was only associated with higher probability of control when adherence was >80%.

CONCLUSIONS: For attaining BP control at the new targets, adherence was more important than intensification, but most patients did not attain control, even with good adherence and intensification.

THE USABILITY AND FEASIBILITY OF AUGMENTED REALITY FOR HOME-BASED CARE: A PRELIMINARY ANALYSIS

Safwan R. Sarker^1,2; Carme Hernandez⁴; David Levine^3,2. ¹Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Harvard Medical School, Boston, MA; ³Medicine, Brigham and Women's Hospital, Boston, MA; ⁴Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA. (Control ID #4047316)

BACKGROUND: Home-based care enables critical services in the homes of patients who otherwise would not receive care. Its scalability and resource-intensive personnel requirements are persistent challenges. Augmented reality (AR), which overlays computer-generated imagery into the real world, presents a promising solution. However, most AR research targets medical education; its role in home-based care remains unexplored. To address this, we evaluated the feasibility and usability of AR and its software stack among older adults.

METHODS: We recruited and enrolled older community-dwelling adults with recent hospitalizations or significant medical comorbidities. We designed AR tasks in both English and Spanish using the Microsoft HoloLens 2 connected to a 4G hotspot: answer a video call, learn voice commands, complete a hand gestures tutorial, and use AR guides to perform standard healthcare procedures such as taking blood pressure and handle medical equipment such as an oxygen concentrator. A trained investigator marked each step of the experimental technique as successful or unsuccessful while attempted in the participant’s home. To assess perceived workload, we used the NASA Task Load Index (TLX), a validated score with six subscales, each out of 20 (where 0 was a low perceived workload). To evaluate AR’s perceived usability, we used the Health Information Technology Usability Evaluation Scale (Health-ITUES) adapted for AR with four subsections on a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree).

RESULTS: Twenty-three adults aged 61-100 (median = 77, IQR = 15) participated in the study. 19 (83%) were English speaking, 15 (66%) were female, 16 (70%) were of White race, 10 (43%) had less than a college education, and none had prior AR experience. 22 participants successfully completed all procedure steps. Of the 22, the NASA TLX subscale median scores (IQR) were mental demand, 2 (5.75); physical demand, 2 (3.25); temporal demand, 0 (0.75); performance, 18 (3); effort, 3 (8); and frustration, 0 (2). The Health-ITUES overall median score (IQR) was 4 (1) and the subsection median scores (IQR) were impact, 4 (1); perceived usefulness, 4 (1); perceived ease of use, 4 (2); user control, 4 (2). 83% (19) of participants indicated they would be "very" to "extremely comfortable" with healthcare providers using AR. 87% (20) would maintain the same level of trust in a doctor using it and 96% (22) desired AR’s frequent or constant use by healthcare providers if it improved care outcomes.

CONCLUSIONS: In this currently enrolling usability and feasibility study, older adults without prior AR experience were able to use an AR headset with minimal training and complete healthcare-related tasks at home without a burdensome task load and with a positive experience. Further research is essential, but if validated, AR could redefine home-based care, offering the opportunity to scale up healthcare services that previously required in-home visits.

USE OF NEW HEALTH TECHNOLOGIES BY ADULTS TO SUPPORT DIABETES SELF-MANAGEMENT: A MIXED METHODS STUDY

Timothy M. Bober¹; Jodi Krall^2,3; Sophia Garvin³; Margaret Zupa^4,3; Christina White⁵; Bhavini Sotaa³; Carissa Low^6,7; Ann-Marie Rosland^1,3. ¹Internal Medicine, University of Pittsburgh, Pittsburgh, PA; ²UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA; ³University of Pittsburgh Department of Medicine, Caring for Complex Chronic Conditions Research Center, Pittsburgh, PA; ⁴Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA; ⁵University of Pittsburgh School of Medicine, Pittsburgh, PA; ⁶Hematology/Oncology, University of Pittsburgh Department of Medicine, Pittsburgh, PA; ⁷Mobile Sensing and Health Institute, University of Pittsburgh, Pittsburgh, PA. (Control ID #4062095)

BACKGROUND: New technologies like mobile applications (apps), continuous glucose monitors (CGMs), and activity trackers are available to support people with diabetes (PWD). It is not clear how PWD harness these tools for diabetes self-management (DSM) or how these technologies can best support daily diabetes routines. This mixed methods study assessed how PWD use technology to relate factors like sleep, stress, activity, and diet to glucose levels and change DSM habits.

METHODS: 61 adults aged 18-75 with Type I or II diabetes who used at least one diabetes medication were recruited via a research registry and completed a survey about past and current use of technology for DSM. Surveys addressed health app and monitor use (glucose-tracking, diet, exercise, weight, sleep, stress, CGMs, and activity trackers) as well as digital and general health literacy. 18 survey respondents also completed 60-minute semi-structured interviews examining how technologies were and could be used in daily DSM.

RESULTS: Survey respondents were 34% African American and 38% female. 52% were aged 18-44; 48% were 45-70. 82% had some college education. 72% had Type II Diabetes, 59% used insulin, and 56% had experience using CGMs. Participants had overall high levels of digital and general health literacy. 74% used at least 1 non-sugar app; 47% had used >/= 3 separate health apps; 59% had used an activity tracker. As expected, use of glucose-tracking apps was more common among CGM users (82% vs. 22% for non-CGM) and insulin users (75% vs. 40% among non-users). Non-glucose-tracking app utilization (74% overall) was similar among CGM/non-CGM users (57% vs. 60%) and insulin/non-insulin users (61% vs. 60%) but less common among those aged 45-70 than those aged 18-44 (52% vs. 70%). People shared self-monitored data with their providers at similar rates across age groups (53% vs. 55%). Interviewees most often described using glucose-tracking apps to personalize dietary choices and, while many tracked sleep and stress, there was much more attention to the impact of stress on glucose levels than sleep. Having larger quantities of health data was anxiety-provoking to some but empowering for others to achieve personal DSM goals and better participate in healthcare. Data that was passively collected, easily integrated across sources, relevant to their health priorities, and easy to visualize was seen as most helpful.

CONCLUSIONS: PWD across different ages, diabetes types, and treatments reported using multiple apps to monitor life factors and behaviors that impact glycemic control and diabetes management. Findings suggest that there are untapped opportunities to harness and integrate new diabetes technologies and trackable lifestyle data to empower PWD.

USE OF PHARMACISTS AND COLLABORATIVE DRUG AGREEMENTS TO MANAGE HEPATITIS C: A SURVEY OF PRIMARY CARE PROVIDERS IN WA STATE

Judith I. Tsui¹; Emalie Huriaux²; Jon Stockton²; Jocelyn R. James¹. ¹Medicine, University of Washington, Seattle, WA; ²WA State Department of Health, Olympia, WA. (Control ID #4055129)

BACKGROUND: Hepatitis C virus (HCV) elimination by 2030 is a national goal which the U.S. is not on target to meet. Policy and practice guidelines highlight the need for more HCV treatment to be delivered in primary care and community-based settings by non-specialists. Pharmacist-led collaborative care models that rely on “Collaborative Drug Agreements” (CDA) can expand access to treatment for HCV, yet little is known about primary care providers’ (PCPs) experience and attitudes toward such an approach.

METHODS: We conducted a cross-sectional survey-based study from a convenience sample of PCPs recruited through professional networks in Internal Medicine, Family Medicine, and Addiction Medicine in Washington (WA) State. Surveys were electronically distributed to provider groups through email lists/newsletters in spring of 2023. A $20 USD gift card was offered to participants from groups with <250 members. The survey was designed to assess perceptions and practices relating to HCV and to explore the acceptability of using collaborative care models that utilize pharmacists to deliver HCV care, including treatment. Analyses generated descriptive statistics of survey responses.

RESULTS: 79 PCPs completed the survey; of those, 63% were female, average age was 46 and 72% identified as White, 13% as Asian, and 1% as Black. Sixteen counties within WA State were represented and 13% were rural practice sites. Most common insurance coverage (estimated) was Medicaid. Of providers surveyed, only 18% reported directly treating HCV among their patients. Nearly half (47%) had a pharmacist embedded in their clinic and 28% reported that pharmacists help deliver HCV care in their practice; however, fewer than half (42%) had heard of a CDA and only 20% had interest in establishing a CDA for HCV. The majority of providers felt comfortable or extremely comfortable with having pharmacists managing many aspects of HCV care including: taking HCV history, ordering tests to diagnose HCV, ordering/interpreting pre-treatment labs, reviewing medication interactions, identifying need for referral, performing pre-treatment counseling and assisting with care coordination.

CONCLUSIONS: Among a sample of WA State PCPs, <1 in 5 directly provide HCV treatment. A majority of PCPs were comfortable or extremely comfortable with pharmacists managing key steps of HCV treatment, yet most were not familiar with CDTAs. More work is needed to leverage pharmacists to treat HCV in primary care settings.

VIRTUAL REALITY AND AUGMENTED REALITY INTERVENTIONS FOR CHRONIC LOW BACK PAIN: A SYSTEMATIC REVIEW

Elizabeth S. Goldsmith^1,2; Nicholas Zerzan^1,3; Collin Calvert¹; Maylen Anthony^1,3; Tonya L. Rich^1,4; Adrienne Landsteiner^1,3; David T. Ewart^5,2; Wendy A. Miller⁶; David Thomas²; Caleb J. Kalinowski^1,3; Kristen Ullman^1,3; timothy wilt^1,3; Wei Duan-Porter^1,3. ¹Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN; ²University of Minnesota Twin Cities School of Medicine, Minneapolis, MN; ³Minneapolis Evidence Synthesis Core, Minneapolis, MN; ⁴Rehabilitation and Engineering Center for Optimizing Veteran Engagement and Reintegration, Minneapolis VA Medical Center, Minneapolis, MN; ⁵Rheumatology, Minneapolis VA Medical Center, Minneapolis, MN; ⁶Medicine, Hennepin Healthcare System Inc, Minneapolis, MN. (Control ID #4057909)

BACKGROUND: Chronic low back pain (cLBP) is a common cause of disability. Extended reality (XR) technologies, including fully immersive virtual reality (VR) and partially or minimally immersive augmented reality (AR), can deliver non-drug therapies for chronic pain. We completed a systematic review on benefits and harms of VR and AR interventions for cLBP.

METHODS: We searched MEDLINE, Embase, CINHAL, PsycINFO, and Scopus databases from inception to May 2023 for English-language articles of VR or AR cLBP interventions. Two independent reviewers screened abstracts, determined eligibility via full-text review using pre-specified criteria (eg, randomized clinical trials), and assessed risk of bias. Data abstraction was conducted by one reviewer and over-read by another. We classified intervention types by key content, including psychological skills development and physical activity. We conducted quantitative meta-analyses for ≥3 studies with sufficiently similar design, populations, interventions, comparators and outcomes. Otherwise, we provided narrative syntheses. We used GRADE to rate overall certainty of evidence (COE).

RESULTS: Among 10,932 unique citations, we identified 22 eligible trials assessing XR interventions for cLBP. All were rated some concerns (k=10) or high (k=12) for risk of bias. Six studies evaluated varied VR intervention types for cLBP; only one reported on adverse events (VR-associated dizziness in 15%). VR psychological skills, compared with VR control or usual care, may result in greater improvement in pain-related functioning and pain intensity in cLBP (low COE), but effects on adverse events are very uncertain (very low COE). All 16 AR studies evaluated AR physical activity cLBP interventions, compared most often with non-AR physical activity (k=10); only two studies addressed adverse events, with both reporting none. The effects of AR physical activity (compared with non-AR physical activity, medications, or usual care) on pain-related functioning, pain intensity, and adverse events in cLBP are very uncertain (very low COE).

CONCLUSIONS: Evidence on benefits and harms of XR interventions to treat cLBP is limited due to methodological concerns, small study size, and lack of reporting on adverse events. The role of immersion in digital environments also remains unclear. VR psychological skills interventions may have benefit in cLBP, but studies did not compare effects to non-VR interventions comprising similar psychological skills content. Minimally immersive AR physical activity did not demonstrate added value compared with non-AR physical activity, but fully immersive VR physical activity was not evaluated. Future work is needed to better understand how XR interventions may impact pain outcomes and add value to analogous non-XR pain interventions, particularly to overcome barriers to non-drug pain therapies in more diverse populations and settings. Larger studies informed by implementation science are important next steps to advance the field.

WHAT DO PATIENTS THINK ABOUT PERSON-CENTERED, HOLISTIC CARE? PERSPECTIVES FROM THE VETERANS HEALTH ADMINISTRATION

Ekaterina Anderson^1,4; Renda S. Wiener^2,5; Brianne K. Molloy-Paolillo¹; Megan McCullough^1,7; Bo Kim^2,8; Seppo Rinne^1,6; Jeanette I. Harris^3,9; Barbara G. Bokhour^1,4. ¹Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA; ²Center for Healthcare Organization & Implementation Research, Veterans Affairs Boston Healthcare System, Boston, MA; ³Mental Health, VA Maine Healthcare System, Augusta, ME; ⁴Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA; ⁵The Pulmonary Center and Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ⁶Division of Pulmonary and Critical Care Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ⁷Department of Public Health, Zuckerberg School of Health Sciences, University of Massachusetts Lowell, Lowell, MA; ⁸Department of Psychiatry, Harvard Medical School, Boston, MA; ⁹Department of Psychiatry, Regents of the University of Minnesota, Minneapolis, MN. (Control ID #4054670)

BACKGROUND: Moving away from the biomedical (illness-centered) model toward person-centered care is increasingly prioritized by health systems in the U.S. and abroad. Researchers have documented profound changes in clinicians’ attitudes and behaviors and shifts in care structures and processes involved in this undertaking. It is logical to posit that successful implementation of person-centered care also requires that patients themselves are able and willing to engage with this approach, yet this issue has been underexplored. The Veterans Heath Administration (VA) is a fortuitous setting to explore this issue. For over a decade, VA has been building a Whole Health (WH) system of care that holistically supports patients in pursuing health and wellness in line with what really matters to them. We sought to understand the VA patients’ familiarity with and openness to VA’s WH system of care, focusing on patients with chronic obstructive pulmonary disease (COPD) as individuals with a complex chronic condition well-positioned to benefit from WH.

METHODS: We conducted semi-structured qualitative interviews with 19 patients with COPD receiving care at a large urban VA Medical Center. Qualitative content analysis was used to generate themes.

RESULTS: Participants understood good care as inclusive of – although not limited to – person-centered care principles, i.e., involving a clinical team that listens to their concerns, displays empathy and respect, and knows them on a personal level. At the same time, participants were largely unfamiliar with WH as a designation for VA’s person-centered, holistic care system. Upon prompting by the interviewer, some were able to recall experiences that, in retrospect, aligned with the WH model; others, however, remained confused about what WH was. Finally, participants displayed a range of receptivity to WH. Whereas some were enthusiastic, others were disinterested or had reservations about the relevance of the WH model to their life and health.

CONCLUSIONS: VA is an internationally recognized leader in person-centered care implementation, with tremendous progress achieved in this sphere in the past decade. However, there are still opportunities to improve outreach to patients and address misconceptions that may prevent them from fully engaging with the WH system. This is particularly crucial for patients living with complex chronic conditions like COPD who stand to benefit greatly from WH. The implications of our findings reach beyond the VA context and are relevant to all general internists – a professional community that is particularly well-positioned by virtue of their training and scope of practice to embrace person-centered care. General internists may consider advocating for creation and maintenance of structures and processes that support person-centered care for the communities they serve, as well as taking advantage of and contributing to resources for patient education and outreach that raise awareness and address concerns about person-centered care.

WHAT IS THE RIGHT MIX? VARIATION IN THE PROPORTION OF PRIMARY CARE DELIVERED VIA VIDEO FOR VETERANS WITH COMMON CHRONIC CONDITIONS

Jacqueline Ferguson¹; Charlie Wray^3,2; Alison L. Greene¹; James Van Campen¹; Donna Zulman^1,4. ¹Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA; ²Medicine, University of California San Francisco, San Francisco, CA; ³Section of Hospital Medicine, San Francisco VA Health Care System, San Francisco, CA; ⁴Medicine, Stanford University, Stanford, CA. (Control ID #4062341)

BACKGROUND: Veterans’ sociodemographic characteristics such as age, gender, and urbanicity predict engagement in video-based care. However, it is unknown whether specific clinical (health) conditions are also associated with increased likelihood of video-based or phone-based care. In this evaluation, we characterized the proportion of patients’ primary care that is delivered via video and via phone by chronic conditions assessed in each encounter.

METHODS: We retrospectively identified over 17 million outpatient (evaluation and management) primary care encounters occurring between January 2020 and May 2022 among 5,273,758 Veterans active in the Veterans Health Administration (VHA). Encounters were classified by care modality (in-person, video, phone) and by 39 commonly treated chronic conditions using ICD-10 diagnoses codes associated with each visit. We calculated the proportion of video encounters (i.e., number of video encounters/ number of video+ phone + in-person encounters) and proportion of phone encounters for each chronic condition. We present the unadjusted percentage of care completed via video and phone by encounter diagnosis. We calculated the probability of an encounter being video-based or phone-based when a given encounter diagnosis is coded (i.e., average marginal effect) adjusting for patient characteristics (e.g., age, gender, rurality).

RESULTS: On average, 10.2% of encounters were video-based. Among the most prevalent conditions managed in primary care settings, the unadjusted proportion of care delivered via video ranged from 6.1% (Peripheral Vascular Disease) to 15.2% (Migraines). Conditions with a higher proportion of video encounters, after accounting for patient characteristics, include those with a diagnosis code of pressure and chronic ulcers, dementia, and Parkinson’s disease which may reflect higher video-based care utilization among homebound Veteran patients. Conditions with lower proportions of video-based care included COPD and acute myocardial infarction.

CONCLUSIONS: : Using a novel measure of virtual care delivery, we found variation in the proportion of visits delivered via video across common chronic conditions, after accounting for patient characteristics. Our findings suggest a Veteran’s chronic conditions, and the management of that condition (e.g., need for a physical exam), may impact whether they receive video care. Additional reasons for variability in the probability of an encounter being video-based by encounter diagnosis include unmeasured facility practice patterns, Veteran preference, and standards of care. Successful implementation of video care among chronic conditions with high levels of video care may be leveraged to support providers managing chronic conditions with lower levels of video care applications. The proportion of care delivered via video or phone may be a valuable measure for studies that seek to identify the optimal mix of virtual and in-person care for various clinical scenarios.

“IT MAKES ME TAKE A MORE COMPREHENSIVE APPROACH TO MY OWN HEALTH”: PERSPECTIVES FROM FREQUENTLY HOSPITALIZED PATIENTS ON PRIMARY CARE TEAM COMMUNICATION AND OUTREACH

Jasmine Rios¹; Jay Suh¹; Alicia Roberts²; Felicia Roberts²; David O. Meltzer³; Joyce W. Tang³. ¹Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²University of Chicago Division of the Biological Sciences, Chicago, IL; ³Hospital Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #4063863)

BACKGROUND: Comprehensive care programs aim to address the complex medical and social needs of frequently hospitalized patients. While the importance of provider-patient communication in such programs is well-established, research has since focused only on in-person communication. Between-visit communication is understudied and may be particularly crucial for patients managing multiple chronic conditions amid social disadvantages. This study aimed to describe patient experiences initiating and receiving communication from primary care teams and the impact of between-visit care on their well-being across three care models: CCP, C4P, and standard care.

METHODS: This qualitative study was embedded within the Comprehensive Care Physician (CCP) study, a randomized control trial to evaluate the impact of an interprofessional care team for frequently hospitalized patients at an academic medical center in the Mid-West Region. Semi-structured interviews were conducted with patients from each of the three care models (CCP, C4P, standard care). The CCP and C4P programs are comprehensive care programs distinguished by smaller patient panels, integrated inpatient and outpatient care by primary care physicians, and interprofessional team members. The C4P program also includes a community health worker, social needs screening, and cultural programming. Standard care patients receive outpatient care from typical academic primary care practices. All participants were Medicare Part A and B enrollees who received care in their respective programs for at least one year. The qualitative data were analyzed using template analysis involving deductive and inductive coding.

RESULTS: Twenty-one interviews were collected to date; 57% of participants were female, 91% were Black, and average age was 66 years (SD 11.6).

Three main themes emerged: 1) Patients had varied thresholds for engaging their primary care teams between visits, influenced by perceived need and relationships with their team; 2) Communication levels between visits influenced patient satisfaction with their primary care teams; 3) Patients perceived effective and timely communication between visits to positively impact their health by improving health awareness, supporting healthcare navigation, facilitating inter-specialty care coordination, and increasing access to social resources (e.g., food, transportation). There was an emerging trend suggesting that interprofessional care team members (e.g., social workers, nurses) contribute to enhanced provider-patient communication.

CONCLUSIONS: These findings highlight the role of effective and timely communication by primary care teams between visits, promoting patient satisfaction and health. More interviews (currently in progress) are needed to power direct comparison of care models. Overall, this study adds to the limited literature on comprehensive care programs and the significance of between-visit communication in enhancing patient care experiences.

Scientific Abstract - Health Care Policy and Health Services Research

ALLOPURINOL ADHERENCE IN US PATIENTS WITH GOUT: ANALYSIS OF THE MEDICAL EXPENDITURE PANEL SURVEY, 2018-2021

Kevin R. Riggs¹; Joshua S. Richman²; Andrea Cherrington¹; Emmitt Turner³; Jasvinder Singh³. ¹Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL; ²SURGERY, The University of Alabama at Birmingham, Birmingham, AL; ³The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL. (Control ID #4064054)

BACKGROUND: Gout is the most common inflammatory arthritis. Acute and chronic manifestations of gout can be reduced by medications that lower serum urate, though adherence to allopurinol–the most common urate lowering medication–is notoriously poor. The factors associated with allopurinol adherence, and whether allopurinol adherence is associated with lower healthcare utilization are not well known.

METHODS: We used 2018-2021 data from the Medical Expenditure Panel Survey (MEPS), a national survey on health care expenditures and utilization. MEPS collects information on health care use, diagnoses, socioeconomic characteristics, and other topics through direct interview, and validates information on medical care events by contacting providers and pharmacies identified by participants. Participants are typically followed for two years, though we evaluated each year separately. We calculated a medication possession ratio (MPR) for allopurinol for participants with gout and categorized each as no allopurinol, low-adherence (MPR ≤ 0.8), or high-adherence (MPR>0.8). We used multivariable logistic regression to identify factors associated with high-adherence, and multivariable linear regression to test whether allopurinol adherence was associated with utilization. We applied sampling weights to make representative estimates.

RESULTS: The analyses included 919 respondents (1453 person-years), representing a weighted total of 15,084,439 person-years. Participant characteristics and utilization outcomes are shown in the table. In multivariable models, Black race (OR 0.49, 95% CI 0.34-0.72 compared to White) and South region (OR 0.55, 95% CI 0.37-0.83 compared to Northeast) were negatively associated with high allopurinol adherence. Adherence was not associated with significant differences in utilization.

CONCLUSIONS: Race and region are associated with allopurinol adherence among US gout patients. Interventions to improve adherence, particularly among Black patients in the South, are needed to maximize benefits of allopurinol.

AMONG INDIVIDUALS WHO DIE OF COVID-19, IS THE PERCENTAGE WHO HAVE DIABETES ACTUALLY HIGHER THAN OTHER VIRAL INFECTIONS?

Neha V. Reddy²; Til Sturmer³; Virginia Pate³; Rachel Wong⁴; Jena Tronieri⁵; Jane Reusch⁹; Jeremy Harper⁸; Kenneth Wilkins⁶; Steven G. Johnson⁷; Carolyn Bramante¹. ¹Medicine, University of Minnesota Twin Cities, Minneapolis, MN; ²General Internal Medicine, University of Minnesota Medical School Twin Cities, Minneapolis, MN; ³Epidemiology, University of North Carolina, Chapel Hill, Chapel Hill, NC; ⁴Stony Brook University, Stony Brook, NY; ⁵University of Pennsylvania, Philadelphia, PA; ⁶National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD; ⁷Institute for Health Informatics, University of Minnesota, Minneapolis, MN; ⁸NA, Owl Health Works LLC, Indianapolis, IN; ⁹University of Colorado System, Denver, CO. (Control ID #4065165)

BACKGROUND: The New York Times exclaimed that '30 to 40% of all coronavirus deaths in the United States have occurred among people with diabetes.' It is unclear why this made headlines because this is the approximate prevalence of diabetes in seniors, the age group most susceptible to COVID-19 mortality. We hypothesized that among COVID-19 decedents, the proportion with diabetes is no higher than the proportion of diabetes among influenza decedents.

METHODS: We used the National COVID Cohort Collaborative (N3C) to calculate the proportion with diabetes among those with inpatient mortality after hospitalization for COVID-19 and compared it to the proportion with diabetes among those with inpatient mortality after influenza in Medicare data. The N3C analysis used COVID-19 hospitalization from March 2020 to February 2022, and the Medicare analysis used influenza hospitalizations in 2017. In both databases, diabetes was defined as any diagnosis code for diabetes (ICD-9 code 250.xx or ICD-10 code E10.xx, E11.xx) or any diabetes medication (ATC code starting with A1C), by prescription in the N3C or Part D claim in the Medicare database with any available look-back.

Death was defined as inpatient mortality for the encounter in which someone was admitted for COVID-19 (N3C) or Influenza (Medicare). The N3C database was restricted to adults over age 65, then the age distribution of death due to COVID-19 in the N3C was calculated within 5-year age strata from 65 to 90+ years. These age-specific weights were used to multiply the stratum-specific percentage with diabetes for those with in-patient mortality from influenza in Medicare. The average of these products represents the percent of individuals dying of influenza who had diabetes, if those dying from influenza in Medicare had the same age distribution as those dying from COVID-19 in N3C.

RESULTS: Among seniors with inpatient mortality from COVID-19, 46.6% had diabetes. Among seniors with inpatient mortality from influenza, 61.2% had diabetes. When this Medicare data was age-standardized to match the N3C COVID-19 data, the percentage of influenza decedents with diabetes was 63.2%.

CONCLUSIONS: Among seniors with inpatient mortality from COVID-19, the proportion with diabetes was lower than the proportion with diabetes among seniors with inpatient mortality from influenza. News media should not have sensationalized the percentage of individuals with diabetes among adults dying of COVID-19. It is notable that among Medicare recipients dying of influenza, over 60% had diabetes. This analysis should not be considered a causal analysis nor an analysis of the risk of mortality in seniors with diabetes. Diabetes affects approximately 29.2% of adults aged 65 and older in the US and is a serious risk factor for mortality from any cause. Diabetes treatments and prevention remain critical to population health in the US.

Among seniors dying from influenza or COVID-19, a greater proportion had diabetes among the influenza decedents than among COVID-19 decedents.

A NATIONALLY REPRESENTATIVE SURVEY OF US VETERANS’ EXPERIENCES WITH VA AND NON-VA HEALTHCARE

Terrence Liu^1,2; Claire Robinson²; Nora Metzger²; Erica M. Paulos²; Brady West³; Megan E. Vanneman^4,5; Tanner Caverly^1,2; Eve Kerr^1,2; Jane Forman²; Angela Fagerlin^4,5; Jeffrey T. Kullgren^1,2. ¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²HSR&D, VA Ann Arbor Healthcare System, Ann Arbor, MI; ³Learning Health Sciences, University of Michigan, Ann Arbor, MI; ⁴Population Health Sciences, University of Utah Health, Salt Lake City, UT; ⁵VA Salt Lake City Health Care System, Salt Lake City, UT. (Control ID #4062302)

BACKGROUND: Veterans navigating healthcare face many choices, including whether to seek care in VA and/or non-VA settings. Such decisions are often informed by personal experiences such as timeliness, affordability, quality, and patient-centeredness of the care they receive. However, no studies have comprehensively described how Veterans experience care they receive within VA, in non-VA settings, or both. As national policies have expanded where Veterans can choose to receive care, our objective was to examine how Veterans experience healthcare in different settings to help them make well-informed healthcare decisions that will meet needs and expectations.

METHODS: We conducted a survey in November 2022 with Ipsos KnowledgePanel, an online survey panel designed to be representative of the US population. Self-identified Veteran respondents (n=3,019) were asked if in the last 12 months they had used VA care (defined as care received at VA facilities or VA-financed care received in the community), non-VA care, or both. Respondents were asked to rate the timeliness, affordability, perceived quality, and patient-centeredness of care received in the last 12 months. We used multivariable logistic regression to estimate associations between healthcare setting (i.e., use of VA care only, non-VA care only, or both VA & non-VA care) and perceptions of timeliness, affordability, perceived quality, and patient-centeredness of their care. We used sample weights to account for sampling design and nonresponse to yield nationally representative estimates. Using estimated coefficients from regression models, we report marginal estimates of adjusted prevalence of Veteran healthcare experiences.

RESULTS: In multivariable analyses, healthcare setting was not significantly associated with Veterans’ perceptions of the quality, affordability, or patient-centeredness of their care. However, healthcare setting was associated with Veterans’ perceptions of the timeliness of their care, depending on the type of care received. For Veterans who had used urgent care, use of only non-VA care was significantly associated with perceptions of care being timelier, compared to those who only used VA care (81.2% vs 72.5%,p<0.05). For Veterans who used specialty care, use of only non-VA care was significantly associated with perceptions of care being timelier, compared to those who used both VA and non-VA care (73% vs 65.2%,p<0.05).

CONCLUSIONS: In this nationally representative survey, Veteran perceptions of the quality, affordability, or patient-centeredness of their care did not significantly differ by their use of VA or non-VA care. However, when seeking urgent or specialty care, Veterans who only used non-VA care were more likely to report timely care. As we defined VA care to include VA-financed care received in the community, these findings may reflect persistent challenges in access and/or expectations in accessing urgent and specialty care through the VA despite efforts to expand access, including under the MISSION Act.

A NOVEL AUTOMATED ALGORITHM TO IDENTIFY LUNG CANCER SCREENING FROM FREE TEXT FIELDS OF RADIOLOGY ORDERS OUTPERFORMS BILLING CODES

Alison S. Rustagi^1,2; Francis J. Graham³; Emily Lum³; Marzieh Vali³; Salomeh Keyhani^1,2. ¹Dept of Medicine, University of California San Francisco, San Francisco, CA; ²San Francisco VA Health Care System, San Francisco, CA; ³Northern California Institute for Research and Education, San Francisco, CA. (Control ID #4064478)

BACKGROUND: Lung cancer screening (LCS) via low dose computed tomography (LDCT) can prevent death from lung cancer. Research on LCS in community settings has used billing codes, which could artificially inflate the number of abnormal scans, diagnostic procedures, and lung cancer diagnoses by including imaging prompted by signs/symptoms of disease. Manual chart review is the gold standard to identify diagnostic tests but is time intensive. We sought to validate an algorithm to automatically identify chest imaging exams done for lung cancer screening, utilizing free text fields of VA radiology orders.

METHODS: We iteratively developed a four-step algorithm: (1) identify outpatient LDCTs from billing and outpatient clinic stop codes, then search free text fields in radiology orders for (2) screening terms (e.g., low dose, screen) and (3) signs/symptoms of disease (e.g., cough), and (4) remove LDCTs that were prompted by signs/symptoms of disease and/or lack screening terms. To validate this algorithm, we applied it to scans received by a nationally representative sample of community-dwelling Veterans ages 65-80 enrolled in a prospective cohort with detailed smoking assessment to verity LCS eligibility. We randomly selected scans for manual chart review, oversampling from screening scans to maximize algorithm specificity. Trained chart abstractors reviewed medical record notes to ascertain if a scan was prompted by signs/symptoms of lung cancer or other disease (i.e., diagnostic) or to detect asymptomatic lung cancer (i.e., screening).

RESULTS: From among n=3,077 Veterans, 508 were LCS-eligible and 2,569 were ineligible. In total, these Veterans received n=1,279 CT scans of the chest in the five years before cohort enrollment. Chart review was conducted on n=80 scans (51 screening, 29 diagnostic). Among LCS-eligible individuals, the algorithm was significantly more sensitive (80%, 95% CI: 63-92% versus 29%, 17-44%) and more specific (90%, 55-100%) than billing codes alone (sensitivity: 29%, 17-44%; specificity: 86%, 68-96%). 97% (82-100%) of scans classified as screening via the algorithm were truly screening upon chart review. Using billing codes alone, 21% (6-46%) of 19 scans classified as “screening” were prompted by signs/symptoms of disease.

CONCLUSIONS: An automated algorithm incorporating free text fields of VA radiology orders is more sensitive and more specific to identify screening LDCTs than billing codes. Relying on billing codes alone may bias estimates of abnormal scans, diagnostic procedures, and lung cancer diagnoses after LCS. This validated algorithm can rapidly identify screening versus diagnostic LDCTs, a necessary first step to an unbiased analysis of LCS using the full breadth of data available in the VA.

A PRAGMATIC RANDOMIZED CONTROLLED TRIAL COMPARING THE EFFECTIVENESS OF CULINARY MEDICINE AND MEDICAL NUTRITION THERAPY ON GLYCEMIC CONTROL AND DIET IN PATIENTS WITH UNCONTROLLED DIABETES

Carolyn Smith-Morris³; Jaclyn L. Albin^1,2; Molly McGuire¹; Vincent Merrill¹; Guadalupe I. Perez¹; Melissa Mendez²; Rebecca Chrasta²; Milette Siler⁴; Miguel A. Lopez⁵; Sandi L. Pruitt³; Patricia M. Chen³; Michael E. Bowen^1,2. ¹The University of Texas Southwestern Medical Center Department of Internal Medicine, Dallas, TX; ²Parkland Health, Dallas, TX; ³O'Donnell School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX; ⁴Culinary Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ⁵Gretchen Swanson Center for Nutrition, Omaha, NE. (Control ID #4064373)

BACKGROUND: Healthy eating is foundational to diabetes management, and Medical Nutrition Therapy (MNT) can improve glycemic control in patients with diabetes. However, the effectiveness of dietitian-led Culinary Medicine (CM) that teaches nutrition with hands-on, experiential cooking classes to improve glycemic control is unknown.

METHODS: We conducted a pragmatic trial comparing the effectiveness of six virtual CM classes with a registered dietitian (RD), CM certified instructor, and six health system RD-delivered MNT visits on glycemic control (A1c). CM classes and MNT visits were delivered in English or Spanish per patient preference and occurred monthly for six months. Patients with type 2 diabetes and an A1c ≥ 7.0% were recruited from a primary care clinic within an integrated, safety net healthcare system. All participants received basic cooking supplies, access to food assistance from a local food pantry, and milestone-based study incentives. CM participants also received basic cooking spices/oils and a $10 grocery gift card per class. Participants completed survey measures at baseline and six months, and A1c values collected in routine clinical practice were extracted from the electronic health record (EHR). We examined within and between group change in A1c using nonparametric tests, and Mediterranean Diet Score (MEDILITE) was examined using a difference in differences analysis.

RESULTS: We randomized 79 participants (43 MNT; 36 CM) between November 2021 and January 2023. Baseline characteristics (median age 50; median BMI 32.8; 65% female; 51% Hispanic; 20% NH Black; 6 % NH White; 65% with hypertension; 41% on insulin; median A1c 8.9%) were similar between groups. Participants with complete data at baseline and 6 months were included in A1c (N=48; 30 MNT and 18 CM) and MEDILITE (N=53; 27 MNT and 26 CM) analyses. Median A1c decreased similarly between baseline and 6 months in both MNT (-0.65%; p<0.01) and CM (-0.60%; p=0.22) groups. There was no difference in A1c change between groups at 6 months (p=0.53). The within group change in MEDILITE score between baseline and 6 months was significant in the CM group (1.7; p=0.008) but not in the MNT group (0.6; p=0.247). Between group change in MEDILITE at 6 months was not significant (p=0.18).

CONCLUSIONS: Both MNT classes and virtual CM classes resulted in clinically meaningful reductions in A1c. CM classes may have a greater impact on the adoption of Mediterranean diet principles than MNT. Additional longitudinal studies evaluating the impact of CM on glycemic control and dietary measures are needed.

A QUALITATIVE ANALYSIS OF PATIENTS’ AND PHYSICIANS’ PERCEPTIONS, ATTITUDES, AND BEHAVIORS TOWARD BILLING FOR ELECTRONIC COMMUNICATION

Jordan Alpert¹; Elizabeth R. Pfoh²; Victoria Criswell²; Maria C. Tang³; Elizabeth E. Stanley⁴; Sandra Hong⁵; Robert Saper⁶; Eric Yudelevich⁷; Michael B. Rothberg⁸. ¹Center for Value-Based Care Research, Cleveland Clinic, Cleveland Clinic, Cleveland, OH; ²Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ³Primary Care Pediatrics, Cleveland Clinic, Cleveland, OH; ⁴Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH; ⁵Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, OH; ⁶Wellness and Preventative Medicine, Cleveland Clinic, Cleveland, OH; ⁷General Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; ⁸Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4047337)

BACKGROUND: Patient-physician communication via the patient portal, also known as secure messaging (SM), is valued by patients as a convenient way to ask questions and address concerns. However, increased use of SM has negatively impacted physicians’ workloads. As a result, several health systems now bill patients and/or insurance for SM if a response requires more than a few minutes of physician time. We interviewed patients and physicians to determine whether the policy has altered attitudes towards SM and communicative behaviors.

METHODS: Patients were eligible to participate if they were ≥18 years of age, seen by a primary care physician in the last two years, and sent ≥1SM in the current year. As part of a larger study, patients previously indicated they were willing to be interviewed. All primary care physicians affiliated with the health system were eligible to participate and sent an invitation. Interviews were conducted using a semi-structured interview guide tailored for each population. Questions focused on education about the policy, initial attitudes, and whether messaging behaviors changed once the policy was in place. Interviews were recorded and transcribed. We analyzed the interview transcripts using an inductive, thematic approach.

RESULTS: Of 52 patients contacted from July - October 2023, 13 (25%) participated. Patients averaged 58 years old (range: 43-76), 69% were white, 23% black, and 62% female. Of 49 physicians contacted, 16 (33%) enrolled. Physicians represented 12 practices, averaged 13 years of experience (range: 1-22), and 63% were female.

Analyses revealed 3 emergent themes: 1) Uncertainty. Patients unsure about sending a message. They were unaware whether their question was “medical advice” and apprehensive about possibly being charged, although financial consequences were considered minor. Physicians believed the billing criteria was ambiguous; 2) Revised expectations. If billed, patients expected faster replies with more detail compared to non-billed messages, and physicians believed the policy would credit them for the work required to answer messages; 3) Anticipated consequences. Patients believed the policy was fueled by greed, which lowered their opinion of the health system, while physicians were concerned that the policy could negatively affect the patient-physician relationship. Physicians thought that billing might cause patients to conceal information and could make communication feel transactional.

CONCLUSIONS: Billing for SM communication impacts patients and physicians. The policy may reduce inboxes due to patients’ sending fewer SMs and could credit physicians for their work. However, the policy evokes negative feelings toward the health system and may suppress important patient-physician communication.

A QUALITATIVE STUDY TO INFORM INTERVENTIONS FOR ADDRESSING FINANCIAL TOXICITY IN PATIENTS WITH MULTIMORBIDITY

Caroline Sloan^1,2; Hudson Hazlewood³; Michael A. Lourie¹; Cara McDermott^1,2. ¹Medicine, Duke University School of Medicine, Durham, NC; ²Duke Margolis Center for Health Policy, Washington, DC; ³Population Health Sciences, Duke University School of Medicine, Durham, NC. (Control ID #4059143)

BACKGROUND: Almost 50% of US patients struggle to pay for their healthcare, especially when they have multimorbidity (2+ chronic conditions). “Financial toxicity” describes the emotional and financial stress associated with unaffordable medical costs and is associated with worse disease control and quality of life. Primary care clinics may serve as a source of resources and advice for patients experiencing financial toxicity. In this qualitative study, we explored the lived experiences of patients facing financial toxicity, as well as the primary care clinic staff who provided their care. The objective of our study was to explore ideas for future interventions to address financial toxicity in patients with multimorbidity.

METHODS: We conducted semi-structured interviews with 8 patients who had >2 of 5 pre-defined conditions (heart failure, coronary artery disease, diabetes, chronic obstructive pulmonary disease, hypertension), took >5 medications, and received primary care at one safety-net clinic. We asked patients to describe material and psychosocial experiences with financial toxicity. We conducted two focus groups with staff from the same clinic to discuss their experiences and to elicit ideas for financial toxicity interventions. We analyzed transcripts using rapid qualitative analysis.

RESULTS: Patients were aged 47-67 years. Most were male (6/8) and enrolled in Medicaid (6/8) or Medicare (3/8). On average, they had 3 conditions and were prescribed 8 medications. Patients described their financial toxicity as a dynamic interaction between medical costs (“Surprise billing is what really throws me under the bus because I live on a fixed income”), non-medical costs (“Make sure I got enough gas to get back and forth to the doctors”), financial prioritization (“I’ve gotta eat first, so medicine comes second”), and financial reserve (“I couldn't afford that if it wasn’t for Medicaid”). Clinic staff included 3 physicians, 2 nurse practitioners, 1 pharmacist, 1 nurse, and 1 social worker. They noted health system-level financial barriers (“many…are being sent to a clinic not on the bus line”) and expressed frustration with these barriers (“you feel like: ‘I think I know how to solve problems, but apparently I don't because the system's telling me no”). They also described many of their own financial prioritization strategies (“We're just gonna have to go with something else”). Our findings will inform future interventions for addressing financial toxicity in primary care settings.

CONCLUSIONS: Financial toxicity in multimorbidity stems from a complex interplay between high costs, insufficient financial reserve, and prioritization. It impinges on patients’ medical care and outcomes while leading to moral injury among staff. As multimorbidity incidence and healthcare costs rise in an aging population, clinical tools and interventions are needed to detect financial toxicity and mitigate its impact on clinical outcomes and quality of life.

A RANDOMIZED CONTROLLED TRIAL OF AN INTERVENTION INCORPORATING BEHAVIORAL ECONOMICS AND SELF-DETERMINATION THEORY TO IMPROVE PATIENT ENGAGEMENT IN DIABETES PREVENTION

Jeffrey T. Kullgren^1,2; Shelley Stoll²; Eli Carter²; Harita Vadari²; Kenneth Resnicow²; William Herman²; H. M. Kim^2,1; Laura McEwen²; Kevin G. Volpp^3,4; Michele Heisler⁵. ¹VA Ann Arbor Healthcare System, Ann Arbor, MI; ²University of Michigan, Ann Arbor, MI; ³University of Pennsylvania, Philadelphia, PA; ⁴Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA; ⁵Internal Medicine, Ann Arbor VA/University of Michigan, Ann Arbor, MI. (Control ID #4065011)

BACKGROUND: Participation in the Diabetes Prevention Program (DPP) and use of metformin each can prevent or delay the onset of type 2 diabetes mellitus (T2DM) among patients with prediabetes. Yet, even when these evidence-based strategies are accessible and affordable, uptake is low. We tested whether novel and scalable behavioral strategies to increase internal (i.e., autonomous) motivation to prevent T2DM, external (i.e., extrinsic) motivation to prevent T2DM, or both could reduce hemoglobin A1c (HbA1c) and weight, and increase engagement in evidence-based strategies to prevent T2DM among patients with prediabetes.

METHODS: In this parallel design trial with individual randomization, participants were adult patients < 65 years old of a Midwest academic medical center who had prediabetes (HbA1c 5.7% to 6.4%) and private health insurance that covered both the DPP at no cost and metformin with little to no copayment. Participants were randomized to one of four arms for 12 months. Control Arm participants received usual care and educational text messages about preventing T2DM. Incentives Arm participants received the Control Arm intervention plus variable monthly financial incentives of $50 to $250 for DPP participation or metformin use. Tailored Messages Arm participants received the Control Arm intervention plus tailored text messages promoting autonomous motivation for preventing T2DM. Combined Arm participants received the Incentives Arm and Tailored Messages Arm interventions plus text messages to increase the personal salience of financial incentives. The primary outcome was 12-month change in HbA1c. Secondary outcomes were 12-month change in body weight, DPP participation, and metformin use across the 12 study months. The primary analytic approach used ordinary least squares regression models for continuous outcomes. All analyses used an intent-to-treat approach.

RESULTS: Among the 380 participants with prediabetes, 40% were men, 68% reported their race/ethnicity as white non-Hispanic, and the mean age was 53.7. There were no statistically significant differences across arms in 12-month changes in HbA1c or weight. However, mean months of participation in the DPP or use of metformin were significantly higher in the Incentives Arm [6.5, P < 0.0001] and the Combined Arm (7.2, P < 0.0001) compared to the Control Arm (3.6).

CONCLUSIONS: Both monthly financial incentives for DPP participation or metformin use and such incentives combined with tailored text messages promoting autonomous motivation for preventing T2DM significantly increased engagement in evidence-based strategies to prevent T2DM. However, this increased engagement did not result in significantly greater improvements in HbA1c or weight. Additional strategies may be needed to ensure that increased engagement in strategies to prevent T2DM translate into meaningful changes in clinical outcomes for patients.

ASSESSING THE VOLUME-OUTCOMES RELATIONSHIP FOR PHYSICIANS PRACTICING IN NURSING HOMES

Brandi Peacock¹; Ziwei Pan¹; Seiyoun Kim²; Hye-Young Jung³; Kira Ryskina¹. ¹Medicine, University of Pennsylvania, Philadelphia, PA; ²School of Medicine, University of Pennsylvania, Philadelphia, PA; ³Weill Cornell Medicine, New York, NY. (Control ID #4055888)

BACKGROUND: More than 2 million individuals receive post-acute care in 15,600 US nursing homes (NH) annually. The outcomes of care for these patients are poor and variable across facilities and the key drivers of the variation are not well understood. While the volume-outcomes relationship has been well documented in other clinical settings, little is known about the role of physician patient volume in post-acute care outcomes in NHs.

METHODS: This was a retrospective cross-sectional study using Medicare Part A and Part B claims and nursing home Minimum Data Set files from 2012 to 2019. Medicare fee-for-service beneficiaries with continuous coverage, who were 65 years of age or older, were hospitalized and discharged to a nursing home for post-acute care and were seen by a generalist physician (internal medicine, family medicine, general practice, or geriatrics) during their stay were included in analysis. Physician patient volume was measured by counting the number of unique patients seen by each physician and categorized into deciles. Four risk-adjusted outcomes of NH care – 30-day rehospitalization, 30-day emergency department (ED) visit, successful discharge to community, and functional improvement at discharge – were measured using Medicare’s quality measures specifications. We used linear probability regression to measure the association between each of the four outcomes and the decile of physician patient volume. Models were adjusted for NH characteristics, and included year and facility fixed effects.

RESULTS: Our sample included 6,199,784 patients. Patients treated by small volume physicians were older, more likely to be white and more likely to be female compared to patients of high-volume physicians. Lower patient volume was associated with higher rate of rehospitalization and ED visits, and with lower likelihood of successful discharge to community and lower functional improvement at discharge from post-acute care in NHs (Figure).

CONCLUSIONS: Patients of higher-volume physicians have better NH post-acute care outcomes. These findings may inform educational initiatives for physicians practicing in NHs, regulatory interventions, and staffing practices in NHs.

ASSESSMENT OF ENDPOINTS AND POSTMARKETING REQUIREMENTS FOR FDA BREAKTHROUGH THERAPIES, 2013-2023

Maryam Mooghali¹; Joshua D. Wallach²; Joseph S. Ross¹; Reshma Ramachandran¹. ¹General Internal Medicine, Yale School of Medicine, New Haven, CT; ²Emory University, Atlanta, GA. (Control ID #4047854)

BACKGROUND: The FDA awards Breakthrough Therapy designation to expedite development and review of drugs intended to treat serious conditions when preliminary clinical evidence demonstrates potential substantial improvement over existing therapies on a clinically significant endpoint. These endpoints could be clinical outcomes or surrogate markers, which serve as substitutes for a direct measure of patient function or survival. Previous research showed that surrogate markers may not have a strong correlation with overall survival or quality of life, necessitating postmarketing studies confirming clinical benefit of therapies approved based on trials using surrogate markers. Accordingly, we evaluated the primary endpoints used in pivotal clinical trials supporting FDA Breakthrough Therapy approvals and determined whether postapproval studies confirming efficacy were required by the FDA for indications approved based on pivotal trials using surrogate markers as primary endpoints.

METHODS: We used FDA’s Breakthrough Therapy Approvals reports to identify original approvals for Breakthrough Therapy-designated drugs and biologics as of June 30, 2023. Next, using Drugs@FDA database, we identified approval pathway and primary endpoints for pivotal trials supporting approvals. For indications approved based on only surrogate markers as primary endpoints, we compared endpoints with those listed in FDA's Surrogate Endpoints Table and determined whether any postmarketing requirements or commitments for confirming efficacy were required.

RESULTS: From 2013-2023, FDA approved 147 original indications with Breakthrough Therapy designation, of which 51 (35%) and 96 (65%) were granted accelerated and traditional approval, respectively. All accelerated approval indications were approved based on pivotal trials with surrogate markers as primary endpoints. Of these, 50 (98%) indications had surrogate markers that were described in FDA’s Surrogate Endpoint Table for the same indication. Among traditional approval indications, 52 (54%) were approved based on pivotal trials with surrogate markers as primary endpoints, of which 34 (65%) had pivotal trials with surrogate markers that were included in FDA’s Surrogate Endpoint Table for the same indication. Postapproval studies confirming efficacy were required for all 51 Breakthrough therapies receiving accelerated approval and for 3 (6%) Breakthrough therapies approved based on surrogate markers under traditional pathway.

CONCLUSIONS: Trials supporting FDA Breakthrough Therapy approvals often use surrogate markers. For indications with traditional approval, many of these markers are not currently recommended by FDA, and manufacturers are often not required to complete postmarketing studies to confirm the expected clinical benefit. Frequent use of surrogate endpoints for Breakthrough Therapies without requiring confirmation of clinical benefit could create uncertainty for clinicians and patients around the efficacy of such treatments.

ASSOCIATIONS BETWEEN SOCIAL AND PHYSICAL ISOLATION, MATERIAL DEPRIVATION, AND INADEQUATE PREVENTIVE HEALTHCARE UTILIZATION IN THE US

Sunny Han²; Lora Stoianova¹; Jacob Riegler¹; David Karjala¹; Preston Williams¹; Gauthami Balagopal¹; Ian Dwyer²; Aditya Chennojwala¹; Adam Gaffney³; Danny McCormick⁴; Charlotte Rastas¹. ¹Internal Medicine, Cambridge Health Alliance, Cambridge, MA; ²Medicine, Cambridge Health Alliance, Cambridge, MA; ³Medicine, Harvard Medical School, Boston, MA; ⁴medicine, Cambridge Health Alliance, Cambridge, MA. (Control ID #4064778)

BACKGROUND: The 2023 Report of the US Surgeon General highlighted the adverse health impacts of social isolation. Physical isolation has also been linked to poor health. Recent national data on the association of each form of isolation with preventive care uptake and with material deprivation — potential drivers of poor health outcomes among the isolated — are lacking, and could inform policy.

METHODS: We analyzed data from the 2022 Behavioral Risk Factor Surveillance System, which included a new social equity module used by 42 US states/territories. We examined two exposures: (1) self-reported social isolation (always/usually/sometimes vs. rarely/never) and (2) physical isolation (inadequate transportation in past year). We examined characteristics of adults with and without each form of isolation, including six indicators of material deprivation, and then analyzed the association between each form of isolation and six preventive healthcare services (three types of vaccines, and three types of cancer screening, among target populations) before and after adjustment for confounders.

RESULTS: Our study population included n=281,592 adults with data on either social (32% prevalence) or physical (8% prevalence) isolation. Each form of isolation was associated with material deprivation, including low income, recent employment loss, food insecurity, inability to afford housing or utility bills, and inadequate health insurance. In unadjusted analyses, both forms of isolation were associated with reduced uptake of most forms of preventive healthcare (Table). With multivariable adjustment, physical isolation remained associated with three forms of preventive healthcare uptake; for social isolation, it resulted in non-significance or reversed associations for several care measures.

CONCLUSIONS: Social and physical isolation are each associated with high levels of material deprivation and reduced preventive care utilization, although the association between social isolation and preventive care is inconsistent after adjustment for confounders. Mitigating the adverse health effects of isolation may require broader investment in material conditions and healthcare access for isolated individuals.

BUNDLED PAYMENTS FOR OUTPATIENT SPINE SURGERY ARE ASSOCIATED WITH REDUCED SPENDING AND HOSPITAL READMISSIONS

Grace Y. Ng¹; Austin S. Kilaru²; Erkuan Wang⁵; Qian E. Huang⁵; Jingsan Zhu⁵; Joshua M. Liao⁴; Deborah Cousins⁵; Torrey Shirk⁵; Neil R. Malhotra³; Amol S. Navathe⁵; Aidan P. Crowley⁶. ¹Neurosurgery, Massachusetts General Hospital, Boston, MA; ²Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁴Medicine, University of Washington, Seattle, WA; ⁵Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; ⁶Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4065088)

BACKGROUND: The volume of outpatient surgical procedures has increased dramatically, now comprising approximately half of all surgeries. The impact of value-based payment programs, including bundled payments, on spending and quality for outpatient surgery has not been previously reported. Medicare introduced bundled payments for outpatient procedures for the first time in the Bundled Payments for Care Improvement – Advanced (BPCI-A) model. Our objective was to evaluate the effect of hospital participation in BPCI-A for back and neck (except spinal fusion) surgeries (BNESF) on healthcare spending and quality.

METHODS: We conducted a retrospective cohort study using Medicare claims data for beneficiaries undergoing BNESF surgery between 2013 and 2019. We identified acute care hospitals that voluntarily participated in the BPCI-A model for BNESF, with separate analyses for outpatient and inpatient episodes. We used propensity score matching to identify comparison groups of similar hospitals that did not participate in BPCI-A. We used a differences-in-differences method to evaluate changes in outcomes after the model began in 2018, adjusting for hospital, market, and patient characteristics. The primary outcome was 90-day total episode spending. Secondary outcomes included 90-day hospital readmissions.

RESULTS: 14,280 beneficiaries received outpatient BNESF at 19 participating and 57 matched non-participating hospitals (mean age 72 years; 44% female). 23,440 beneficiaries received inpatient BNESF at 41 participating and 123 matched non-participating hospitals (mean age 73 years; 45% female). In adjusted analyses, participation in outpatient episodes was associated with reduced spending (-$1201; 95%CI -2184 to -219). Inpatient episode participation was not associated with reduced spending (-$217; 95%CI -2334 to 1990). Participation in outpatient episodes was associated with reduced 90-day readmissions (-2.2%; 95%CI -4.2 to -0.01). Inpatient participation was not associated with reduced readmissions (3.4%; 95%CI -0.4% to 7.1%).

CONCLUSIONS: Bundled payments for outpatient spine surgery episodes were associated with significant reductions in total episode spending and 90-day readmissions. Future analyses should evaluate additional outpatient procedures, over a longer period, in value-based payment models. Bundled payments may be an approach to improve value for services delivered in the outpatient setting.

CHANGES IN MEDICARE SPENDING ON LOW AND HIGH VALUE BREAST CANCER SCREENING

Ilana Richman¹; Jessica B. Long²; Meghan Lindsay¹; Cary P. Gross¹. ¹Department of Medicine, Yale University, New Haven, CT; ²General Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4060992)

BACKGROUND: Over the past decade, breast cancer screening has changed substantially, with the development of digital breast tomosynthesis (DBT) and the addition of supplemental screening for women with dense breasts. Although these newer approaches may provide small benefits, they have not been shown to be cost-effective. The goal of this study was to quantify spending on high versus low value breast cancer screening in Medicare during a period of rapid technological change.

METHODS: This was a serial cross sectional study using data from SEER-Medicare from 2009-2019. We included women 66 and older enrolled in Medicare fee-for-service who did not have a history of breast cancer. From this group, we identified women who underwent screening mammography in each year. We categorized screening as either high value (2-dimensional screening mammography for women 66-79) or low value (2D screening mammography for women 80 and older, use of digital breast tomosynthesis or supplemental ultrasound at any age) based on consistent, high quality cost effectiveness analyses in the published literature. Using this framework, we evaluated trends in breast cancer screening test utilization, and average expenditures on high and low value screening per screened beneficiary. We then estimated total spending on screening for the full Medicare population, based on test use, cost, and screened population size. All costs were inflated to 2019 dollars.

RESULTS: Our sample included approximately 300,000 Medicare beneficiaries in each year. Screening use was stable for women 66-79 over time at 40% each year. For women 80 and older, screening declined from 18% in 2009 to 12% in 2019. Among screened women, average cost rose from $158 (95% CI 157-158) in 2009 to $185 (95% CI 185-186) in 2019. The cost of high value screening was stable, at $122 (95% CI 121-122) per screened woman in 2009 and $121 (95% CI 121-122) in 2019, low value screening costs increased from $36 (95% CI 35-36) to $64 (95% CI 64-65). From 2009-2019, total spending on high value screening in Medicare rose from 873 million to 1.07 billion, a 22% increase, while spending on low value screening rose from 223 million to 588 million, a 164% increase (Figure).

CONCLUSIONS: Although screening in populations for which screening is low value has declined, total spending on low value screening in the Medicare population has risen considerably, driven by use of newer screening technologies

CHARACTERISTICS AND CLINICAL CONTEXT OF OUTPATIENT OPIOID TREATMENT THROUGH VA CARE IN THE COMMUNITY

Wei Duan-Porter^1,2; Andrea Cutting¹; Catherine Sowerby¹; Collin Calvert^1,2; Beth DeRonne¹; Susan Diem^1,2; Kristine Ensrud^1,2; Erin E. Krebs^3,2; Hanna Lefchak¹; Orly Vardeny^1,2; Siamak Noorbaloochi^1,2; Michele Spoont^1,4; Lisa Anderson⁵. ¹VA Center for Care Delivery and Outcomes Research, Minneapolis, MN; ²Medicine, University of Minnesota Twin Cities, Minneapolis, MN; ³Medicine, Minneapolis VA Health Care System, Minneapolis, MN; ⁴Psychiatry & Behavioral Sciences, University of Minnesota Twin Cities School of Medicine, Minneapolis, MN; ⁵Pharmacy, Minneapolis VA Medical Center, Minneapolis, MN. (Control ID #4056861)

BACKGROUND: Since 2013, the Department of Veterans Affairs (VA) Opioid Safety Initiative has expanded resources for pain management and reduced high-risk opioid prescriptions across VA facilities. In 2019, MISSION Act expansion of VA Care in the Community (CITC)—VA-purchased services provided by non-VA facilities and clinicians. This included greater authorization for CITC-prescribed medications to be filled by VA pharmacies, including opioids for outpatient pain management. The MISSION Act also charges VA to ensure that CITC-prescribed opioids meet VA standards for safety and appropriateness. However, past studies reported substantial challenges in communication and tracking infrastructure for CITC-prescribed medications, raising concerns about risks related to CITC-prescribed opioids. To properly evaluate risks and pain outcomes associated with CITC-prescribed opioids, it is important to first understand how patient, community, and clinical factors affect the likelihood of veterans receiving CITC vs. VA-prescribed opioids.

METHODS: We used VA data (June 2022-May 2023) to identify veterans who received outpatient opioids with a minimum prescribed duration of 2 weeks, excluding those with a diagnosis of cancer, palliative care, or opioid use disorder. We determined receipt of CITC-prescribed opioids using VA prescription and prescriber data. Veteran demographics and medical conditions were identified using VA data. To assess clinical context of opioid prescriptions, data on clinical training and specialty of prescribers were obtained from the National Provider Identifier (NPI) Registry.

RESULTS: We identified 111,919 veterans who received opioids for outpatient pain treatment, 12.5% (n=14,020) of these with CITC-prescribed opioids. Veterans receiving CITC-prescribed vs. only VA-prescribed opioids were slightly younger (mean age 63.8 [SD 13.03] vs. 65.3 [12.99]), and more likely to live in rural communities (50.4% vs. 42.3%). CITC-prescribed opioids were also more often related to post-surgical (18.5% vs 6.0%) or pain specialist care (24.0% vs 4.1%). The prevalence of chronic medical conditions and pain diagnoses was similar for veterans receiving CITC vs. only VA-prescribed opioids.

CONCLUSIONS: Receipt of CITC-prescribed opioids was more common in veterans residing in rural settings and those receiving specialty care, such as surgical referrals. These findings are consistent with higher CITC utilization in rural areas and frequent use of CITC referrals for surgical and procedural indications. Future evaluations of opioid safety and pain treatment outcomes from CITC referrals must account for differences in veteran characteristics and clinical context of treatment.

CHARACTERISTICS OF HOSPITALS WITH REAL-TIME PRESCRIPTION BENEFIT TOOLS

Matthew J. Klebanoff, Jalpa A. Doshi. Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4060603)

BACKGROUND: High out-of-pocket (OOP) drug costs pose a financial burden to patients and are associated with reduced medication adherence. Real-time prescription benefit tools (RTBTs) are tools embedded in the electronic health record that provide OOP drug cost estimates to clinicians at the point of prescribing. Since 2021, Medicare has required Part D plans to support RTBTs, helping to spur uptake of these tools. In this study, we assessed the prevalence of RTBT adoption among US acute care hospitals and examined the association of RTBT adoption with hospital and community characteristics.

METHODS: This observational study assessed the prevalence of RTBT adoption using the American Hospital Association (AHA) Information Technology (IT) Supplement Survey in 2022—the first year that it asked about RTBTs. Hospital characteristics were obtained from the AHA Annual Survey. County characteristics were obtained from the American Community Survey. Social Deprivation Index (SDI) was included as a composite measure of socioeconomic disadvantage. Inverse probability weighting was used to account for the likelihood of hospitals responding to the IT Supplement.

RESULTS: A total of 2,503 hospitals responded to the IT Supplement. 65.8% reported having an RTBT. RTBT-adopters were more often small with <100 beds (49.3% of RTBT-adopters vs. 38.7% of non-adopters, p<0.001), non-teaching (37.9% vs. 30.7%, p<0.001), and non-profit (73.8% vs. 40.6%, p<0.001). RTBT-adopters were more often located in the Midwest (31.4% vs. 16.5%, p<0.001) and Northeast (15.0% vs. 6.8%, p<0.001), and less often located in the South (33.7% vs. 56.5%, p<0.001). RTBT-adopters were less often located in counties with the lowest household income, classified as <$45,000 (6.9% vs. 14.9%, p<0.001); highest social deprivation, classified as SDI>60 (39.0% vs. 47.6%, p<0.05); highest diabetes prevalence, classified as >10% (46.6% vs. 61.5%, p<0.001); and highest fair or poor health prevalence, classified as >18% (17.9% vs. 31.4%, p<0.001). RTBT-adopters were also located in counties with a lower percentage of Black (mean 10.1% vs. 10.9%, p<0.001) and Hispanic population (mean 13.9% vs. 16.8%, p<0.01).

CONCLUSIONS: The majority of US hospitals have adopted RTBTs. Hospitals that have not adopted RTBTs are more likely to be located in counties with lower income, higher social deprivation, higher prevalence of diabetes, higher prevalence of fair or poor health, and higher percentage of Black or Hispanic population. While RTBTs have the potential to improve drug affordability, this technology is available less often in the most vulnerable communities. Continued monitoring of RTBT use in US hospitals is needed to ensure equitable access to this technology.

CLINICIAN RESPONSIVENESS TO THE 2021 USPSTF RECOMMENDATION REGARDING COLORECTAL CANCER SCREENING FOR AVERAGE RISK ADULTS AGED 45-49 YEARS

Joseph C. Powers³; Michael B. Rothberg²; Jeff D. Kovach¹; Elizabeth E. Stanley¹; Nicholas J. Casacchia¹; Kathryn A. Martinez¹. ¹Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ²Internal Medicine, Cleveland Clinic, Cleveland, OH; ³Center for Value Based Care Research, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH. (Control ID #4060113)

BACKGROUND: In 2021, the US Preventive Services Task Force (USPSTF) updated their colorectal cancer (CRC) screening recommendations to support screening for average risk patients beginning at 45 instead of 50 years. Clinicians have varied in their responsiveness to updated USPSTF screening guidelines for other cancer types. The objective of this study was to describe clinician responsiveness to the updated CRC screening recommendation.

METHODS: This is an observational cohort study in a large integrated health system using data from the electronic health record. Clinicians included Internal Medicine and Family Medicine physicians and Advanced Practice Providers who saw primary care patients. Patients included in this study were aged 45-49 years, CRC screening naïve, and had a primary care appointment during either the period before (2018-2020) and/or after (2021-2023) the guideline change. We excluded patients with conditions that may increase their risk of CRC including inflammatory bowel disease, genetic predisposition to cancer, and diverticular disease. We described changes in orders for specific screening types (FOBT/FIT, Cologuard, or colonoscopy) from the pre- to the post-period. We used mixed effects logistic regression to model the adjusted odds of any screening being ordered by time period (pre versus post), controlling for patient sex, race, and insurance type, and accounting for clustering by clinician. We estimated adjusted rates using marginal effects. We also generated individual CRC screening ordering rates per physician and compared individual rates from before to after the guideline change.

RESULTS: There were 23,797 patients seen in the pre-period by 410 unique clinicians and 18,839 patients seen in the post-period by 499 unique clinicians. The majority of patients were white (77%), commercially insured (84%), and female (55%). Orders increased for all screening modalities from the pre- to post-period (210 vs. 308 for FOBT/FIT; 7 vs. 1,600 for Cologuard; 722 vs. 5,798 for colonoscopy). The adjusted odds of an order for any CRC test were 29.7 times higher in the post-period compared to the pre-period (95%CI: 27.3-32.5). Marginal effects demonstrated screening increased from 4% in the pre-period to 41% in the post-period. Among the 313 clinicians who saw eligible patients in both the both periods, the median CRC screening rate was 2.3% (IQR:0-5%) in the pre-period and 47.5% (IQR:25-64%) in the post-period. While 86% of clinicians increased their screening rates by ≥10%, 14 clinicians did not order screening for any patient aged 45-49 in the pre- or the post-period.

CONCLUSIONS: Primary care clinicians in our health system were highly responsive to the updated USPSTF CRC screening recommendation for younger patients and predominantly ordered colonoscopy. Future studies should evaluate completion rates and test findings to characterize the clinical benefit for this population.

CLINICIANS’ PERSPECTIVES ON LOW-VALUE HEALTH SERVICES DELIVERED TO VETERANS FROM WITHIN AND OUTSIDE THE VETERANS HEALTH ADMINISTRATION (VA): A QUALITATIVE STUDY

Thomas R. Radomski^1,2; Zachary A. Cupler⁴; Kristina L. Hruska²; Nicole Beyer²; Loren J. Schleiden²; Keri L. Rodriguez²; Liam Rose⁵; Aimee N. Pickering^1,2; Carolyn T. Thorpe^3,2. ¹Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA; ³Pharmaceutical Outcomes and Policy, The University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC; ⁴VA Butler Healthcare, Butler, PA; ⁵VA Palo Alto Healthcare System, Health Economics Resource Center, Palo Alto, CA. (Control ID #4064276)

BACKGROUND: Veterans commonly receive low-value health services from VA and non-VA sources of care due to high rates of dual enrollment in Medicare and use of VA Community Care (VACC) programs. However, optimal strategies to reduce such low-value services remain poorly understood. Our objective was to characterize the drivers of and acceptable approaches to reduce the delivery of low-value services within and outside VA from the perspective of VA clinicians.

METHODS: From 8/2022–9/2023, we interviewed 65 VA clinicians (physicians, nurse practitioners, physician assistants), including 32 generalists and 33 medical or surgical sub-specialists. We sampled roughly equal numbers of generalists and sub-specialists from 3 groups of VA Medical Centers (VAMCs), which we previously characterized based upon the relatively high degree of low-value service use by the Veterans they serve from VAMCs, VACC, or Medicare in FY 2018. We conducted semi-structured interviews that explored influences on low-value service use and sought feedback on approaches to reduce low-value services in VA and non-VA settings. Interviews were audio recorded and transcribed verbatim. Using a codebook based on the Theoretical Domains Framework, two analysts co-coded 20% of the transcripts, and established intercoder consensus. We used thematic analysis to identify key themes in the data.

RESULTS: VA clinicians perceived that low-value service use in VAMCs was primarily driven by Veteran requests; fear of negative consequences of missing a diagnosis, such as litigation; and unnecessary testing requirements, including pre-operative testing. One clinician stated, “Patients request certain tests, and if they are felt to be noninvasive (and) maybe fairly inexpensive, a lot of providers probably do it (order the test) to maintain patient satisfaction.” In VACC and Medicare, low-value service use was perceived to be driven mostly by inadequate communication between VA and non-VA clinicians and financial incentives, respectively. To reduce low-value service use in VA, clinicians recommended enhanced patient and clinician education and the effective use of pop-up alerts. One clinician said, “Just empowering patients with more knowledge would be helpful. And reminding providers (about) the newest guidelines… is always good.” To reduce low-value service use in both VACC and Medicare, clinicians recommended enhanced communication between VA and non-VA clinicians and timely access to medical records. However, many felt there were no feasible solutions for VA to reduce low-value services delivered via Medicare to VA-enrolled Veterans.

CONCLUSIONS: We have identified key Veteran, clinician, and facility-level drivers of and promising strategies to reduce low-value services delivered to Veterans in VA and Non-VA settings. Our findings may directly inform the development of policies and interventions that overcome the challenges inherent in reducing low-value service use among Veterans, given their enhanced access to non-VA sources of care.

COMPARING ENGAGEMENT IN CULINARY MEDICINE VS. MEDICAL NUTRITION THERAPY: QUALITATIVE FINDINGS FROM A PRAGMATIC TRIAL OF VIRTUAL CULINARY MEDICINE AND MEDICAL NUTRITION THERAPY CLASSES WITHIN A SAFETY-NET HEALTHCARE SYSTEM

Carolyn Smith-Morris¹; Patricia M. Chen²; Molly Maguire³; Marisel Ponton¹; Guadalupe I. Perez^3,4; Jaclyn L. Albin⁴; Milette Siler⁵; Miguel A. Lopez⁶; Rebecca Chrasta⁹; Melissa Mendez⁷; Vincent Merrill⁴; Michael E. Bowen⁸. ¹O'Donnell School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX; ²School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX; ³General Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ⁴Internal Medicine, The University of Texas Southwestern Medical Center Department of Internal Medicine, Dallas, TX; ⁵Culinary Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ⁶N/A, Gretchen Swanson Center for Nutrition, Salt Lake City, UT; ⁷Nutrition, Parkland Health, Dallas, TX; ⁸Medicine, UT Southwestern Medical Center, Dallas, TX; ⁹Parkland Health, Dallas, TX. (Control ID #4063399)

BACKGROUND: Culinary medicine (CM) classes provide a complementary approach to traditional office-based nutrition education and can lead to improved dietary variety, culinary skill, and greater confidence and self-efficacy about food-related behavior change. However, randomized studies in food-insecure patients with uncontrolled type 2 diabetes are lacking, and the comparative impacts of CM versus traditional Medical Nutrition Therapy (MNT) is unknown.

METHODS: As part of a pragmatic trial comparing the effectiveness of virtual CM to MNT on diabetes outcomes among patients with uncontrolled type 2 diabetes within a safety-net healthcare system, we conducted semi-structured interviews with participants on program content, utility of the information and the experience, and self-assessed ability to use and sustain dietary changes. Interviews were recorded, transcribed verbatim, and double-coded using deductive techniques followed by inductive analysis within large and thematic code sets.

RESULTS: Twenty-six participants (10 CM; 16 MNT; median age 50; median BMI 32.8; 65% female; 51% Hispanic; 20% NH Black; 6 % NH White) completed interviews. Three emergent themes exposed key factors in the differential success of these two strategies. First, coded narratives addressing class experience, lifestyle changes made, personal results from participation in the program, and suggestions overwhelmingly reflect a positive reception for both CM and MNT. Second, narratives addressing barriers to completion of the program, though few overall, were higher for the CM arm (n=16) compared to the MNT arm (n=8). These included: difficulty picking up the class materials (for CM participants only); difficulty using the computer/internet; and lack of childcare (for MNT participants only), and together they point to differential barriers and facilitators of each program. Third, cross-analysis of narratives coded for “information-sharing” (sharing what they learned with family or friends) and for “family” (narratives about family) revealed a dominant sub-theme: the responsibility carried by many female participants that family’s “like” the meals they serve.

CONCLUSIONS: Qualitative data from this trial comparing the effectiveness of virtual CM to MNT point to influential and program-specific barriers and facilitators of participant experience. The hands-on nature and virtual format of CM group classes posed greater barriers to participation than traditional MNT services which included both group and individual classes. Barriers would be minimized by offering diverse formats and timing of classes, including in-person and virtual options, and improving pre-class awareness of the hands-on CM approach. Both CM and MNT programs may produce greater uptake by participants if educational content includes gender- or family-role-specific (e.g., role of cook for the family) is included. Finally, greater understanding of the family context for meals and nutrition decisions is needed to enhance long-term program effectiveness.

COMPARING PRIOR AUTHORIZATION ACROSS INSURERS: EVIDENCE FROM MEDICARE ADVANTAGE

Ravi Gupta^1,2; Joseph P. Newhouse^3,4; Aaron Schwartz⁵. ¹Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; ²Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; ³Department of Health Care Policy, Harvard Medical School, Boston, MA; ⁴Department of Health Policy and Management, Harvard University T H Chan School of Public Health, Boston, MA; ⁵Medical Ethics and Health Policy, General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4062232)

BACKGROUND: Prior authorization (PA) is a controversial managed care tool employed by private health insurers within Medicare Advantage, but used minimally in traditional Medicare. Despite active policy debate regarding PA regulation, research on the extent of PA is lacking. The purpose of this study was to measure 1) the extent of PA requirements for medical services among major Medicare Advantage insurers, 2) the use of PA across clinical service categories, and 3) the extent of disagreement across insurer PA policies.

METHODS: We collected 2021 PA policies for five insurers (UnitedHealthcare, Humana, CVS Health, Centene, and Cigna) serving the majority of beneficiaries covered by privately administered Medicare Advantage. We determined the frequency of services delivered in Medicare Part B in 2021 that would have required PA by each Medicare Advantage insurer, and calculated the associated spending. We assessed the extent of PA by clinical service categories and by clinician specialty. We examined the extent of disagreement across the five insurers’ prior authorization policies.

RESULTS: Among the 30,540,086 Medicare Part B beneficiaries in 2021, 14,130 unique types of medical services were delivered. Across the five Medicare Advantage insurers, PA was required for between 7% and 21% (median 13%, weighted mean 10%) of service types. The proportion of Part B spending requiring PA ranged from 17% to 33% (median, 28%; weighted mean, 23%); the proportion of utilization requiring PA ranged from 9% to 41% (median 22%; weighted mean, 18%). Forty percent ($57 billion) of total Part B spending and 48% of total services would have required PA at one or more Medicare Advantage insurer. Twelve percent of total Part B spending, corresponding to 6% of total utilization, would have required PA at all five Medicare Advantage insurers. For all Medicare Advantage insurers, medications represented the plurality of spending requiring PA (46% to 62%; median, 57%; weighted mean, 57%). By clinical specialty, the proportion of spending on services uniformly subject to PA at all five insurers ranged from 1% for emergency medicine to 79% for rheumatology.

CONCLUSIONS: The coverage policies of five major Medicare Advantage insurers would have required PA for a large portion of fee-for-service Medicare Part B spending, particularly for medications. However, there was not widespread consensus among insurers regarding which medical services require prior authorization. Given the growth of Medicare Advantage and its use of PA to manage spending and use for their enrollees, our study informs ongoing reform efforts to focus PA more effectively on low-value services and to reduce the associated administrative burden. The lack of uniformity in PA policies among insurers suggests the challenge of identifying and discouraging low-value services.

COST-EFFECTIVENESS OF ARTIFICIAL INTELLIGENCE (AI) IN BREAST CANCER SCREENING WITH DIGITAL BREAST TOMOSYNTHESIS

Matthew C. Andersen¹; Ilana Richman². ¹N/A, Yale School of Medicine, New Haven, CT; ²Department of Medicine, Yale University, New Haven, CT. (Control ID #4055418)

BACKGROUND: Using artificial intelligence (AI) for breast cancer screening with mammography may improve diagnostic accuracy, but whether improvements translate into long-term health benefits, and whether AI is cost-effective at current prices, is uncertain. The goal of this study was to estimate the long-term benefits, risks, and cost-effectiveness of breast cancer screening with AI compared to standard screening mammography with digital breast tomosynthesis (DBT) alone. We specifically evaluated Saige-Dx, a commercially available product marketed to consumers at an out-of-pocket cost of $60.

METHODS: We developed a Markov microsimulation model that projects lifetime outcomes and costs of biennial screening from ages 40-74 with or without AI. Women enter at age 40, and in each annual cycle, they can remain healthy, be diagnosed with breast cancer, or die. AI screening benefits are modeled through the probability of a true positive versus false negative screen, influencing stage at diagnosis based on national data. In the cohort screened with DBT and AI, the probability of a false negative screen was reduced by 8.8 percentage points, based on published data for Saige-Dx. False positive screens result in downstream costs and quality of life decrements. For women screened with AI, probability of a false positive was reduced by 0.9 percentage points. In both arms, health outcomes after screening were based on stage-specific survival from a large national cancer registry (SEER). Costs were based on claims data. Utility values were based on quality-of-life metrics from EQ-5D scores.

RESULTS: Our model projected the age-specific 10-year breast cancer incidence and mortality within 0.6 percentage points of those reported in SEER. In the base case (DBT alone), screening 1,000 women biennially from ages 40-74, resulted in 9.4 false negative screens versus 2.2 per 1,000 for AI-assisted screening. Cumulative false positive mammograms decreased from 1,091 per 1,000 women screened with DBT alone to 954 with DBT and AI. AI-assisted mammography resulted in 0.81 fewer advanced breast cancer cases (regional or metastatic cancer) at diagnosis and 0.37 fewer breast cancer deaths per 1,000 women, compared to screening without AI. Using AI yielded an incremental gain of 0.0063 quality adjusted life years per screened woman over a lifetime, with a lifetime incremental cost of $708, and an incremental cost-effectiveness ratio (ICER) of $111,680. Sensitivity analyses showed ICER values were most affected by specificity improvements.

CONCLUSIONS: Using a validated breast cancer screening simulation model, we found that adding AI to breast cancer screening with DBT resulted in modest improvements in health outcomes, including small reductions in breast cancer mortality. At current pricing, AI is not cost-effective at a willingness-to-pay threshold of $100,000 but would become cost effective with small improvements in performance.

COVID-19 PANDEMIC-RELATED CHANGES IN REVENUE BY PHYSICIAN SPECIALTY: 2018-2022

Ravi B. Parikh¹; Ezekiel J. Emanuel¹; Yueming Zhao²; David Pagnotti¹; Pankti P. Pathak³; Stuart Hagen³; David A. Pizza³; Amol S. Navathe^4,5. ¹Perelman School of Medicine, Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; ²Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³Blue Cross Blue Shield Association, Chicago, IL; ⁴Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; ⁵Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA. (Control ID #4063514)

BACKGROUND: US health care utilization declined during the initial phase of the COVID-19 pandemic in 2020.This created a massive financial shock to the health care delivery system, under which providers experienced large drops in revenue. This shock may have catalyzed responses such as greater consolidation of physician practices or leaving practice altogether. However, physicians across different specialties, such as those performing elective procedures and cancer screenings, may have experienced disproportionate revenue declines.

METHODS: This observational study examined professional claims from US commercially insured members in the BCBSA Axis Database from 2018-2022, linked to national datasets to identify specialties and practice characteristics. We used interrupted time series models to estimate pandemic-associated impacts to physician revenue – defined as per-member, per-month actual payments to eligible physicians from professional claims, indexed to 2018 values – by specialty and practice characteristics. We separated our sample into four time periods: one pre-COVID-19 (May 2018 to December 2019) and three COVID-19 (January to December 2020; January to December 2021; January to June 2022) periods.

RESULTS: Among 427,140 eligible physicians, the most commonly represented specialties were internal medicine (15.4%), primary care (14.2%), and emergency medicine (6.6%). The median age was 50 and 132,929 were female. Surgical specialties (-11.0%) emergency medicine (-9.9%) and medical subspecialties (-10.7%) experienced the largest adjusted revenue decline in 2020, relative to pre-pandemic baselines. For most specialties, revenue recovered to near baseline by June 2022, although the magnitude of recovery varied by specialty. For example, psychiatry recovered to 6.0% above baseline in June 2022, while oncology specialties (hematology/oncology + radiation oncology) remained -5.4% below baseline even in June 2022. Recovery in revenue also varied by practice setting. Revenue decline was similar among all practice subgroups in 2020. However, by June 2022, revenue recovery was greater for physicians practicing in hospital-owned vs. non-hospital-owned practices (adjusted difference relative to pre-pandemic baseline 9.5% vs. -3.5%, interaction p-value <0.001), practices participating vs. not participating in accountable care organizations (adjusted difference 9.5% vs. -3.5%, p=0.005), and larger vs. small practices (adjusted difference 4.3% vs. -2.2%, p=0.097).

CONCLUSIONS: The COVID-19 pandemic led to a large decline in physician gross revenue across all specialties in 2020; however, revenue recovery in 2021 and 2022 varied by specialty and practice setting. Given that financial constraints among physicians have been associated with health care consolidation and/or leaving practice, policymakers may consider closer monitoring of revenue trends among specialties with sustained gross revenue reductions during the pandemic.

CULTURALLY TAILORED HYPERTENSION INTERVENTIONS IN MULTI-ETHNIC COMMUNITIES: SYSTEMATIC REVIEW AND META-ANALYSIS

Li-Jung Liang²; Natalie Robles¹; Sean Faulk³; Sarmen Hakopian¹; Stefanie D. Vassar¹; Arleen F. Brown². ¹Division of Internal Medicine & Health Service Research, UCLA, Los Angeles, CA; ²Medicine, University of California Los Angeles, Los Angeles, CA; ³Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4064393)

BACKGROUND: As the US becomes more diverse, addressing hypertension (HTN) disparities in multiple ethnicities is increasingly important. This study reviews culturally tailored interventions for improving HTN control in multiethnic communities.

METHODS: We searched PubMed, Embase, and CINAHL for US-based randomized controlled HTN trials (2000–2022). Studies had to include adult racial/ethnic minority participants, systolic blood pressure (SBP) as an outcome, and >6 months of follow-up. These analyses focus only on studies that incorporated cultural tailoring. Abstraction of participant demographics, cultural tailoring strategies, and intervention type was performed by two reviewers and differences reconciled. Studies with multiple interventions were included. The standardized mean difference (SMD) in change of SBP (with 95% CI) between intervention and control was estimated and compared among subgroups using meta-analysis random-effects models. A larger SMD indicates a greater SBP reduction for intervention vs control.

RESULTS: Of 1035 articles identified, 52 met eligibility. Of the 26 articles with cultural tailoring, 2 classified participants as non-White (NW), 12 included African American (AA) participants, 9 Hispanic participants, and 4 Asian participants (1 Filipino American [FA], 2 Korean American [KA], 1 South Asian [SA]). Culturally tailored interventions with pharmacist medication management had a greater SBP reduction compared to those without at 6 months (SMD: 1.24±0.15, p<.001). Greater SBP reduction was observed in studies involving NW participants at 6 and 12 months (0.41±0.13 vs 0.30±0.13; p<.05); studies involving AA or KA participants at 6 months (0.22±0.10 and 0.39±0.13, p<.05); and studies involving FA participants at 12 months (1.12±0.24, p<.001). No pharmacist studies identified HA participants. Most studies involving Hispanic and Asian participants utilized CHWs, but impact on SBP was inconsistent.

CONCLUSIONS: This systematic review demonstrated improved HTN control in studies with pharmacist medication management. Notably, we found no studies of this strategy for some ethnic groups. This review underscores the need for additional studies in specific populations, particularly disaggregating Asian subgroups, when designing trials to improve hypertension control in diverse populations.

CULTURE OF PATIENT SAFETY IN BLACK AND NON-BLACK-SERVING HOSPITALS

Lucy Schulson^2,1; Andrew Dick¹; Flora Sheng³; Denise D. Quigley⁴. ¹Health Care, RAND Corp Boston office, Boston, MA; ²Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ³RAND Corp Washington Office, Arlington, VA; ⁴RAND Corporation, Santa Monica, CA. (Control ID #4062484)

BACKGROUND: Care for patients who are Black is concentrated in 25% of US hospitals. On average, patients in these hospitals—known as Black-serving hospitals (BSHs)—experience higher rates of patient safety events compared to patients in non-BSHs. Patient safety culture may contribute to these disparate outcomes; health systems with a robust patient safety culture have fewer safety events. We examine patient safety culture in BSH and non-BSHs.

METHODS: Using Medicare data, we identified hospitals as BSHs if >13% of their admissions were patients who identified as Black, i.e., greater than the percentage of individuals who are Black in the US. Our sample included 161 (131,832 respondents) BSHs and 210 (113,420 respondents) non-BSHs. Our primary outcome was patient safety culture as measured by the Agency for Healthcare Research and Quality 2021-2022 Hospital Survey on Patient Safety Culture 2.0 (HSOPS). HSOPS, completed by hospital employees, includes 10 composite measures, two single-item summary measures and respondent and hospital characteristics. We compared respondent and hospital characteristics by BSH status. Using ordinary least squares regression models at the respondent-level, we compared components of patient safety culture (using HSOPS composites and summary measures) in BSH and non-BSHs, controlling for respondent and hospital characteristics and including weights to account for variation in number of staff reporting and hospital-level clustered error terms. We also ran models including interaction terms between BSH status and hospital characteristics to identify what characteristics were associated with differences in patient safety culture in BSH and non-BSHs.

RESULTS: BSHs were more likely to be teaching hospitals, (66% vs 50%, p<.01), in the South (61% vs 36%, p<.01), and larger (i.e., had >300 beds (39% vs 23%, p<.01) compared to non-BSHs. Hospital ownership was not significantly different in BSH and non-BSHs. Respondent characteristics were similar. In models that included respondent and hospital characteristics, BSHs had relatively more positive patient safety culture (i.e., percent positive scores) on 5 out of 10 aspects of patient safety culture: Organizational Learning—Continuous Improvement (2 percentage points (pp), p=.02), Supervisor, Manager, or Clinical Leader Support for Patient Safety (1pp, p=.02), Communication About Error (2pp, p=.004), Reporting Patient Safety Events (2pp, p=.006), and Handoffs and Information Exchange (3pp, p<.0001). Patient Safety Rating and Number of Events Reported were not statistically significantly different. There were significant interactions between BSH status and region in the probability of reporting any safety events (p<.05).

CONCLUSIONS: Some aspects of patient safety culture are more positive in BSH vs non-BSHs, controlling for respondent and hospital characteristics. These results raise concerns about whether patient safety culture can reduce inequities in patient safety.

DEMOGRAPHIC REPRESENTATION OF STUDIES REQUIRED UNDER CMS’S COVERAGE FOR EVIDENCE DEVELOPMENT

Maryam Mooghali¹; Sanket S. Dhruva²; Joseph S. Ross¹; Reshma Ramachandran¹. ¹Internal Medicine, Yale School of Medicine, New Haven, CT; ²University of California San Francisco, San Francisco, CA. (Control ID #4049330)

BACKGROUND: Medicare beneficiaries are inadequately represented in clinical studies supporting FDA medical product approvals due to factors such as advanced age, comorbidities, and concurrent medication use. In 2005, Center for Medicare and Medicare Services (CMS) introduced Coverage with Evidence Development (CED) program to provide beneficiary access to promising FDA-approved items and services that would not otherwise meet Medicare’s coverage standard of “reasonable and necessary” by requiring study participation to generate evidence in Medicare beneficiaries. However, the extent to which patients enrolled in CED studies reflect the Medicare beneficiary population is unknown. Thus, we evaluated representation of older adults, women, and racially and ethnically minoritized patients in CED studies.

METHODS: Using CMS webpage, we identified items and services covered under CED and corresponding CED studies. We extracted age, sex, race, and ethnicity of enrolled participants from ClinicalTrials.gov or corresponding publications. We then calculated participation to prevalence ratios (PPRs) by dividing the percentage of each demographic group enrolled in the pivotal trial by percentage of that group in Medicare beneficiaries, with PPRs 0.8-1.2 indicating adequate representation, PPRs<0.8 indicating underrepresentation, and PPRs>1.2 indicating overrepresentation.

RESULTS: From 2005 to 2023, CMS approved 119 CED studies for 26 items and services, with a median of 2 (IQR [1,6]) studies per item/service. As of September 15, 2023, 54 (45.4%) studies had publicly available results on ClinicalTrials.gov and/or as a publication. Of these, 14 (26%) studies enrolled only Medicare beneficiaries.

Twelve (22%) CED studies reported the proportion of older adults, of which older adults were underrepresented in 1 (8%) and adequately represented in 11 (92%) studies (median [IQR] PPR; 1.14 [1.10-1.14]). The overall median of mean age among participants of all 54 studies was 73.6 (IQR, 67.1-80.8) years, compared with the median age of 71.3 among Medicare beneficiaries. Women were underrepresented in 30 (57%), adequately represented in 20 (38%), and overrepresented in 3 (6%) studies (median [IQR] PPR; 0.76 [0.59-0.91]).

Data about race and ethnicity was missing in 29 (54%) and 30 (56%) studies, respectively. Among those with available data, Black patients were underrepresented in 19 (79%), adequately represented in 3 (13%), and overrepresented in 2 (8%) studies (median [IQR] PPR; 0.44 [0.33-0.72]). Hispanic ethnicity was underrepresented in 20 (95%) studies and adequately represented in 1 (5%) study (median [IQR] PPR; 0.31 [0.20-0.55]).

CONCLUSIONS: Among CMS CED studies with publicly available results, we found that although older adults are overall adequately represented in CED studies, women, Black, and Hispanic patients are often underrepresented. As this lack of representativeness could limit generalizability of CED study results, CMS and study sponsors should address health disparities in generating evidence.

DEMOGRAPHICS, HOUSING STATUS, AND DIAGNOSES ASSOCIATED WITH PATIENTS PLACED ON INVOLUNTARY PSYCHIATRIC HOLDS IN A COHORT USING COUNTY URGENT AND EMERGENT SERVICES

Christina K. Wang¹; Sara Colom Brana²; Kenneth Perez²; Dave Graham-Squire²; Hillary Kunins³; Hali Hammer⁴; Maria Raven^5,2; Hemal Kanzaria^5,2. ¹Department of Internal Medicine, University of California San Francisco, San Francisco, CA; ²Benioff Homelessness and Housing Initiative, University of California San Francisco, San Francisco, CA; ³Department of Behavioral Health Services and Mental Health, San Francisco Department of Public Health, San Francisco, CA; ⁴Department of Ambulatory Care, San Francisco Department of Public Health, San Francisco, CA; ⁵Department of Emergency Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4024164)

BACKGROUND: For individuals with serious mental illness, policymakers are increasingly considering a history of involuntary psychiatric holds to guide mental health treatment planning. Involuntary holds are used to mandate acute treatment for people who are a danger to themselves or others, or are gravely disabled. However, we know little about the demographics, co-morbidities, and housing status of people placed on involuntary holds and even less about the relationship between these characteristics and involuntary psychiatric holds. We sought to describe characteristics of people placed on holds and to identify risk factors for hold placement.

METHODS: We used an interagency dataset from a department of public health that integrates county services data regarding physical and behavioral health, admissions to county jails, shelter, and housing services. We included all clients who used any county urgent or emergent services reported in our dataset at least once each year between July 2017 to June 2020. We used descriptive statistics to examine patient-level characteristics (age, gender, race, ethnicity, housing status, diagnoses of mental health disorders or substance use disorders, insurance status) and compared patients with and without a history of involuntary psychiatric hold placement between July 2019 and June 2020. We extracted diagnosis codes for each encounter associated with an involuntary hold. We then employed a logistic regression model to identify characteristics associated with holds, controlling for age, gender, race, ethnicity, housing status, outpatient behavioral health visits in prior year, and substance use diagnoses.

RESULTS: A total of 10,730 patients met inclusion for study. The mean age of clients was 48 (±15), 56% were male, 25% identified as white, and 68% were Medicaid beneficiaries. Approximately 30% identified as experiencing homelessness in the prior year, 43% had an identified substance use disorder and 51% had a mental health diagnosis. Clients who had involuntary holds were younger, more likely to identify as male, have experienced homelessness in the prior year, had mental health and substance use diagnoses, and be Medicaid beneficiaries. Top diagnoses associated with holds were psychoses (30% of holds); major depressive disorder, single episode (13%); and schizophrenia (6%). After controlling for observable characteristics, holds placed in the prior year were associated with increased odds of a hold (OR = 1.89, P<0.01). Individuals who experienced homelessness the prior year or had a substance use diagnosis also had increased odds (adjusted OR=1.25 [P=0.04] and adjusted OR=2.05 [P<0.001], respectively) of receiving a hold compared to individuals who did not experience homelessness, or had no substance use diagnosis.

CONCLUSIONS: In a cohort using county urgent and emergent services, involuntary holds in the prior year, substance use and housing status were independently associated with increased risk of involuntary psychiatric holds in the following year.

DEMOGRAPHIC TRENDS IN THE UTILIZATION OF BEHAVIORAL HEALTH SERVICE MODALITIES, 2018-2023

Artem Romanov¹; Lauryn Walker²; Cheryl Damberg³; Melody Craff⁴; Dale Skinner⁵; Michael Hadfield⁶; A. Mark Fendrick⁷; John N. Mafi⁸. ¹General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Virginia Center for Health Innovation, Richmond, VA; ³Health Care, RAND Corporation, Santa Monica, CA; ⁴MedInsight, Milliman Inc, Seattle, WA, US, Seattle, WA; ⁵MedInsight, Milliman Inc Seattle, Seattle, WA; ⁶Strategic Analytics, MCG Health, Seattle, WA; ⁷Internal Medicine, University of Michigan, Ann Arbor, MI; ⁸Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4064751)

BACKGROUND: As the healthcare system settles in to a new normal following the pandemic, one thing is clear– telehealth is now a key component of the healthcare system. With few permanent national telehealth requirements, payers, providers, and patients have largely determined their own telehealth practices. In behavioral health, general consensus is that telehealth has increased capacity to services that previously were difficult to access; however, to ensure equitable access to these services, it is important to know how behavioral health-related telehealth utilization and in-person utilization vary across different patient groups and payers.

METHODS: We performed a retrospective cohort analysis of behavioral health-related telehealth and overall (telehealth plus in-person) visits between 1/1/2018-6/1/2023 across age groups, rurality, and payer. De-identified data were sourced from Milliman MedInsight’s Emerging Experience database. Our cohort included patients enrolled in ≥12 months of continuous coverage in Medicaid, Medicare-Medicaid, traditional Medicare (TM), Medicare Advantage (MA), or commercial plans from all 50 U.S. states.

RESULTS: Our sample included 19.4 million insured U.S. adults with a mean age of 50 years and 56% female. Overall behavioral health visits increased by 56.7%, from a pre-pandemic (1/1/2018-2/29/2020) total of 728.5 visits per 100 patients (0.2% telehealth visits) to a post-pandemic onset (3/1/2020-6/1/2023) total of 1283.4 visits per 100 patients (38.1% telehealth visits). This increase in overall behavioral health-related visits was accompanied by a 49.5% increase in behavioral health-related telehealth visits relative to their pre-pandemic baseline.

Notably, MA beneficiaries had far fewer overall behavioral health visits than any other payer and less uptake of telehealth. TM beneficiaries accessed behavioral health visits at more than twice the rate of MA beneficiaries (217.8 vs. 77.6 total visits per 100 patients after 3/1/2020). 80+ year-olds exhibited the only downward trend in utilization among patient groups over the study period (13.9% relative decrease in mean monthly behavioral health-related visits per 100 patients, pre- vs post-pandemic onset). Over the same period, rural patients experienced a 46.4% increase in overall behavioral health visits relative to their pre-pandemic baseline—exceeding the 32.7% relative increase experienced by urban patients. Even still, urban patients accessed more overall behavioral health visits than rural patients (6.6 vs 4.4 mean monthly visits per 100 patients) after the pandemic’s onset.

CONCLUSIONS: With MA now comprising over 50% of the Medicare program, these findings suggest that more research is needed into the drivers of MA’s low behavioral health utilization in order to inform future policy solutions. These findings also suggest that present telehealth flexibilities may be improving access to behavioral health services for individuals in rural areas.

DIFFERENCES IN EXPERIENCES WITH VA COMMUNITY CARE FOR VETERANS WITH SERIOUS MENTAL ILLNESS

Alessandra Leong¹⁰; Yaming Li⁸; Florentina E. Sileanu⁸; Utibe R. Essien^1,2; Megan E. Vanneman^3,4; Maria K. Mor^8,5; Michael J. Fine^8,7; Carolyn T. Thorpe^6,8; Thomas Radomski^8,7; Katie Suda^8,7; Walid Gellad^8,7; Eric Roberts⁹. ¹VA Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; ³Internal Medicine & Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, UT; ⁴VA Informatics, Decision Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT; ⁵Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA; ⁶Pharmaceutical Outcomes and Policy, The University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC; ⁷Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ⁸VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; ⁹General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ¹⁰University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4027442)

BACKGROUND: Veterans diagnosed with Serious Mental Illness (SMI) frequently suffer from multiple medical comorbidities and therefore require greater care coordination to address their complex health needs. Notably, since major policy expansions in 2019, an increasing number of Veterans enrolled in the Veterans Affairs (VA) have been utilizing VA-funded community care (VACC). However, Veterans with SMI may face distinct challenges accessing and receiving high-quality VACC given their complex needs. The objective of this study was to examine how the VACC experiences of Veterans with SMI differ from the experiences of Veterans without SMI.

METHODS: This observational study of VACC experiences analyzed responses to the Survey of Healthcare Experiences of Patients–Community Care Survey (SHEP-CCS) from 2016-2021. Ratings of care across 9 domains (overall care satisfaction, overall clinician rating, clinician communication, eligibility determinations, first appointment access, recent appointment access, non-appointment access, care coordination, and billing) were compared for Veterans with and without SMI in unadjusted analyses over time as well as adjusted linear and logistic regression models. Analyses were adjusted for demographics, health status, insurance and socioeconomic status, geography, type of specialty care, and year fixed effects. Diagnosis of SMI included bipolar disorder, major depression, post-traumatic stress disorder, schizophrenia, and psychosis.

RESULTS: Our sample included 231,869 person-year observations for Veterans who received VACC from 2016-2021, of which 62,911 observations were Veterans with SMI. Among Veterans with SMI, 18.5% were female, 15.1% had substance use disorders, 29.9% had ≥3 Elixhauser comorbidities, and 8.8% were enrolled in Medicaid. Compared to Veterans without SMI, those with SMI had lower care ratings across all 9 care domains. In adjusted analyses, differences in average care ratings between Veterans with versus without SMI ranged from -0.05 to -0.10 standard deviations of domain scores; P<0.001 for all comparisons). In analyses that examined the binary outcome of care rating in the top versus bottom deciles (better versus worse ratings, respectively), Veterans with SMI were 0.1 to 3.1 percentage points less likely to report better care ratings and 1.2 to 2.4 percentage points more likely to report worse ratings across all care domains (P<0.001 for all comparisons). Although ratings improved over the study period, disparities in VACC experiences between Veterans with and without SMI persisted in all care domains from 2016-2021.

CONCLUSIONS: Our work highlights disparities in VACC experiences of Veterans with SMI and underscores the challenges that medically vulnerable subgroups of Veterans experience when receiving community care. These analyses illuminate areas where tailored care coordination and quality enhancement efforts may improve community care experiences for vulnerable subpopulations of Veterans.

EFFECT OF MEDICAID EXPANSION ON QUALITY OF CARE FOR VETERANS WITH CHRONIC KIDNEY DISEASE WHO TRANSITION TO DIALYSIS

Patrick O'Mahen^1,2; Chase S. Eck^3,1; Suja S. Rajan^4,1; Laura A. Petersen³. ¹Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX; ²Baylor College of Medicine, Houston, TX; ³Medicine, Baylor College of Medicine, Houston, TX; ⁴The University of Texas Health Science Center at Houston School of Public Health, Houston, TX. (Control ID #4064129)

BACKGROUND: Medicaid expansion is associated with improved outcomes for patients in renal failure. However, many Veterans qualifying for Medicaid coverage via the Affordable Care Act’s Medicaid expansion already have access to care through the Veterans’ Health Administration (VA). This dual- eligibility opens the potential for improved access to health care, but also increases the potential for duplicate care or poor care coordination which may be reflected in emergency initiation of dialysis and inadequate engagement with specialty care services. Our goal was to assess whether the ACA’s Medicaid expansion is associated with changes in dual-enrollment and the quality of care for Veterans transitioning to dialysis.

METHODS: We used a difference-in-differences approach with a linear probability model to determine the association between Medicaid expansion and VA-Medicaid dual enrollment, placement of a fistula prior to hemodialysis (vs. emergency initiation of dialysis), and whether the dialysis recipient had been under the care of a nephrologist or dietitian within six months of initiating dialysis. We controlled for age in years, self-reported sex and race (white, black, Asian, American Indian, and Pacific Islander), Hispanic ethnicity, logged driving distance to the nearest VA facility, state of residence, and year of dialysis initiation. Data sources for dialysis-related dependent variables included the U.S. Renal Data Services’ Core dataset, which included the Medical Evidence file. For VA enrollment and demographic data, we used files from the VA Corporate Data Warehouse Assistant Deputy Undersecretary for Health’s (ADUSH) Enrollment files. For Medicaid enrollment, we used the Medicaid Analytic Extract (MAX) and T-MSIS Analytic Files (TAF).

RESULTS: We identified 17,932 Veterans with who were enrolled in the VA across all 50 states and Washington DC, and transitioned to dialysis between 2011 and 2016, inclusive, 4,785 of whom were dual enrolled in Medicaid. Medicaid expansion was associated with a statistically significant 6.7% increase in dual enrollment (95% CI: 4.1 to 9.4. However, expansion was not associated with meaningful differences in fistula placement (-1.4%, (-4.2 to 1.3)), being under the care of a nephrologist (2.4%, (-0.5 to 5.4)) or a dietician (1.7%, (-4.3 to 1.0).

CONCLUSIONS: Medicaid expansion is associated with significant increases in VA-Medicaid dual-enrollment among Veterans. However, expansion does not appear to be associated with changes in receiving care from nephrologists or dietitians for VA-enrolled Veterans. Nor does expansion appear to be associated with any changes in emergency initiation of dialysis, as measured by the likelihood of placement of a fistula prior to the beginning of dialysis.

ENROLLMENT IN THE QUALIFIED MEDICARE BENEFICIARY PROGRAM AND ACCESS TO CARE FOR LOW-INCOME MEDICARE BENEFICIARIES

J. W. Koma^1,2; Zhiyou Yang²; David Cheng^4,3; Tej Patel²; Felippe O. Marcondes^5,3; Mary Price²; Margarita Alegria^2,3; John Hsu^2,3; Joseph P. Newhouse⁶; Vicki Fung^2,3. ¹Interfaculty program in health policy, Harvard University, Cambridge, MA; ²Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA; ³Harvard Medical School, Boston, MA; ⁴Biostatistics, Massachusetts General Hospital, Boston, MA; ⁵Division of General Internal Medicine, Massachusetts General Hospital, Roxbury , MA; ⁶Health care policy, Harvard Medical School, Boston, MA. (Control ID #4062020)

BACKGROUND: About 8 million Medicare beneficiaries with incomes below the federal poverty limit and limited assets receive financial assistance with Medicare premiums and cost-sharing for inpatient and outpatient services as Qualified Medicare Beneficiaries (QMB). The Centers for Medicare and Medicaid Services recently finalized rules to streamline enrollment processes to increase take-up of this assistance. We examined QMB enrollment among Medicare beneficiaries 2016-2021, individual and state characteristics associated with enrollment, and the association between QMB enrollment and cost-related barriers to care.

METHODS: We used data from the Medicare Current Beneficiary Survey (MCBS) survey files for community-dwelling beneficiaries from 2016-2021; these data include Medicare administrative data on QMB enrollment. We identified QMB-eligible beneficiaries based on self-reported income and assets and defined QMB enrollment as having at least one month of QMB in the year. We used a multivariable linear probability model to examine the association between individual demographics, health status, and insurance status, and state policy characteristics and the likelihood of QMB enrollment. We examined the association between QMB enrollment and cost-related barriers to care including reports of delaying care due to cost and problems paying medical bills using similar models.

RESULTS: Between 2016-2021, enrollment grew from 61.4% to 68.1% of eligible enrollees with at least one month of QMB. Among QMB-eligible beneficiaries in 2021, 35.5% were <65 years old; 41.1% were White, 28.0% Black, and 26.1% Hispanic; 87.2% had 2 or more chronic conditions; 44.8%% had difficulty with 1 or more activities of daily living; 55.6%% lived in Medicaid expansion states, and 22.2% lived in states that increased income or asset limits for the QMB program above federal standards. In adjusted analyses among eligible beneficiaries, QMB enrollment was more likely among racial/ethnic minority vs. White beneficiaries and beneficiaries living in Medicaid expansion states and states with higher income and asset limits for QMBs; enrollment was lower among beneficiaries age 65+ vs. <65; in Medicare Advantage vs. Traditional Medicare; and with Medigap or employer sponsored insurance vs. not. Among eligible beneficiaries, those enrolled vs. not enrolled in QMB were less likely to report any delayed care due to cost in the past year (10.2% vs. 17.3%; adjusted diff=-7.1 pct pts, 95% CI: -10.7 to -3.5) and problems paying medical bills (11.1% vs. 22.5%; adjusted difference=-11.6 pct pts, 95% CI: -14.9 to -8.3).

CONCLUSIONS: Low-income beneficiaries eligible for financial assistance with Medicare cost-sharing frequently have multiple chronic conditions and limited functional status. From 2016-2021, about 2 in 3 QMB-eligible Medicare beneficiaries enrolled. Reducing barriers to enrollment could reduce cost-related barriers to care for millions of low-income Medicare beneficiaries.

EVALUATING A POTENTIAL TRADEOFF BETWEEN GLYCEMIC CONTROL AND MACROVASCULAR RISK REDUCTION IN PATIENTS WITH DIABETES, 2021-2022

Glen B. Taksler^1,2; Phuc H. Le³; Kathryn A. Martinez⁴; Michael B. Rothberg⁵. ¹Medicine Institute, Cleveland Clinic, Cleveland, OH; ²Population Health and Equity Research Institute, MetroHealth Medical Center, MetroHealth Medical Center, Cleveland, OH, US, academic/hospital, Cleveland, OH; ³Center for Value-based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH; ⁴Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ⁵Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4063765)

BACKGROUND: Type 2 diabetes management focuses on HbA1c control. However, as patients with type 2 diabetes age and time since diagnosis increases, macrovascular disease becomes a larger concern than microvascular sequelae. Although glycemic control offers unclear potential to reduce macrovascular risk, the control of hypertension, hyperlipidemia and tobacco cessation offer large, evidence-based benefits.

METHODS: We analyzed clinical practice patterns for control of macrovascular and microvascular risk in patients with diabetes, utilizing electronic health records for 2021-2022 at a large health system in the Midwest. We included those 40-75 y with HbA1c >8% at the last measurement in 2021 (“initial HbA1c”), and at least 1 HbA1c test in 2022 (as a proxy for ongoing diabetes care in the health system). We documented 7 cardiovascular risk factors and related prescriptions as-of the last encounter in 2021 (uncontrolled hypertension, hyperlipidemia, current smoker, comorbid cardiovascular disease, heart failure, chronic kidney disease, obesity). Then, we assessed prescription patterns for control of A1c, blood pressure, cholesterol and tobacco during 2022. Patients with heart failure were considered ineligible for thiazolidinediones. Recognizing potential frailty in older patients, a sensitivity analysis restricted initial HbA1c to >8% in patients 40-64 y and >9% in patients 65-75 y.

RESULTS: We included 13,224 patients. Of these, 62% had BP ≥130/80, 42% had 10 y ASCVD risk ≥20% or cardiovascular disease, and 17% were current smokers. Among patients with uncontrolled BP, new antidiabetes medications were prescribed more often than new antihypertensives (18.8% vs. 7.8%, P<0.001). Among those eligible for high-dose statins, new antidiabetes medications were prescribed more often than high-dose statins (19.7% vs. 4.6%, P<0.001), and among current smokers, new antidiabetes medications were prescribed more often than tobacco cessation agents (16.7% vs. 6.1%, P<0.001).

In 2022, 19.8% of patients were prescribed a new class of antidiabetes medication. Those with comorbidities who could benefit from newer agents that also improve cardiovascular and renal outcomes often received older agents with potential to cause comorbidity harm. Patients with atherosclerotic cardiovascular disease were less likely to be prescribed an SGLT2i as compared with older agents (6.3% vs. 10.6% for sulfonylureas or thiazolidinediones, P<0.001), as were those with heart failure (3.6% vs. 9.1% for sulfonylureas, P<0.001) and chronic kidney disease (3.0% vs. 7.4% for sulfonylureas or thiazolidinediones, P<0.001). Similarly, patients with obesity (BMI ≥30 kg/m²) were less likely to be prescribed a GLP-1 RA or SGLT2i compared with older agents (6.0% vs. 6.9% for sulfonylureas or thiazolidinediones, P=0.016). In the sensitivity analysis, results were similar except for obesity (P=0.27).

CONCLUSIONS: In practice, physicians appear to be more focused on controlling HbA1c than reducing macrovascular risk.

EVALUATION OF THE EFFECTIVENESS OF CARE COORDINATION ON MEDICATION ADHERENCE AMONG HIGH-COST, HIGH NEED COMMERCIALLY INSURED BENEFICIARIES

Rintu Saju¹; Jessica Harwood¹; Norman Turk¹; Chi-Hong Tseng¹; Tannaz Moin²; Carol Mangione¹; O. Kenrik Duru¹. ¹Division of GIM/HSR, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Medicine, UCLA/VA Greater Los Angeles, Los Angeles, CA. (Control ID #4064567)

BACKGROUND: High-cost, high-need (HCHN) patients experience several biopsychosocial stressors that complicate their health care and medication management. Although care coordination programs may improve outcomes for HCHN patients including medication adherence, prior studies that often utilize pre-post or quasi experimental study designs and may lack control groups have shown mixed findings. Thus, we analyzed data from a randomized controlled trial conducted by a large national insurer that delivered a robust and comprehensive care coordination program and assessed its impacts on medication adherence for three chronic medical conditions: diabetes, atrial fibrillation, and hypothyroidism.

METHODS: We performed an intention-to-treat analysis using administrative and pharmacy claims data for HCHN patients from 2019-2022. We examined adherence to metformin in patients with diabetes (n=2,875), statin in patients with diabetes (n=3,057), direct oral anticoagulants (DOACs) in patients with atrial fibrillation (n=267), and levothyroxine in patients with hypothyroidism (n=1,983). To define adherence, we calculated proportion of days covered (PDC) for each medication and created a binary variable defined as PDC > 80%. We used logistic regression to model the difference in likelihood of having PDC > 80% between treatment and control. Similarly, linear regression was used to model the difference in mean PDC between treatment and control. Covariates included age, gender, geographic location, plan type, and 18 comorbidity indicators.

RESULTS: We did not identify a significant difference in medication adherence between treatment and control groups across the four drug classes examined. Among the intervention group with diabetes compared to the control group, we did not see significant difference in metformin adherence (66% vs. 68%, p = 0.38) or statin adherence (70% vs. 70%, p = 0.98) as measured by a PDC > 80%. Among the intervention group with atrial fibrillation compared to the control group, we did not see significant differences in DOAC adherence (71% vs. 67%, p = 0.44) as measured by a PDC > 80%. Lastly, among the intervention group with hypothyroidism compared to the control group, we did not see significant differences in levothyroxine adherence (77% vs. 74%, p = 0.10) as measured by a PDC > 80%. In addition, we examined PDC as a continuous measure and found no significant difference across the four drug classes.

CONCLUSIONS: Our results align with prior studies showing that comprehensive care coordination programs for HCHN patients may not improve medication adherence. This may be in part because these interventions tend to be broad and not targeted specifically to medication adherence. In order to have a greater effect, future interventions may need to focus specifically on the facilitators and barriers to medication adherence among HCHN patients.

EXAMINING DIFFERENCES IN SMOKING HISTORY CONTAINED IN EMR AND OBTAINED DURING STUDY RECRUITMENT

Abigail Feinberg¹; Francesca Minardi¹; Hillary Ramos Espinoza¹; Juan Wisnivesky¹; Cardinale Smith²; Minal Kale¹. ¹Medicine, Mount Sinai Health System, New York, NY; ²Medicine, Icahn School of Medicine at Mount Sinai Tisch Cancer Institute, New York, NY. (Control ID #4064511)

BACKGROUND: Lung cancer is the leading cause of cancer-related mortality in the United States. Lung cancer screening reduces lung cancer mortality, however successful screening is contingent on the accurate identification of screening-eligible individuals based on age (50-80 y) and smoking history (20 pack years and having quit within 15 years for former smoking history). In this study, we compared smoking history contained within the electronic medical record (EMR) compared to self-reported smoking history obtained during study recruitment.

METHODS: We assessed the smoking history of 211 primary care patients between July 2022 and December 2023 at a Mid-Atlantic academic medical center as a part of recruitment procedures for an observational study on lung cancer screening. Individuals with a history of smoking based on the EMR (both former and current) were contacted and administered sociodemographic and smoking history questionnaires, including smoking status (never, current, former), smoking start age, smoking quit age, average cigarettes smoked per day, and years smoked. We examined the sociodemographic characteristics of these patients. A Kappa statistic and the 95% confidence interval (CI) were calculated to determine agreement between self-reported (obtained by study recruitment) and EMR-documented smoking status. Mean differences between the self-reported and EMR data and the standard deviations were calculated for age start, age quit, packs per day, years smoked, and pack years.

RESULTS: The average age of patients was 64.4 (SD: 7.8), 60.2% identified as women, 46.8% identified as Hispanic, and 34.5% identified as Black or African American (non-Hispanic). Agreement between self-reported and EMR data was low for smoking status (κ = 0.29 [0.25, 0.33]). The average absolute difference in smoking start age between self-reported and EMR data was 3.11 years (SD: 5.86); 89.1% of the data was missing from the EMR. Among the patients who had quit, the mean absolute difference in age they had quit smoking between self-reported and EMR data was 4.51 years (SD: 6.86); 45.0% missing in EMR. The mean absolute difference in packs per day between self-reported and EMR data was 0.37 packs (SD: 0.54); 28.4% missing in EMR. The mean absolute difference in years smoked between self-reported and EMR data was 7.44 years (SD: 6.51); 36.4% missing in EMR. The mean absolute difference in pack years between the self-reported and medical record data was 13.69 packs (SD: 13.16); 73.5% missing in EMR.

CONCLUSIONS: The EMR contained a concerning number of missing smoking history data, and there were clinically important differences in smoking history in EMR vs self-reported during study recruitment. These differences may lead to missed screening for eligible individuals, and may be contributing to the poor adoption of lung cancer screening. Future research will examine causes of variability in smoking history.

HEALTH CARE UTILIZATION AND EQUITY IN MEDICARE ADVANTAGE COMPARED TO TRADITIONAL MEDICARE

Lucy Schulson¹; Timothy Anderson²; Alan Zaslavsky⁴; John Z. Ayanian³; Bruce E. Landon⁴. ¹Boston University Chobanian & Avedisian School of Medicine, Boston, MA; ²Medicine/General Medicine, University of Pittsburgh, Boston, MA; ³Internal Medicine, University of Michigan, Ann Arbor, MI; ⁴Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #4062512)

BACKGROUND: Over half of Medicare beneficiaries are enrolled in private Medicare Advantage (MA) health plans that receive fixed monthly payments to provide care to their enrollees. To control excess utilization, MA plans have implemented programs to control use that may disproportionately negatively impact minoritized beneficiaries.

METHODS: Our study cohort included all Medicare beneficiaries enrolled in MA and a 20% sample of those enrolled in traditional Medicare (TM) from 2013-2018. We focused on enrollees identified as Black, Hispanic, or White according to the Research Triangle Institute race variable in the Medicare Beneficiary Summary File. Using Healthcare Effectiveness Data and Information Set (HEDIS®) measures, we compared utilization of specified services in MA health plans with utilization in TM, stratified by race and ethnicity and compared disparities. We matched each race and ethnicity subgroup relative to matched White enrollees on geographic distribution, age, and sex. Because differences were generally stable over time, we present results for 2018 only.

RESULTS: Our cohort consisted of 16,391,896 MA and 4,927,784 TM beneficiaries. There was a lower proportion of White beneficiaries in MA compared to TM (72.8% vs. 85.0%), but higher proportions of both Black and Hispanic beneficiaries in MA compared to TM (10.6% vs. 7.3% for Black beneficiaries; 11.5% vs. 5.1% for Hispanic beneficiaries). Ambulatory visit rates for both MA and TM were greater for White beneficiaries compared to matched Black beneficiaries (9.24 vs. 9.10 per beneficiary for MA; 9.92 vs. 8.86 for TM), but disparities were narrower in MA (0.14 vs. 1.06). In contrast, for both MA and TM, emergency department visit rates were lower for White beneficiaries (0.41 vs. 0.51 per beneficiary for MA; 0.62 vs. 0.74 for TM), but disparities were similar (-0.10 vs. -0.12). For both MA and TM, knee and hip replacement rates were greater for White beneficiaries (5.2 vs. 3.7 per 1000 beneficiaries for MA; 5.8 vs. 3.8 for TM), but disparities were narrower for both in MA (1.15 vs. 1.90 for knee replacement; 1.50 vs. 2.06 for hip replacement). Similar findings were observed for back surgery. Finally, coronary artery bypass graft surgery rates for both MA and TM were greater for White beneficiaries (2.29 vs. 1.43 per 1000 beneficiaries for MA; 2.15 vs. 1.43 for TM), but disparities were greater in MA (0.86 vs. 0.72) due to an increase in CABG rates for White beneficiaries. Findings for the Hispanic population compared to White beneficiaries were similar with the exception that disparities were greater in MA for hip replacements. All differences were significant at a p< .0001.

CONCLUSIONS: While inequities in health care utilization persist among Medicare beneficiaries, for many measures of health care utilization, including ambulatory care visits and some elective surgeries, MA appears to deliver care more equitably than TM.

HEALTH INSURANCE INSTABILITY FOLLOWING FIREARM INJURY

George Karandinos¹; Mia Giuriato²; Peter T. Masiakos³; Chana A. Sacks¹; Zirui Song². ¹Medicine, Massachusetts General Hospital, Boston, MA; ²Health Care Policy, Harvard Medical School, Boston, MA; ³Surgery, Harvard Medical School, Boston, MA. (Control ID #4064337)

BACKGROUND: Health insurance instability is associated with negative clinical outcomes, including care delays, prescription interruptions, provider discontinuity, increased ED visits, reduced preventive and primary care, and negative patient perceptions of care and health. In the aftermath of firearm injuries, continuity of health care is particularly important given sharply increased physical, mental, and rehabilitative needs. However, the impact of firearm injury on insurance instability is unknown.

METHODS: Using detailed employer-sponsored commercial health insurance claims and enrollment data, we identified individuals with incident firearm injury from 2007 to 2021. We matched each injured individual to up to 5 controls, with exact matching on year, month, plan type, prescription drug coverage, relationship to employee, sex, metropolitan statistical area, and state. We balanced the means of two continuous variables: age and risk adjustment score. Our primary outcome was time to insurance disenrollment, defined as plan termination date minus date of firearm injury or matching. We plotted survival curves and fit a Cox regression model with the outcome of disenrollment as a function of exposure to firearm injury. We adjusted for age and risk score in our regression, which were not exactly matched.

RESULTS: After matching, the final cohort included 13,189 individuals injured by firearms and 62,689 controls. Mean age was 31.4 and 83.4% were male, without significant difference between injured individuals and controls. At 12 months, 35% of injured individuals and 28% of controls experienced disenrollment (Figure) with an estimated hazard ratio of 1.34 (95% CI: 1.30-1.39).

CONCLUSIONS: Firearm injury is associated with an increased risk of subsequent insurance disenrollment. Insurance instability has important implications for the comprehensive, trauma-informed care that survivors often need. Health systems should create or strengthen existing multidisciplinary violence intervention and wrap-around care programs that can provide additional support following firearm injury and can help ensure continuous insurance coverage.

HIGHER-ORDER DISEASE INTERACTIONS IN MULTIMORBIDITY MEASUREMENT: MARGINAL BENEFIT OVER ADDITIVE DISEASE SUMMATION

Melissa Y. Wei^1,2; Chi-Hong Tseng¹. ¹Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA. (Control ID #4063890)

BACKGROUND: Current multimorbidity measures often oversimplify complex disease interactions by assuming a merely additive impact on health outcomes. This oversimplification neglects clinical observations that certain disease combinations can exhibit synergistic effects, resulting in a more pronounced impact on health than when considered individually. Thus, we aimed to examine simultaneous higher-order disease interactions, with a particular focus on diseases associated with physical functioning. Additionally, we evaluated the extent of model improvement resulting from the inclusion of disease interactions, compared with models that considered only additive disease effects.

METHODS: Participants from the Health and Retirement Study, with linked Medicare data, contributed repeated measures of a modified Short Form-36 physical functioning scale and ICD-9-CM diagnostic code claims spanning from 2000 to 2012. We focused on conditions with the top 10-20 highest prevalence and the top 10-20 worst associations with physical functioning and assessed them through higher-order interactions (e.g., two-way, three-way, etc.). We applied the least absolute shrinkage and selection operator (LASSO) and bootstrapping to identify and retain significant disease interactions. We compared model fit for the previously validated ICD-9 coded multimorbidity-weighted index (MICD), both with and without disease interactions. To minimize overfitting and yield a more robust estimate of generalizability, we report the coefficient of determination (R²) from the testing set across all models.

RESULTS: We analyzed 73,830 observations from 18,212 participants (training set N=14,570, testing set N=3,642) with a mean age ± SD of 70.7 ± 8.1 years. Of the 14,568 ICD-9 codes initially considered, the final set comprised 69 chronic condition groups representing 2,021 ICD-codes. The ICD-coded multimorbidity-weighted index (MICD) without interactions (72 possible covariates) produced an overall R² of 0.26. Introducing two-way interactions for the top 10 most common plus impactful conditions (256 possible covariates) resulted in a R² of 0.27, while expanding to the top 20 most common and impactful conditions (683 possible covariates) yielded a R² of 0.26. For three-way interactions, the top 10 most common and impactful conditions (1,223 possible covariates) produced a R² of 0.26, while considering the top 20 most common plus impactful conditions (6,613 possible covariates) resulted in a R² of 0.24.

CONCLUSIONS: We present novel insights into simultaneous higher-order disease interactions for potential integration into multimorbidity measurement, supported by improved model performance. Incorporating two-way disease interactions for the top 10 prevalent and impactful conditions in physical functioning showed a modest improvement in model fit. The culmination of these findings is a more precise multimorbidity index that encompasses both the main effects of diseases and their significant interactions.

HOSPITAL COMPETITION: A BOON OR BANE FOR HEALTHCARE VALUE

Joshua Ross¹; Mahip Grewal¹; Caleb Irvine¹; Jeph Herrin²; Huihui Yu²; Leora I. Horwitz¹. ¹New York University Grossman School of Medicine, New York, NY; ²Yale School of Medicine, New Haven, CT. (Control ID #4063936)

BACKGROUND: The United States healthcare system has witnessed an overwhelming trend towards mergers and acquisitions of hospitals. Existing evidence suggests that consolidation has driven higher costs but has had mixed effects on quality. We investigated the relationship between hospital market concentration and healthcare value.

METHODS: We constructed a measure of value using Centers for Medicare and Medicaid Services (CMS) Overall Hospital Quality Star Ratings, which rate hospital performance by pooling 57 quality measures, and Medicare spending per beneficiary (MSPB). The value score for a hospital was defined as the difference between its Star summary score and MSPB score, with each score standardized to range from 0 – 10; thus, the maximum value score was 10 and minimum -10.

The Health Care Cost Institute (HCCI): Hospital Concentration Index dataset was used to assess market concentration. This dataset is based on 2017-2021 inpatient healthcare claims for individuals under 65 with commercial health insurance, and it provides the Herfindahl-Hirschman Index (HHI), a validated calculation for market concentration, for 186 Core-Based Statistical Areas (CBSAs), representing 3,131 hospitals. Very highly concentrated markets had HHI values between 5000 and 10000, highly concentrated between 2500 and 5000, moderately concentrated between 1500 and 2500, and unconcentrated had HHI values less than 1500.

Hospital level characteristics, including geography, ownership, and teaching status, were obtained via the American Hospital Association 2020 survey. A zip code to CBSA crosswalk across the United States was used to map hospitals to CBSAs and their corresponding HHI values.

To assess the association of HHI with value, we estimated two mixed effects linear regression models with value (high vs other) as the dependent variable and HHI as the independent variable, with a random effect for CBSA. The first model included only HHI, the second also included hospital characteristics.

RESULTS: 67.2% of CBSAs examined were very highly or highly concentrated. Mean hospital value was highest in very highly concentrated CBSAs (2.41), followed by moderately concentrated (2.35), highly concentrated (2.27) and lowest in unconcentrated regions (2.22). The percentage of high value hospitals per concentration, defined as > 3 quality stars and top quintile MSPB, was highest in the very highly concentrated group (14.29%) and lowest in the unconcentrated (4.21%).

In regression analyses including only HHI, there was no association with high value; after adjusting for hospital characteristics, the OR (95% CI) for high value associated with each 1000 point increase in HHI was 1.239 (1.004,1.530); P=0.045.

CONCLUSIONS: In contrast to concerns that increasing hospital market concentration negatively impacts healthcare value, our study found that hospitals in unconcentrated markets provide lower value care. As such, concentrated markets may create incentives or synergies that facilitate higher value care.

HOSPITAL READMISSIONS REDUCTION PROGRAM PENALTIES AND THE UTILIZATION OF REVASCULARIZATION PROCEDURES AMONG DUAL-ELIGIBLE MEDICARE BENEFICIARIES IN FOUR STATES

Benjo A. Delarmente^1,2; Darrell J. Gaskin³. ¹Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; ²School of Economics, University of the Philippines Diliman, Quezon City, Metro Manila, Philippines; ³Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4065105)

BACKGROUND: Beginning in FY 2013, Medicare’s Hospital Readmissions Reduction program (HRRP) imposed financial penalties on hospitals whose excess readmission rates for six conditions (including AMI) are higher than the national averages. Penalties on Medicare payments may represent a significant burden on certain hospitals, especially those who serve high percentages of high-risk Medicare beneficiaries who are dually enrolled in Medicaid. Dual-eligible AMI patients have been less likely to receive appropriate revascularization during the index hospital stay, in comparison to Medicare-only beneficiaries. Bringing revascularization rates into parity could reduce dual-eligibles’ risk of readmission. We investigate whether HRRP penalties had an impact of the utilization of coronary revascularization among dual-eligible AMI patients.

METHODS: We use discharge data from the Healthcare Cost and Utilization Project’s (HCUP) State Inpatient Databases (SID). The analytical sample includes 35,349 AMI discharges from four states (NJ, NY, NC, WA) for 2009, 2011, 2013, and 2015. The primary outcome of interest is the receipt of a revascularization procedure (PCI or CABG) while the primary independent variable of interest is the HRRP penalty due to excess AMI readmissions, calculated from CMS. For each state, we estimated models using linear probability regressions with year fixed effects, controlling for age, gender, race/ethnicity, Elixhauser comorbidities, and patient’s county’s income level at the patient level, and total admissions, diagnostic catheterization, interventional catheterization, and adult cardiac surgery capabilities at the hospital level. Elasticities between the receipt of either a PCI or a CABG and hospital AMI penalties were then calculated at the means of all variables and errors were clustered at the hospital level.

RESULTS: A one percent increase in the AMI penalty increases the probability of getting a PCI by 0.147, 0.145, and 0.0721 is New Jersey, New York, and North Carolina in models that only include patient-level controls. Among STEMI patients, a one percent increase in AMI penalty is associated with a 0.0648 percent increase in the probability of receiving a PCI in New York in models with both patient- and hospital-level controls. A one percent increase in hospital AMI penalty increases the probability of receiving a CABG by 0.048 in Washington among all Medicare patients, and by 0.0723 among NSTEMI patients.

CONCLUSIONS: AMI penalties appear to have relatively stronger effects in New York and Washington, states with relatively higher percentages of dual-eligible Medicare beneficiaries among the four states included in this study.These results suggest that in states with higher proportions of dual-eligibles, HRRP penalties are associated with an improvement in the quality of care given to certain dual-eligible AMI patients in that it increases the likelihood of their receipt of evidence-based revascularization procedures during their initial AMI hospitalization.

IMAGING PATTERNS FOR LOW BACK PAIN AMONG PRIMARY CARE PHYSICIANS AND DOWNSTREAM UTILIZATION OF SPECIALIST REFERRALS, INJECTIONS, AND SURGERIES

Sumit Agarwal^1,2; Jose Zubizarreta³; Jeffrey Souza²; Bruce E. Landon². ¹Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, MA; ²Health Care Policy, Harvard Medical School, Boston, MA; ³Health Care Policy, Biostatistics, and Statistics, Harvard University, Cambridge, MA. (Control ID #4064956)

BACKGROUND: Low-value imaging for back pain is common, but downstream consequences (“cascades”) are not well understood. Because of confounding by indication, it is challenging to isolate the impact of early imaging on downstream utilization of services.

METHODS: Using a 100% sample of continuously enrolled beneficiaries in traditional Medicare, we identified patients with an index visit to a primary care physician for low back pain from 2017 through 2019 with no prior visit for back pain in at least the prior 3 months. We first categorized primary care physicians based on quartiles of the intensity with which they ordered plain x-rays, computed tomography, or magnetic resonance imaging within 6 weeks of an initial encounter among patients they had seen in the prior year for low back pain. Leveraging quasi-randomized variation in who patients see for the evaluation of new back pain, we compared outcomes after an index visit among patients who see a high-ordering physician versus low-ordering physician. The key assumption of our strategy for reducing selection bias is that patients do not choose their primary care physician based on the intensity with which they order diagnostic imaging for back pain that may develop in the future. After categorizing patients by whether they visited physicians in the top or bottom quartile of imaging intensity, we additionally used cardinality matching to identify similar patients across the top and bottom quartiles based on a set of observable characteristics. Our outcomes included rates of imaging within six weeks, visits with surgical and non-surgical subspecialists, epidural steroid injection, and back surgery within six months after the index visit.

RESULTS: There were 142,478 matched beneficiaries included in our study population, equally split between high- and low-ordering physicians. After visiting a high-ordering physician, 37% of patients with an index visit to primary care for back pain had imaging, as compared to 15% of patients seeing a low-ordering physician. More patients who had visited a high-ordering physician subsequently saw a surgeon (14.4% vs. 10.5%), a non-surgical specialist such as a pain anesthesiologist or physiatrist (18.5% vs 13.5%), or either type of specialist (28.4% vs 21.3%). Finally, 10.9% of patients who initially saw a high-ordering primary care physician received a corticosteroid back injection and 2.6% had back surgery versus 5.8% and 1.3%, respectively, of patients who initially saw a low-ordering primary care physician.

CONCLUSIONS: The propensity to order imaging for low back pain varies substantially across physicians and, for otherwise similar patients, leads to a doubling of downstream invasive procedures including potentially low-value injections and back surgeries.

IMPACT OF A HEALTH SYSTEM INTERVENTION ON QUALITY OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE CARE AFTER HOSPITAL DISCHARGE: SECONDARY ANALYSIS OF A STEPPED-WEDGE CLINICAL TRIAL

Joseph H. Joo^1,2; Lucas M. Donovan^1,2; Scott S. Coggeshall²; Laura C. Feemster^1,2; Joshua M. Liao¹; David H. Au^1,2. ¹Medicine, University of Washington, Seattle, WA; ²Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA. (Control ID #4063747)

BACKGROUND: To better coordinate care between specialists and generalists, we developed a health system intervention with interdisciplinary, pragmatic, and proactive review of patients following inpatient chronic obstructive pulmonary disease (COPD) exacerbations. We previously demonstrated that this intervention led to improved patient quality of life. However, the impact of such an intervention on quality of care is unclear. This study aims to evaluate whether such a health system intervention can improve the quality of COPD care.

METHODS: We performed secondary analysis of a stepped-wedge clinical trial (NCT02021955) that enrolled 365 primary care providers caring for 352 patients after hospital discharge for COPD exacerbation at 2 VA medical centers and 10 outpatient clinics. Over a 30-month period, 191 patients were included in the control and 161 in the intervention groups. An interdisciplinary team proactively reviewed EHRs and delivered treatment recommendations to primary care providers via E-consult.

We defined quality of care based on 7 evidence-based practices: spirometry to diagnose COPD, reassessment of home oxygen, receipt of long-acting bronchodilators, escalation of inhaled therapy post-discharge, assessment of smoking status, smoking cessation treatment, and pulmonary rehabilitation referral. Among the evidence-based practices for which each patient was eligible, we calculated the proportion received within 180 days post-discharge.

We compared the proportions between groups using mixed-effects linear regression models adjusted for clustering by provider, temporal trends, and markers of COPD severity.

RESULTS: The unadjusted mean proportion of evidence-based practices being performed in the control group was 0.53 (SD = 0.26) compared to 0.60 (SD = 0.30) in the intervention group. In adjusted models, patients in the intervention group received on average 6 percentage points higher proportion of evidence-based practices (95% CI: -1 to 13 percentage points) relative to the control group.

The intervention group had higher percentage of patients receiving long-acting bronchodilators (70.6% intervention vs 61.8% control), escalations of inhaled therapy post-discharge (68.6% vs 55.5%), and pulmonary rehabilitation referrals (32.9% vs 10.5%). The percentage of patients receiving spirometry (33.9% vs 30.6%), reassessment of home oxygen (91.3% vs 91.0%), and assessment of smoking status (71.4% vs 70.7%) between the two groups were similar. The percentage of patients receiving smoking cessation treatment (56.6% vs 63.0%) was lower in the intervention group.

CONCLUSIONS: Improvements in quality of life were unlikely related to overall changes in quality of COPD care, though may be attributable to selected interventions, such as medication use and pulmonary rehabilitation. Future work should explore the mechanisms whereby proactive health system interventions that coordinate care between specialists and generalist led to improved patient outcomes.

IMPACT OF BILLING REFORMS ON HOSPITALIST PHYSICIAN AND ADVANCED PRACTICE PROVIDER COLLABORATION: A QUALITATIVE STUDY

Sara Westergaard¹; Kasey Bowden⁷; Gopi Astik²; Gregory Bowling³; Angela Keniston⁷; Anne S. Linker⁴; Matthew Sakumoto⁵; Natalie Schwatka⁶; Andrew Auerbach⁵; Marisha Burden⁷. ¹Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; ²Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ³Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ⁴Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁵Medicine, University of California San Francisco, San Francisco, CA; ⁶Environmental and Occupational Health, University of Colorado, Denver, CO; ⁷Medicine, University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #4057181)

BACKGROUND: In the hospital care setting, clinician groups employ a range of staffing models utilizing physicians and advanced practice providers (APPs). The Centers for Medicare and Medicaid Services (CMS) previously announced plans to change billing rules for inpatient visits that are shared by physicians and APPs whereby the clinician spending greater than 50% time on the patient visit would bill services for the visit. We aimed to understand how hospital medicine teams utilize APPs in patient care and how billing policies might impact future APP utilization.

METHODS: We conducted focus groups with hospitalist physicians, APPs, and other leaders across 21 academic institutions. Using rapid qualitative methods, six semi-structured focus groups were held virtually, and audio files were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. A brief REDCap survey was also included.

RESULTS: Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in focus groups conducted via Zoom videoconferencing on March 20, 2023. Twenty-seven of the 33 individuals (81.8%) completed the survey. Participating hospitalist groups ranged in size from 28 to 125 physicians (mean 65.5, IQR 44.25-76.25) and zero to 70 APPs (mean 22.2, IQR 9.75-28.75). Fifteen participants (57.7%) responded that APPs bill independently, 17 participants (65.4%) responded that physicians and APPs bill shared services and three participants (11.5%) responded that APPs do not provide billable services.

Four themes emerged from analysis of the focus groups: (1) Staffing models with APPs are rapidly evolving and include a variety of staffing models. (2) These changes were driven by staffing shortages, financial models, and governance with minimal consideration given to teamwork and relationships. Participants described greater autonomy for APPs in response to surge demand from the pandemic that has persisted due to perceived cost and operational efficiencies; however greater independence has also led to less collaboration between physicians and APPs with the perception that independent models are seen as less safe. (3) Time-based billing models were perceived to value tasks over cognitive workload, and this may disincentivize physician involvement in care. (4) The proposed billing changes may create unintended consequences including dissatisfaction among both physicians and APPs as well as erosion of culture between physicians and APPs.

CONCLUSIONS: Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations. While CMS has now revised billing rules for split or shared visits to include either time or medical decision making, understanding which staffing models produce optimal patient, clinician and organizational outcomes is needed and should inform billing policies rather than the reverse.

IMPACT OF GLOBAL PAYMENTS FOR UNINSURED UNCOMPENSATED CARE: EVALUATING CALIFORNIA’S GLOBAL PAYMENT PROGRAM

Justin W. Timbie²; Maria DeYoreo²; Jodi L. Liu²; Denise D. Quigley²; Katherine L. Kahn^1,2. ¹Medicine, University of California Los Angeles, Los Angeles, CA; ²Health, RAND Corporation, Santa Monica, CA. (Control ID #4065052)

BACKGROUND: California’s Medi-Cal 2020 waiver authorized a new payment model for reimbursing services provided to the state’s remaining uninsured, the Global Payment Program (GPP). Under GPP, which included California’s 12 county-based public healthcare systems (PHS), the state gained unprecedented flexibility to use its federal Medicaid Disproportionate Share Hospital (DSH) allotment to make prospective payments for services provided to the uninsured in the hospital, clinic, and community settings. Historically, DSH funding was used to retrospectively finance only hospital-based care. GPP was designed to encourage participating PHS to invest in infrastructure and processes that could better tailor care to patients’ needs and expand the delivery of preventive services. We assessed changes in utilization of services through the first three years of GPP.

METHODS: Study Design: We used service utilization data submitted by the 12 county-based PHS that collectively served most of the state’s uninsured (nearly 3 million annually). We compared changes in utilization by type of service during the demonstration’s first three years. We stratified results for physical and behavioral health services given the high prevalence of behavioral health conditions among the uninsured.

The study included uninsured California residents receiving care from participating PHS. The majority of uninsured individuals were those without satisfactory immigration status.

RESULTS: Principal Findings: The number of uninsured served by PHS increased 6% over three years. For physical health services, outpatient non-emergent service use increased by 12% whereas use of emergency room (ER) and inpatient services decreased by 14% and 15% respectively. For behavioral health services, outpatient mental health and substance abuse treatment services decreased by 4%. Although ER and crisis stabilization services decreased by 14%, mental health inpatient service use increased by 21%. Use of non-traditional services increased by 10%, driven by greater use of case management, mobile clinic visits, PharmD visits, eConsults, and store-and-forward telehealth. PHS varied widely in their relative use of physical, behavioral, and non-traditional services and trends over time in these services.

CONCLUSIONS: Conclusions: Access to services increased and use of physical health and non-traditional services changed in directions consistent with the program’s goals; however behavioral health utilization showed several unexpected trends. These results suggest that implementing global payments for the uninsured is feasible although the long-term effects of the observed changes in utilization on health outcomes and expenditures must also be assessed. States may now consider using Section 1115 waiver authority to test similar value-based payment programs that efficiently use Medicaid DSH funding. This is especially so as the first of $32 billion in Medicaid DSH funding cuts are expected to begin nationwide in 2024.

IMPACT OF MEDICAID ELIGIBILITY THRESHOLD FOR PREGNANT PEOPLE ON INFANT HEALTH AND HEALTHCARE UTILIZATION

Elizabeth Boggs¹; Lindsay Admon²; Sharon Scarbro⁶; Renuka Tipirneni^3,4; Richard C. Lindrooth⁵. ¹Department of Medicine, University of Colorado Health, Aurora, CO; ²Department of Obstetrics & Gynecology, University of Michigan Michigan Medicine, Ann Arbor, MI; ³Department of Medicine, University of Michigan, Ann Arbor, MI; ⁴Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; ⁵Health Systems, Management, and Policy, University of Colorado Anschutz Medical Campus, Aurora, CO; ⁶Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4044424)

BACKGROUND: Insurance coverage during pregnancy facilitates access to timely prenatal and postpartum care, which improves birth outcomes and promotes long-term health of mothers and infants. Medicaid income eligibility limits for pregnant people vary widely by state (138-380% Federal Poverty Level [FPL]). While evidence exists on maternal health benefits of Medicaid coverage, the association between Medicaid eligibility for pregnant people and spillover effects on infant health is less clear. The study objective was to evaluate the association between state Medicaid income eligibility limit during pregnancy and infant health and utilization.

METHODS: This pooled cross-sectional study examined how state Medicaid income eligibility threshold for pregnant people predicts the binary outcomes of caregiver-reported infant health (health described as very good or excellent, primary outcome), identified source of preventive care, and emergency department (ED) use (secondary outcomes) during the first year of life. Infants under 1 year of age in households with income <380% FPL in the nationally representative National Survey of Children’s Health from 2016-2019 were included. We conducted logistic regression, controlling for infant and family characteristics and year fixed effects (Table).

RESULTS: Among infants in households <380% FPL, infants residing in states with higher Medicaid income eligibility during pregnancy more likely to be in very good or excellent health (Table, OR 1.08, p=0.005), even after controlling for infant and family characteristics (OR 1.09, p =0.01). Lower educational attainment among caregivers was also associated with poorer reported infant health. There was no significant association between state Medicaid income eligibility during pregnancy and usual source of care or ED use for the infant in adjusted or unadjusted analysis.

CONCLUSIONS: Greater generosity of Medicaid coverage during pregnancy is associated with better caregiver reported infant health. However, the mechanism for this association may not be related to primary care utilization in the form of a usual source of care.

IMPACT OF TELEMEDICINE USE ON CARBON EMISSIONS: AN ESTIMATE FROM A NATIONAL COHORT

Benjo A. Delarmente^1,2; A. Mark Fendrick³; Chi-Hong Tseng⁴; Melody Craff⁵; Dale Skinner⁶; Michael Hadfield⁷; Cheryl Damberg⁸; Catherine Sarkisian⁴; John N. Mafi⁹. ¹Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; ²School of Economics, University of the Philippines Diliman, Quezon City, Metro Manila, Philippines; ³Internal Medicine, University of Michigan, Ann Arbor, MI; ⁴Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵MedInsight, Milliman Inc, Seattle, WA, US, Seattle, WA; ⁶MedInsight, Milliman Inc Seattle, Seattle, WA; ⁷Strategic Analytics, MCG Health, Seattle, WA; ⁸Health Care, RAND Corporation, Santa Monica, CA; ⁹Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4065054)

BACKGROUND: The U.S. health care system contributes to nearly 9% of domestic U.S. carbon emissions, exacerbating climate change and threatening human health. The use of telemedicine decreases both the need to use transportation to receive health care services and carbon emissions. The COVID-19 telemedicine expansion and associated generous payment policies led to unprecedented uptake of this care modality; however, the climate impacts of the shift to telemedicine have not been quantified. We estimated the carbon dioxide (CO₂) emissions averted from the avoidance of travel by patients using telemedicine instead of their usual source of in-person care.

METHODS: The primary data source is the Milliman MedInsight Emerging Experience de-identified research database. Our cohort included adults enrolled for ≥12 months in Medicare fee-for-service, Medicare Advantage, Medicare-Medicaid, Medicaid, and commercial plans across all 50 U.S. states. The total number of telemedicine visits in our cohort in May 2023 formed the basis of our calculations. To estimate telemedicine’s effects on carbon emissions, we included distance data from the 2017 National Household Travel Survey, carbon emissions and market share data from the 2022 EPA Automotive Trends Report, 2022 Congressional Budget Office report on transportation sector emissions, and Stanford Health Care carbon life-cycle data. For the base estimate, we first multiply the total numbers of telemedicine visits by a substitution ratio derived from Reed et al (2023) that estimates that each telemedicine visit substituted for approximately 0.84 in-person visits. We then multiply this product by the average distance to patients’ usual source of care, stratified by rurality, and the CO₂ emissions per mile traveled by an average passenger car. To produce lower-bound estimates, we computed several alternative scenarios that conservatively used lower average emissions per mile, accounted for the production shares of different vehicle types, and accounted for the use of public transportation.

RESULTS: In May 2023, there were 1,359,737 million telemedicine visits, of which 60,605 were located in rural areas. Telemedicine visits that would have otherwise been in-person visits averted 7,771,121.6 kg of CO₂ (7,043,270.1 kg in urban areas; 727,851.5 kg in rural areas). When 2021 emissions per mile levels were used, the estimate decreases to 6,727,034.8 kgs. The estimate was similar when accounting for 2021 production shares of different vehicle types. Estimates accounting for different assumptions of public transportation use ranged from 7-7.5 million kg CO₂ averted.

CONCLUSIONS: The use of telemedicine in June 2023 among patients included in our nationwide database averted between 6.7-7.7 million kgs of CO₂ emissions, roughly equivalent to the monthly emissions of approximately 20,000 passenger vehicles. Clinically appropriate use of telemedicine use can contribute to ongoing efforts to decrease the carbon footprint of U.S. health care delivery.

LEADING A HEALTH CARE ORGANIZATION DURING A PERIOD OF SOCIAL CHANGE: A QUALITATIVE STUDY OF CHIEF EXECUTIVE OFFICERS

Kerry Meltzer^1,2; Zoe Bouchelle^3,4; Jaideep Grewal⁵; Kevin B. Mahoney^6,7; David Grande^7,8. ¹National Clinician Scholars Program at University of Pennsylvania, Philadelphia, PA; ²Primary Care, Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA; ³Pediatrics, Denver Health Main Campus, Denver, CO; ⁴PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA; ⁵University of Pennsylvania, Philadelphia, PA; ⁶Office of the Chief Executive Officer, Penn Medicine, Philadelphia, PA; ⁷Leonard Davis Institute of Health Economics, Philadelphia, PA; ⁸General Internal Medicine, Penn Medicine, Philadelphia, PA. (Control ID #4058595)

BACKGROUND: In recent years, organizational leaders have faced growing pressure to respond to social and political issues. Although previous research has examined the experiences of corporate CEOs engaging in these issues, less is known about the perspectives of health care leaders.

METHODS: We conducted a qualitative study using semi-structured interviews with 25 CEOs from U.S.-based hospitals and health systems from February-July 2023. A research team member conducted thirty-minute audio-recorded interviews via telephone or videoconferencing. The interview guide asked CEOs what polarizing issues they’ve faced during their time as CEO, factors they consider in their decisions around if and how to respond, and the positive and negative impacts of responding. The guide specifically probed how CEOs responded to the police killing of George Floyd in May 2020 and the U.S. Supreme Court’s Dobbs v. Jackson decision in June 2022. Interviews were professionally transcribed and analyzed in QSR NVivo using thematic analysis. When available, CEOs were asked to provide examples of internal communications they sent to their employees surrounding these two specific incidents.

RESULTS: The study included 25 CEOs of U.S.-based hospitals and health systems. Almost half (12) were between ages 60 to 69, 19 identified as male, and 20 identified as White. Most (15) hospitals and health systems were private nonprofits. Health systems from 44 states were included because several operated across state lines. The interviews organized around four major themes with several subthemes (see Table). We found that CEOs’ felt increased pressure to engage in social and political issues in recent years but had mixed feelings regarding if and how they should engage. They cited how their own personal beliefs, organizational characteristics as well as the political environment influenced their decision to respond to a particular issue. CEOs noted positive as well as negative impacts of speaking out and also shared strategies used to better engage on polarizing issues.

CONCLUSIONS: In this qualitative study, health care CEOs describe their decision-making and leadership experiences engaging in health-related social and political issues in recent years. Given that health care leaders are increasingly being asked to address major policy debates, it’s important to determine how they respond to this shifting landscape.

LOW PROVISION OF PRIMARY CARE SERVICES ACROSS US OPIOID TREATMENT PROGRAMS

Bryant Shuey¹; Paul Joudrey¹; Timothy Anderson²; Jane Liebschutz³. ¹General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²Medicine/General Medicine, University of Pittsburgh, Boston, MA; ³Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4064977)

BACKGROUND: Only federally certified opioid treatment programs (OTPs) are authorized to dispense methadone for opioid use disorder (OUD). OTPs require nearly daily patient attendance for medication dosing. As patients with OUD frequently face multimorbidity, these daily dosing requirements could inadvertently create a barrier to engaging in broader health care. Alternatively, OTPs could serve as vital access points for primary care services for individuals typically reluctant to engage with the healthcare system. This study aims to (a) assess the prevalence of primary care services in OTPs, and (b) investigate the relationship between primary care service availability and key OTP characteristics.

METHODS: We conducted a cross-sectional study of the 2021 National Substance Use and Mental Health Services Survey (78.8% response rate). We included all methadone-dispensing OTPs. Our primary outcome, the provision of primary care services within OTPs, was assessed using a limited set of survey questions pertaining to ancillary physical health service provisions. We defined this outcome based on the availability of (1) screening or diagnostic testing (metabolic testing, HIV, hepatitis C, or sexually transmitted infections), (2) preventive care (hepatitis A or B vaccination), and (3) medications for medical conditions (HIV treatment, HIV pre-exposure prophylaxis, or hepatitis C treatment). OTPs offering all three types of services met criteria for the main outcome. We used univariate logistic regression to analyze associations between primary care service provisions and OTP characteristics, including profit status, hospital affiliation, federally qualified health center (FQHC) affiliation, rurality, and acceptance of Medicare.

RESULTS: Among 1,641 OTPs, 1,550 (94.5%) offered screening or diagnostic testing, 275 (16.8%) offered preventive care, and 281 (17.1%) offered medications for medical conditions. Only 143 (8.7%) provided primary health services. For-profit (vs. non-profit) OTPs had a lower odds of offering primary care services (OR 0.13, 95% CI 0.09, 0.21). OTPs affiliated with an FQHC (OR 2.50 95% CI 1.61, 3.87) and accepting Medicare (OR 2.12 95% CI 1.10, 4.10) were significantly more likely to offer primary health services. There were no differences in primary care service provisions by rurality or affiliation with a general hospital.

CONCLUSIONS: In 2021, only 9% of methadone-dispensing OTPs provided primary care services spanning screening, prevention, and treatment. Despite nearly daily touchpoints with the health system, patients on methadone have limited access to primary care services in OTPs. This represents a significant missed opportunity for patient-centered care. To enhance patient-centered approaches for individuals on methadone, policymakers should explore strategies to integrate primary care services into OTPs and consider permitting methadone prescribing and dispensing in community pharmacies.

MEDICARE INFLATION REBATES FOR PRESCRIPTION DRUGS DID NOT PREVENT MANUFACTURER PRICE INCREASES IN 2023

Alexander Egilman, Aaron S. Kesselheim, Benjamin N. Rome. Department of Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4064961)

BACKGROUND: After a brand-name drug is approved in the US, its manufacturer sets a launch price and then generally raises the price each year, leading to higher costs for patients and the health care system. Starting in 2023, the Inflation Reduction Act required that manufacturers pay Medicare rebates to offset price increases exceeding inflation. We examined whether drugs most affected by the new policy because they derive more sales from Medicare had smaller price increases after the policy took effect.

METHODS: We identified 200 drugs with the highest US net sales in 2023 from SSR Health; we excluded vaccines, generics, and biosimilars exempt from Medicare inflation rebates. We calculated each drug’s Medicare share of net US sales using the 2021 Medicare Parts B and D drug dashboards; net Part D spending was estimated using rebates calculated by SSR Health. To ensure adequate data before and after the policy took effect, we excluded drugs without reported Medicare spending in 2021, drugs with generic or biosimilar competitors before January 2023, and drugs approved after December 2020. For each drug, we calculated the change in price from January 2021 to January 2022 (pre-policy) and January 2022 to January 2023 (post-policy). To align with the policy, for Part B drugs we used the Medicare payment limits which are based on post-rebate average sales prices, while for Part D drugs, we used manufacturer list prices (wholesale acquisition cost). We used linear regression to test whether the share of Medicare sales was associated with a difference in annual price changes from 2022-2023.

RESULTS: We analyzed 159 drugs, including 53 (33%) Part B and 106 (67%) Part D drugs. The median Medicare share of net sales was 28% (IQR: 18%-37%) for Part B drugs and 32% (IQR: 16%-49%) for Part D drugs. In the pre-policy period, inflation was 7.5%, the median price change for Part B drugs was 3.1% (IQR: 1.3%-4.8%), and the median price change for Part D drugs was 5.0% (IQR: 4.0%-6.1%). In the post-policy period, inflation was 6.4%, the median price change for Part B drugs was 2.8% (IQR: 1.2%-4.9%), and the median price change for Part D drugs was 5.9% (4.2%-7.1%). Annual price changes were similar in 2022 and 2023 for Part B drugs (median difference 0.0%, IQR: -0.7%-2.6%) and Part D drugs (median 0.1%, IQR: 0.0%-1.5%). There was no association between Medicare share of net sales and differences in annual price changes pre- vs. post-policy for Part B (p=0.23) or Part D (p=0.18) drugs.

CONCLUSIONS: Medicare inflation rebates that took effect in 2023 did not lead to smaller price increases among top-selling drugs most affected by the policy. The rebates were enacted during a period of historically high inflation; manufacturers may respond differently when inflation is lower. Additional measures are needed to contain manufacturer price increases on highly profitable brand-name drugs, such as extending inflation rebates to the commercial market.

MENTAL HEALTHCARE UTILIZATION BY TRANSGENDER AND CISGENDER VETERANS WITH DEPRESSION: A MATCHED ANALYSIS

Joy L. Lee^1,6; Stanley Taylor⁶; Jocelyn Mineo⁷; Stephanie Dickinson⁷; Adam Hirsh²; Jennifer Carnahan³; Archana Radhakrishnan⁴; Michael Weiner^5,6. ¹Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA; ²Psychology, Indiana University Purdue University Indianapolis, Indianapolis, IN; ³Medicine, Indiana University School of Medicine, Indianapolis, IN; ⁴General Medicine, University of Michigan, Ann Arbor, MI; ⁵Department of Medicine, Indiana University, Indianapolis, IN; ⁶VA Center for Health Information and Communication, Indianapolis, IN; ⁷Indiana University Bloomington, Bloomington, IN. (Control ID #4059366)

BACKGROUND: Transgender and gender non-binary (TGN) individuals experience significant social and economic disparities that often translate into measurable mental health consequences. But the link between depression and mental healthcare utilization among transgender veterans is not well understood. This study is a critical first step toward understanding the needs and care patterns of transgender veterans with depression.

METHODS: Using data from the VA Central Data Warehouse, we created a 1:3 matched nationwide cohort of TGN and cisgender (CG) veterans with depression. The veterans were matched on age and VA facility. We used descriptive statistics to characterize mental healthcare utilization, including outpatient, telehealth, and emergency department visits and inpatient stays between 2018-2020, and tested for significant differences between TGN and CG veterans. Logistic regression was used to compare utilization (yes/no), controlling for other patient characteristics including age, sex, race, and number of mental-health medications, and using random effects to account for clustering within facilities.

RESULTS: In our cohort of 10,564 Veterans with depression (2,643 TGN matched with 7,921 CG veterans), mental healthcare utilization by TGN veterans was significantly higher than utilization by CG veterans across almost every type of visit. TGN veterans had significantly more in-person mental-health encounters than CG veterans (mean = 14 vs 8 encounters per year, p<0.01). TGN veterans also had significantly more mental health encounters by phone and secure messaging via the patient portal, My HealtheVet (mean = 4.25 vs 3.62 calls, p<0.01; mean = 0.54 vs 0.45 messages; p<0.01). The TGN group also had more mental health-related ED visits and inpatient stays than the CG group (mean = 0.13 vs 0.10 visits, p<0.01; mean = 0.17 vs 0.12 visits, p<0.01), although the absolute difference was small. In adjusted regression models, we found that age group, gender identity, Charlson Comorbidity Index (CCI), and the number of anti-depressant, anti-psychotic, and anxiolytic medications prescribed to a veteran were significantly associated with mental healthcare utilization. All else being equal, the odds of having a mental health outpatient visit (non-primary care) for a TGN veteran was 2.6 times that of a CG veteran.

CONCLUSIONS: TGN veterans had higher utilization of mental-health services compared to CG veterans, even after adjusting for relevant demand health factors. These differences may be driven by patient, clinician, or system factors. For example, due to barriers in access, TGN patients may require more visits than CG patients to have their mental-health concerns adequately addressed by clinicians. Further studies are needed to understand the mechanisms of these disparities and how to address them.

NATIONAL TRENDS IN GENERIC AND BRAND NAME PRESCRIPTION OUT-OF-POCKET COSTS

Christopher Cai¹; Aaron S. Kesselheim²; Benjamin N. Rome². ¹Internal medicine, Brigham and Women's Hospital, Boston, MA; ²Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4064550)

BACKGROUND: In the US, high out-of-pocket (OOP) costs for prescription drugs lead to non-adherence and worse clinical outcomes. Although this problem is well-described for brand-name drugs, most prescriptions in the US are for less expensive generic drugs. The relative contribution of brand versus generic drugs to patient OOP spending has not been described.

METHODS: We conducted a cross-sectional analysis using the 2014-2021 Medical Expenditure Panel Survey, which includes medication fill information collected directly from pharmacies. We included all survey respondents and tabulated the number of different generic and brand name drugs used by National Drug Code. We calculated annual OOP costs as the sum of costs for all filled medications, stratified as brand vs. generic using an identifier from First Databank. We stratified results by insurance type and calendar year. All spending was adjusted to 2021 dollars using the Consumer Price Index for OOP payments and Gross Domestic Product Index for national expenditures.

RESULTS: We included 251,951 individuals representing a population of 2.60 billion from 2014-2021. Overall, 23.8% (95% CI 23.4%-24.2%) filled at least 1 brand-name drug, and 54.4% (53.8%-55.0%) filled at least 1 generic drug each year. Patients taking generics took a median of 3 generics (IQR 1-6) annually; patients taking branded drugs took a median of 1 (IQR 1-2) annually. Median annual out-of-pocket spending was $32 (IQR $5-$121) on generics and $0 (IQR $0-$21) on branded drugs. Among patients who took at least 1 generic, median annual OOP spending on generics was $39 (IQR $8-$131); among those who took at least 1 branded drug, median annual OOP spending on branded drugs was $46 ($2-$217). Use and spending varied by insurance (Table). From 2014-2021, total national OOP spending was $167 billion (95% CI $156 billion-$178 billion) for generic medications and $167 billion (95% CI $158 billion-$176 billion) for branded drugs.

CONCLUSIONS: Although brand-name prescription drugs are more expensive than generics, more patients use generic drugs. As a result, total national OOP spending on generic medications is cumulatively similar but more dispersed than total national OOP spending on brands. Efforts to decrease the financial toxicity of brand and generic drugs are needed.

NATIONWIDE UTILIZATION AND SPENDING FOR TWO LOW-VALUE COVID-19 PHARMACEUTICALS BEFORE AND AFTER FDA APPROVAL OF PAXLOVID AND LAGEVRIO

Michelle S. Rockwelll¹; Michael Hadfield²; Melody Craff³; Dale Skinner⁴; A. Mark Fendrick⁵; Cheryl Damberg⁶; Katherine L. Kahn⁷; John N. Mafi⁷. ¹Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA; ²Strategic Analytics, MCG Health, Seattle, WA; ³MedInsight, Milliman Inc, Seattle, WA, US, Seattle, WA; ⁴MedInsight, Milliman Inc Seattle, Seattle, WA; ⁵Internal Medicine, University of Michigan, Ann Arbor, MI; ⁶Health Care, RAND Corporation, Santa Monica, CA; ⁷Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4063802)

BACKGROUND: Use of hydroxychloroquine [HCQ] and ivermectin [IVER] soared during the pandemic despite evidence disproving their effectiveness for treating COVID-19. We hypothesized that while low-value utilization of these drugs substantially impacted national health spending, their use would begin to decline after FDA approval of nirmatrelvir-ritonavir (Paxlovid) and molnupiravir (Lagevrio) for the treatment of COVID-19.

METHODS: In this cross-sectional quasi-experimental study, we used a nationwide sample of patients from all 50 U.S. states from the Milliman MedInsight de-identified research database to analyze HCQ and IVER use rates from 3/1/19 to 5/31/23. We compared use during the pandemic prior to approval of Paxlovid and Lagevrio (PAN1, 6/1/20-12/31/21 for HCQ and 3/1/20-12/31/21 for IVER) to expected (pre-pandemic) use rates. We also evaluated the relative change in use vs expected rates between PAN 1 and the pandemic period following approval of Paxlovid and Lagevrio (PAN2, 1/1/22-5/31/23). Use that exceeded expected rates was classified as low-value. Results were stratified by U.S. census region and payer. We used Micromedix Redbook® per script pricing of $188 (HCQ) and $84 (IVER) to calculate spending.

RESULTS: Our cohort of 7.9 million U.S. adults (23% >65 years; 55% female) received 1.8 million prescriptions for HCQ or IVER during the pandemic, 5% of which were low-value, totaling >$15m in spending. Overall use of HCQ and IVER was 102% and 285% of expected rates during PAN1, respectively. Relative overall decreases of 9% (HCQ) and 71% (IVER) were observed between PAN1 and PAN2, although low-value HCQ use increased among patients in the South and covered by Medicaid (TABLE).

CONCLUSIONS: In this nationwide cohort, two low-value COVID drugs contributed substantially to healthcare spending. Use of low-value COVID drugs generally declined after FDA approval of two viable antiviral alternatives, with the exception of HCQ use, which rose in one region (Southern U.S.) and in patients covered by one payer (Medicaid).

NO DECLINE IN AVOIDABLE EMERGENCY DEPARTMENT VISITS AND HOSPITALIZATIONS AMONG PATIENTS WITH DEMENTIA AND MILD COGNITIVE IMPAIRMENT, 2010–2018

Frank F. Zhou¹; Mei Leng¹; Chi-Hong Tseng¹; Nina Harawa¹; Cheryl Damberg²; Catherine Sarkisian^1,3; John N. Mafi¹. ¹Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Health Care, RAND Corporation, Santa Monica, CA; ³Geriatrics Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA. (Control ID #4064739)

BACKGROUND: Emergency and inpatient medical services are associated with significantly increased costs, poor clinical outcomes and unique risks in older patients with dementia. National policies, including the Medicare Shared Savings Program and Hospital Readmissions Reduction Program, were implemented in 2012 and aimed to reduce unnecessary reliance on such services through payment reform and enhanced care coordination. However, their long-term impacts on avoidable emergency department (ED) visits and hospitalizations in this vulnerable population remain unclear.

METHODS: We performed a nationwide retrospective longitudinal analysis of avoidable ED visits and hospitalizations between January 1, 2010 and December 31, 2018. Our patient cohort was a nationally-representative sample of Americans aged ≥65 years with dementia and mild cognitive impairment (MCI) from the Health and Retirement Study (HRS) with linked Medicare fee-for-service claims and cost data. ED visits and hospitalizations were classified as avoidable if their primary diagnosis code matched previously published criteria by the Agency for Healthcare Research and Quality. Trends in percentages of patients experiencing at least one avoidable ED visit or hospitalization were assessed using mixed linear regression, controlling for age, sex, race/ethnicity, Medicaid-Medicare dual-eligibility status and comorbidities using the Wei index, with survey weights applied for national representativeness and non-response.

RESULTS: We identified 1497–1906 HRS participants with dementia or MCI (MCID) during the study period, representing an estimated 5.2–7.0 million Americans respectively. Among patients with MCID, the percentages of patients experiencing at least one avoidable ED visit or hospitalization in 2010 were 7.8% and 7.4% respectively, and in 2018 were 8.6% and 7.3% respectively, representing no significant change during this timeframe (p=0.927, p=0.135 respectively). These avoidable ED visits and hospitalizations represented nearly $31 billion in estimated total expenditures over the study period. A significantly higher percentage of Medicaid-Medicare dual-eligible patients with MCID experienced at least one avoidable ED visit (p<0.001) or hospitalization (p<0.001) than non-dual-eligible patients; interaction testing showed that this disparity did not change over time (p=0.369, p=0.217 respectively).

CONCLUSIONS: Older Americans with dementia or MCI continued to receive similar levels of avoidable emergency and inpatient care between 2010 and 2018, despite the implementation of national policies aiming to realign financial incentives and improve care coordination. Health inequities for low-income, Medicaid-Medicare dual-eligible patients have also not improved, highlighting the need for further interventions such as enhanced integration of care between Medicare and Medicaid.

PATIENT AND PROVIDER PERSPECTIVES ON ADHERENCE TO ACTIVE SURVEILLANCE FOR MEN WITH PROSTATE CANCER: A QUALITATIVE STUDY

Jason C. Chen¹; Ted A. Skolarus²; Lalita Subramanian¹; Sarah T. Hawley^1,4; Aaron J. Rankin³; Michael D. Fetters⁵; Karla Witzke⁶; Tudor Borza⁷; Archana Radhakrishnan^1,4. ¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Surgery, University of Chicago Division of the Biological Sciences, Chicago, IL; ³Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ⁴VA Center for Clinical Management Research, Ann Arbor, MI; ⁵Family Medicine, University of Michigan, Ann Arbor, MI; ⁶Urology, MyMichigan Health, Midland, MI; ⁷Urology, University of Michigan, Ann Arbor, MI. (Control ID #4014626)

BACKGROUND: Active surveillance (AS) is a guideline-recommended treatment option for low-risk prostate cancer which involves routine provider visits, lab tests, imaging, and prostate biopsies. Despite good uptake, adherence to AS, in terms of receiving recommended follow-up testing and remaining on AS as long as there is no evidence of cancer progression, remains challenging. We sought to better understand provider and patient experiences with AS care delivery to identify opportunities to improve adherence.

METHODS: We conducted interviews with primary care providers (PCPs, 19), urologists (15), and patients (15) in Michigan through a statewide quality improvement collaborative from June 2020 to April 2021. We used the Theoretical Domains Framework and the Behavior Change Wheel’s Capability, Opportunity, and Motivation model to guide our interviews, coding, and thematic analysis.

RESULTS: We identified three major themes shared by providers and patients as key to maximizing AS adherence: 1) Building trust between patients and providers; 2) Importance of psychosocial support; 3) Operationalizing AS within healthcare systems. Building trust between patients and providers focused on the importance of defining provider roles and communication. Importance of psychosocial support highlighted the importance of family and friends (“built-in support group”) in addressing anxiety and stress about AS. Operationalizing AS within healthcare systems described possible interventions leveraging electronic health record (EHR) systems that participants felt would improve receipt of AS care (e.g., create automated summaries).

CONCLUSIONS: Our study illustrates challenges to AS care delivery shared by both providers (PCPs and urologists) and patients that impact adherence. We also identified several multi-pronged and multi-level strategies which may help address barriers to successful implementation of AS care in complex healthcare systems.

PATIENTS OF CLINICS WITH HIGHER RATES OF TIMELY PRIMARY CARE FOLLOW UP AFTER HOSPITALIZATION HAVE LOWER RATES OF 30-DAY READMISSIONS AND RETURN TO HOSPITAL

Timothy Anderson¹; Laura Hatfield²; Eran Politzer³; John Z. Ayanian⁴; Jeffrey Souza²; Bruce E. Landon². ¹Medicine/General Medicine, University of Pittsburgh, Boston, MA; ²Health Care Policy, Harvard Medical School, Boston, MA; ³Hebrew University of Jerusalem, Jerusalem, Jerusalem, Israel; ⁴University of Michigan, Ann Arbor, MI. (Control ID #4063577)

BACKGROUND: Whether timely primary care follow up after hospitalization improves patient outcomes is not known. Prior studies have been constrained by selection bias and confounding by indication.

METHODS: Retrospective cohort study of a 100% sample of Medicare fee-for-service beneficiaries discharged home after an acute hospitalization in 2019. To overcome confounding posed by individual level analyses, we leveraged clinic-level variation to assess whether clinics with higher rates of timely post-discharge follow up (within 14 days of discharge) had differences in 30-day outcomes of: readmissions, return-to-hospital (readmission, observation stay, or ED visit), and mortality. Analyses were conducted at the primary care clinic level, with each patient attributed to the clinic that accounted for the majority of their visits in the prior year, and limited to clinics with at least 10 patients with eligible hospitalizations. For each outcome, we constructed multivariable linear regression models grouping clinics into quartiles and adjusting for clinic characteristics (size, specialty-mix, hospital affiliation, region, rurality, accountable care organization participation, participation in Medicare's electronic health record incentive program, and delivery of any transitional care management services) and aggregated patient demographics (race, dual-eligible, hierarchical condition category risk score).

RESULTS: The cohort included 18,066 primary care clinics caring for a median of 57 discharged patients (IQR 33-110). The median proportion of patients receiving timely follow up for each quartile was 30.2%, 42.3%, 51.0%, and 61.9%. Compared to clinics in the lowest quartile of post-discharge follow-up those in the highest quartile had a 1.2 percentage point (pp) (95% CI, 1.0 pp - 1.4 pp) lower rate of 30-day readmissions (8.0% vs 9.2%), a 2.0 pp (95% CI, 1.7 pp - 2.4 pp) lower rate of return to hospital (26.3% vs. 28.3%), and no significant difference in 30-day mortality (2.2% vs 2.2%). There were no significant differences in outcomes among clinics adopting transitional care management billing codes or clinics participating in accountable care organizations.

CONCLUSIONS: Health system and policy efforts to increase rates of timely primary care follow up after hospitalization may reduce readmissions and ED visits.

PATTERNS OF POST-ACUTE CARE UTILIZATION IN MEDICARE ADVANTAGE AND TRADITIONAL MEDICINE BY RACE/ETHNICITY AND INCOME

Syama Patel²; Franya Hutchins²; Song Zhong²; Xing Chen²; Indrakshi Roy³; Robert E. Burke¹. ¹University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ³Indiana University Bloomington, Bloomington, IN. (Control ID #4064945)

BACKGROUND: Previous research suggests Medicare Advantage (MA) plans limit the use of post-acute care after a hospitalization for beneficiaries – in particular, MA beneficiaries receive fewer overall days of post-acute care compared to Traditional Medicare (TM). However, it is unclear whether these reductions in post-acute care days are distributed equally across MA populations. We sought to describe differences in post-acute care use in racial and ethnic minorities and dual-eligible beneficiaries (representing a population with limited financial resources).

METHODS: We conducted a descriptive retrospective analysis utilizing national Medicare administrative and assessment data: Medicare Provider Analysis and Review (MedPAR), Master Beneficiary Summary File (MBSF), Minimum Data Set (MDS), and Outcome and Assessment Information Set (OASIS) datasets from 2015-2019. The population included Medicare beneficiaries aged 66 years and older with any acute hospitalization from 2015 through 2019. Outcome measures included hospitalizations and post-acute care utilization among MA beneficiaries stratified by race/ethnicity, and dual-eligibility for both Medicare and Medicaid. We acknowledge these constructs represent crude measurements of equity used for preliminary results. Post-acute care utilization was measured in the most common settings, skilled nursing facilities (SNF) and home health care agencies (HH).

RESULTS: Our study sample included 26,414,801 hospital admissions. More than twice as many MA beneficiaries were dual-eligible (37.7%) compared to the overall population (17.6%). We found racial and ethnic minority populations had higher rates of hospitalizations (52.0% non-White populations compared to 34.8% White), however, minority populations had lower rates of post-acute care. Contrastingly, dual-eligibles had higher rates of hospitalizations (42.6% rate of hospitalization among dual-eligibles compared to 37.7% for non-duals) and had higher rates of post-acute care use. For example, in 2019, 13.9% of beneficiaries of minority race or ethnicity went to SNFs following hospitalization compared to 16.2% of White beneficiaries. In contrast, dual-eligibles had a rate of SNF use of 16.9% following hospitalization, compared to 15.4% among non-duals in 2019.

CONCLUSIONS: Overall, our results suggest a potential disparity in post-acute care use among racial and ethnic minority MA beneficiaries compared to White MA beneficiaries, despite increased rates of hospitalization among minority populations. In addition, we found an unexpected contrast between the trends of post-acute care use among dual-eligibles and racial and ethnic minorities. Our findings demonstrate the significance for future research evaluating the impact of MA on racial and ethnic and income disparities within post-acute care utilization among Medicare beneficiaries to improve equity in post-acute care.

PATTERNS OF POST-ACUTE CARE UTILIZATION IN MEDICARE ADVANTAGE AND TRADITIONAL MEDICINE VARY BY MARKET AND PLAN CHARACTERISTICS

Syama Patel¹; Franya Hutchins¹; Xing Chen¹; Song Zhong¹; Indrakshi Roy²; Robert E. Burke¹. ¹Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ²Indiana University Bloomington, Bloomington, IN. (Control ID #4064931)

BACKGROUND: Medicare Advantage (MA) plans may seek to limit post-acute care use following hospital discharge due to their capitated model of payment. MA penetration across the United States is variable, with some counties with very low or very high MA enrollment. MA enrollment is concentrated across plans, with seven plans accounting for 74% of MA enrollment. However, it is unclear how post-acute care use may vary by MA plan or by region; it is possible that having larger market concentration allows plans to exert more influence over utilization. We sought to describe how post-acute utilization may vary by regions with high and low MA penetration and across MA plans of different size.

METHODS: We conducted a descriptive retrospective analysis utilizing national Medicare administrative and assessment data: Medicare Provider Analysis and Review (MedPAR), Master Beneficiary Summary File (MBSF), Minimum Data Set (MDS), and Outcome and Assessment Information Set (OASIS) datasets from 2015-2019. The population included Medicare beneficiaries aged 66 years and older with any acute hospitalization from 2015 through 2019. Outcome measures included post-acute care utilization in MA in counties in the highest and lowest quartile of MA enrollment. Post-acute care utilization was measured in the most common settings, skilled nursing facilities (SNF) and home health care agencies (HH). We also compared overall post-acute care utilization for enrollees in the seven largest MA plans.

RESULTS: Our study sample included 26,414,801 hospital admissions. At the county level, 13.7% of MA beneficiaries received post-acute care in SNFs in high-MA counties compared to 12.3% of MA beneficiaries in low-MA counties. Similarly, 14.6% of MA beneficiaries received post-acute care in HH in high-MA counties compared to 12.0% of MA beneficiaries in low-MA counties. SNF utilization rates after hospital discharge in 2019 varied from 12.6% to 17.3% across the seven largest MA plans, while HH utilization rates varied from 11.2% to 16.6% across plans.

CONCLUSIONS: Contrary to our expectations, MA beneficiaries in areas of high MA concentration did not have lower rates of post-acute care use. Additionally, there was substantial variation in post-acute care rates across different health plans. The implications of this findings are uncertain but important to understand in determining how MA plans may influence utilization, costs, and outcomes of care. Our findings provide some of the first evidence using different market-level lenses to measure post-acute care utilization patterns.

PAXLOVID DISTRIBUTION POLICY IN CANADA: A NATURAL EXPERIMENT

John N. Mafi^1,2; Sitaram Vangala³; Moira K. Kapral⁴; Manying Cui¹; Artem Romanov¹; Peter E. Wu⁴; Katherine L. Kahn¹. ¹Medicine, University of California Los Angeles, Los Angeles, CA; ²RAND Corporation, Santa Monica, CA; ³Medicine, University of California, Los Angeles, Los Angeles, CA; ⁴University of Toronto, Toronto, ON, Canada. (Control ID #4063758)

BACKGROUND: The effectiveness of Paxlovid on mortality and hospitalizations in vaccinated patients remains an open question in light of conflicting studies. In 2022, Ontario reserved Paxlovid for symptomatic, COVID-test positive adults and restricted to age ≥70 years unless patients were immunocompromised or received <3 COVID vaccines plus another risk factor (e.g., diabetes). This policy offers a rare natural experiment to rigorously compare outcomes in adults with vs without restricted access to Paxlovid.

METHODS: Using aggregated claims data from Ontario’s Institute for Clinical Evaluative Sciences, we studied 1.5 million enrollees aged 65-74 living in Ontario when the age ≥70 prescribing restriction was active in 4/1/22-11/30/22. Using a fuzzy regression discontinuity design, we capitalized on the fact that patients just under and above the age ≥70 threshold (roughly 69 vs 70 years old) would have different probabilities of receiving Paxlovid, but similar potentially confounding factors. The exposure was receipt of Paxlovid prescription claims. Outcomes included all-cause mortality, all-cause hospitalization, and COVID hospitalizations per 100,000 patients-per-month. We also analyzed COVID vaccine rates, since higher rates in those aged ≥70 vs <70 could bias toward overestimating Paxlovid's effects in ≥70-year-olds.

RESULTS: Paxlovid prescriptions increased as a function of age, but then markedly rose for patients just above the age 70 threshold, increasing by 129 [115-143] more prescriptions per 100,000 patients-per-month than those just below age 70 (115% relative increase, p<0.001) (FIGURE). Outcomes also rose as a function of age; however, those aged just above vs just below the age 70 threshold demonstrated no significant differences in mortality (5 [-1-11], p=0.16), all-cause hospitalizations (-5 [-4-39], p=0.85), or COVID hospitalizations (3 [-2,8], p=0.27) per 100,000 patients-per-month. Mean COVID vaccine doses per 100 patients given during the study period were 86 and 89 in 69- and 70-year-olds respectively.

CONCLUSIONS: A doubling in the probability of Paxlovid prescriptions was not associated with significant differences in mortality or hospitalizations. Nevertheless, our study cannot exclude the possibility of a modest (~5%) relative reduction in all-cause and COVID hospitalizations. Further, results may not apply to vulnerable older subgroups, such as those with frailty, immunosuppression, or multimorbidity.

PERFORMANCE OF PHYSICIAN GROUPS AND HOSPITALS IN BUNDLED PAYMENTS FOR CARE IMPROVEMENT ADVANCED FOR LOWER EXTREMITY JOINT REPLACEMENT

Aidan P. Crowley^1,2; Qian E. Huang¹; Torrey Shirk¹; Deborah Cousins¹; Jingsan Zhu¹; Joshua M. Liao³; Austin S. Kilaru⁴; Amol S. Navathe^5,2. ¹Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Health Care Management and Economics, University of Pennsylvania Wharton School, Philadelphia, PA; ³Medicine, University of Washington, Seattle, WA; ⁴Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁵Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA. (Control ID #4065103)

BACKGROUND: Bundled Payments for Care Improvement Advanced (BPCI-A) is the most recent bundled payment program from the Centers for Medicare and Medicaid Services (CMS). Under BPCI-A, hospitals and physician group providers (PGPs) elect to participate in any of 32 clinical episodes across 8 service lines, where they assume accountability for the costs and quality of care across a hospital admission and 90 days post discharge. The highest volume surgical bundle is lower extremity joint replacement (LEJR). Past studies have evaluated prior bundled payment programs for LEJR, finding modest reductions in spending with no change in quality. However, no studies have examined the effects of participation in LEJR episodes in BPCI-A or compared outcomes for hospitals to PGPs. Our objective was to compare the effect of BPCI-A on healthcare spending and quality for hospitals and PGPs participating in BPCI-A LEJR episodes.

METHODS: We conducted a retrospective cohort study of patients receiving LEJR using Medicare claims data from 2016-2018 Q3 (pre-BPCI-A) and 2018 Q4-2019 Q3 (BPCI-A Model Years 1 and 2). We identified hospitals and PGPs participating in BPCI-A for LEJR episodes. We used propensity score matching to identify a comparison group of hospitals and PGPs that did not participate in any episode included in the orthopedic service line for BPCI-A. We conducted a difference-in-differences analysis comparing patients receiving care from LEJR participants versus matched non-participants. This quasi-experimental design mirrored a 2x2 factorial randomized trial in which patients received care from either PGPs in BPCI-A for LEJR, hospitals in BPCI-A for LEJR, both, or neither. Our primary outcome was 90-day total episode spending. Secondary outcomes included 30-day spending and 30- and 90-day mortality and readmissions.

RESULTS: PGP participants in BPCI-A for LEJR had lower spending than PGP non-participants at 90 days (adjusted difference-in-difference [aDID] -$657, 95% CI -$792, -$522, p<0.001). Hospital participants had no significant difference in spending compared to non-participants at 90 days. At 30 days, spending was significantly lower for both PGP and hospital participants than for respective non-participants (PGP aDID -$515, 95% CI -$611, -$421, p<0.001; hospital aDID -$301, 95% CI -$466, -$137, p<0.001). Compared to LEJR BPCI-A episodes at hospitals, episodes at PGPs saved $455 more at 90 days (95% CI $213, $698, p<0.001) and $214 more at 30 days (95% CI $44, $385, p=0.01). There were no significant differences in readmissions or mortality for either participant type at 30 or 90 days.

CONCLUSIONS: We find that PGPs participating in LEJR episodes in BPCI-A had significantly lower spending compared to BPCI-A participating hospitals without changes in mortality or readmissions for either participant type. Future bundled payment models should consider the different potential for cost savings across participant types to optimize impact on cost and quality.

PERFORMANCE OF PHYSICIAN GROUPS AND HOSPITALS IN BUNDLED PAYMENTS FOR CARE IMPROVEMENT ADVANCED FOR SEPSIS

Aidan P. Crowley^1,2; Qian E. Huang¹; Torrey Shirk¹; Deborah Cousins¹; Jingsan Zhu¹; Joshua M. Liao⁵; Austin S. Kilaru³; Amol S. Navathe^4,2. ¹Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Health Care Management and Economics, University of Pennsylvania Wharton School, Philadelphia, PA; ³Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁴Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; ⁵Medicine, University of Washington, Seattle, WA. (Control ID #4065053)

BACKGROUND: Over two decades, a range of policy approaches have sought to implement evidence-based practices that improve the quality of care for sepsis. Value-based payment models represent one approach. Medicare recently extended Bundled Payments for Care Improvement Advanced (BPCI-A), its most recent episode-based bundled payment program. Evaluations of prior bundled payment programs did not find improved quality or reduced spending for sepsis. However, the impact of BPCI-A on sepsis episodes has not been evaluated. In addition, prior evaluations have not compared the impact of the model among hospital participants with physician group practice (PGP) participants. Our objective was to compare the effect of hospital and PGP participation in BPCI-A for sepsis episodes on healthcare spending and quality.

METHODS: We conducted a retrospective cohort study of patients hospitalized for sepsis using Medicare claims data from 2016 to 2019. We identified hospitals and PGPs participating in sepsis episodes for BPCI-A starting in the final quarter of 2018. We used propensity score matching to identify similar groups of hospitals or PGPs that did not participate in any BPCI-A episode in the sepsis service line group. We conducted a differences-in-differences analysis to compare outcomes for patients receiving care from BPCI-A participants to those from non-participants, adjusting for patient, hospital, and market characteristics. Our quasi-experimental design mirrored a 2x2 factorial randomized trial in which patients received care from either PGPs in BPCI-A for sepsis, hospitals in BPCI-A for sepsis, both, or neither. The primary outcome was 90-day total episode spending. Secondary outcomes included 30-day spending as well as mortality and readmissions at 30 and 90 days.

RESULTS: In adjusted analyses, there was no significant difference in 90-day spending between BPCI-A participating and non-participating hospitals or BPCI-A participating and non-participating PGPs. BPCI-A hospitals spent $172 less than non-participating hospitals at 30 days (95% CI -$316 to -$28, p=0.02). PGP participants had no significant difference in spending at 30 days compared to PGP non-participants. There were no significant differences in mortality and readmissions for either BPCI-A hospitals or PGPs at 30 or 90 days.

CONCLUSIONS: Hospitals participating in bundled payments for sepsis episodes in BPCI Advanced did not demonstrate reduced spending across the total episode duration compared to non-participating hospitals but did have reduced spending at 30 days, with no difference in mortality or readmissions at either time point. These findings suggest that the impact of bundled payments on spending for complex acute medical episodes may vary by participant type with differences concentrated in the first month. Future bundled payment models and their evaluations should consider participant type and episode duration as key facets of model design to enhance improvements in spending and quality.

PHENOTYPING ADHERENCE THROUGH TECHNOLOGY-ENABLED REPORTS AND NAVIGATION (PATTERN): AN ELECTRONIC HEALTH RECORD BASED-STRATEGY FOR ADDRESSING MEDICATION ADHERENCE CHALLENGES AMONG OLDER ADULTS IN PRIMARY CARE

Allison Pack, Stacy Bailey, Rachel O'Conor, Evelyn Velazquez, Guisselle Wismer, Fangyu Yeh, Laura M. Curtis, Kenya Alcantara, Michael Wolf. General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4064404)

BACKGROUND: Older adults are likely to have multiple chronic conditions and polypharmacy. Problems with medication adherence among this population are common, particularly in primary care, and contribute to suboptimal treatment benefits and adverse drug events. We sought to adapt an intervention previously used among transplant recipients to promote medication adherence among older primary care patients taking complex treatment regimens. Specifically, our PATTERN strategy sought to leverage the patient portal to identify, phenotype, and respond to patient medication adherence concerns.

METHODS: To adapt and refine PATTERN, we conducted in-depth interviews with primary care patients, clinicians, and administrators from an academic health center in Chicago, IL. Patients were eligible if they were aged 65 or older, living with multiple chronic conditions, and were prescribed ≥8 medications. Clinicians and administrators were eligible if they were employed in any primary care practice within the health center. Interview guides were informed by the Exploration, Preparation, Implementation, Sustainment Framework, and analysis of qualitative data drew from the Rapid Identification of Themes from Audio Recordings Procedures.

RESULTS: A total of 13 patients and 12 clinicians or administrators participated. Patients were an average of 71 years old, about half were female (54%), and most (77%) identified as White. Clinicians and administrators were mostly physicians or nurse practitioners (92%); most were female (75%) and White (84%). Thematic analysis revealed the intervention idea was acceptable and appropriate. Participants perceived the target population would benefit from PATTERN and that they could complete assessments via the patient portal to identify and ‘phenotype’ adherence challenges. Some suggested identifying whether assessments are completed by the patient or a ‘proxy user’. Participants also offered suggestions for improvement generally pertaining to the frequency of assessments. Though patients were open to monthly assessments, as occurred in the original intervention, clinicians and administrators suggested linking assessments to an upcoming visit. They perceived this to be more appropriate for primary care and that challenges could be addressed more efficiently without overwhelming the patients or practice. Additional suggestions from clinicians and administrators pertained to how practices should be informed of results. They suggested results be actionable with clear guidance on how to address concerns. As resources vary widely in primary care, guidance will likely need to be tailored.

CONCLUSIONS: Interviews from patients, clinicians and practice administrators meaningfully informed intervention adaptation. PATTERN is currently being pilot tested in a randomized controlled experiment among 80 primary care patients to assess process, acceptability, and feasibility outcomes. Results from this pilot test are pending.

PHYSICIANS’ AWARENESS OF FDA’S TEMPORARY ENFORCEMENT DISCRETION POLICY FOR RISK EVALUATION AND MITIGATION STRATEGY (REMS)-REQUIRED LABORATORY TESTING AND REPORTED CHANGES TO LABORATORY TESTING PRACTICES DURING THE COVID-19 PANDEMIC

Catherine S. Hwang¹; Zhigang Lu¹; Massimilano Russo¹; Gita Toyserkani²; Cynthia LaCivita²; Gerald Dal Pan²; Aaron S. Kesselheim¹; Ameet Sarpatwari¹. ¹Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA; ²US Food and Drug Administration, Silver Spring, MD. (Control ID #4064459)

BACKGROUND: The FDA requires drug manufacturers to implement Risk Evaluation and Mitigation Strategies (REMS) for medications with serious safety concerns. The REMS for ambrisentan, bosentan, clozapine, isotretinoin, lenalidomide, pomalidomide, and thalidomide require certain laboratory testing before initiation and during treatment. In March 2020, in response to the COVID-19 pandemic, the FDA issued a temporary enforcement discretion policy, in which prescribers could apply medical judgment for completing the REMS-required laboratory testing, such as reducing the frequency of testing or accepting home pregnancy tests. We evaluated the extent to which physicians were aware of FDA’s policy and reported making changes to their laboratory testing practices.

METHODS: We surveyed a random sample of 4481 physicians who prescribed at least 1 of the 7 REMS-covered medications from May 2022 to January 2023. Survey questions included whether physicians were aware of FDA’s policy and whether they changed their laboratory testing practices. We used chi-squared testing to evaluate the relationship between these questions and multivariable logistic regression to examine factors associated with physician awareness and reported changes to laboratory testing practices.

RESULTS: Nine-hundred-sixty-two physicians returned surveys, corresponding to a response rate of 21%. Four-hundred-and-thirty-eight (46%) were aware of FDA’s policy, and 192 (20%) reported changed laboratory testing practices. Physicians aware of FDA’s policy were more likely to report changing laboratory testing practices (40% vs. 3%, p<0.001). Characteristics associated with awareness included sex (female vs. male: odds ratio [OR]=1.85, 95% confidence interval [CI]=1.34-2.54), years since medical school graduation (£15 vs. 16-30: OR=1.64, 95% CI=1.11-2.42), and number of patients prescribed the REMS-covered medication over 3 years (≥ 21 vs. 1-10: OR=2.83, 95% CI=2.03-3.94). The same characteristics were associated with reported changes to laboratory testing practices: sex (female vs. male: OR=2.30, 95% CI=1.59-3.32), years since medical school graduation (£15 vs. 16-30: OR=1.51, 95% CI=0.98-2.32), and number of patients prescribed the medications with a REMS in the preceding 3 years (≥ 21 vs. 1-10: OR=2.56, 95% CI=1.67-3.95).

CONCLUSIONS: About half of surveyed physicians were aware of FDA’s temporary enforcement discretion policy. Although policy awareness was correlated with changes to laboratory practices, fewer than half of physicians who were aware of FDA’s policy reported changing their laboratory testing practices. Use of more active targeted messaging during public health crises can help improve awareness of FDA policy changes and physician decision-making.

PNEUMOCOCCAL ENIGMA? EVALUATING THE PUBLIC HEALTH IMPACT AND COST-EFFECTIVENESS OF IN-DEVELOPMENT VACCINES FOR OLDER ADULTS

Kenneth J. Smith¹; Angela R. Wateska¹; Mary Patricia Nowalk²; Chyongchiou J. Lin³; Shoroq M. Altawalbeh⁴; Richard K. Zimmerman². ¹Medicine, University of Pittsburgh Department of Medicine, Pittsburgh, PA; ²University of Pittsburgh School of Medicine, Pittsburgh, PA; ³The Ohio State University College of Nursing, Columbus, OH; ⁴Jordan University of Science and Technology, Irbid, Jordan. (Control ID #4027379)

BACKGROUND: Currently recommended higher-valency pneumococcal conjugate vaccines (PCV), 15-valent (PCV15) and 20-valent (PCV20), have increased protection from pneumococcal disease. Clinical trials of even higher valency vaccines are ongoing, e.g., a 24-valent PCV (PCV24) that covers more serotypes than currently recommended vaccines. Most current and in-development vaccine formulations are based on childhood pneumococcal serotype epidemiology; thus, PCV24 covers only 53%-73% of disease-causing serotypes in adults. However, an in-development 21-valent PCV (PCV21) is formulated based on adult disease epidemiology and could afford greater protection for adults.

METHODS: A Markov model estimated PCV24 public health impact and cost-effectiveness compared to currently recommended PCV20 or PCV15 plus 23-valent pneumococcal polysaccharide vaccine and no vaccination in Black and non-Black 65-year-old cohorts. A secondary analysis added PCV21 to comparisons. Age-, race-, and chronic medical condition-specific pneumococcal illness risks and serotype-specific pneumococcal disease risks were obtained from CDC data. Vaccine effectiveness was estimated by a Delphi panel and clinical trial data. Vaccination and pneumococcal illness costs were from US databases. Sensitivity analyses examined potential indirect effects on adult disease from childhood PCV15/PCV20 vaccination, and variation of the undetermined costs of in-development vaccines. All parameters were varied in 1-way and probabilistic sensitivity analyses.

RESULTS: PCV24 had the fewest pneumococcal disease cases and deaths in both cohorts in the primary analysis; adding PCV21 prevented more cases and deaths. In the primary analysis, PCV24 cost $185,584 per quality adjusted life-year (QALY) gained in Black cohorts and $226,565/QALY in non-Black cohorts compared to no vaccination, rising to >$270,000/QALY in either population when considering childhood vaccination indirect effects. Compared to PCV24, current recommendations were economically unfavorable in either population regardless of childhood indirect effects. Varying base case PCV24 cost ($278) in the primary analysis from $250-$350 resulted in costs from $166,541-$355,932/QALY gained in both cohorts. In secondary analyses, added PCV21 (estimated cost $333) was the only economically favorable vaccination strategy, costing $110,450 and $161,215/QALY gained in Black and non-Black cohorts. In all sensitivity analyses considering either indirect effects or potential PCV21 use, PCV24 remained economically unfavorable.

CONCLUSIONS: At a relatively high $250,000/QALY gained willingness-to-pay threshold, PCV24 could be considered cost-effective for Black and non-Black older adults, but only when childhood vaccination indirect effects or potential use of the adult-formulated PCV21 were not considered. Continuing use of vaccines covering the same pneumococcal serotypes in both children and adults is unlikely to be clinically or economically reasonable.

POTENTIAL SAVINGS FOR MEDICARE PART D BENEFICIARIES FROM A $2 MONTHLY GENERIC DRUG COPAYMENT CAP

Christopher Cai¹; Aaron S. Kesselheim²; Benjamin N. Rome². ¹Internal medicine, Brigham and Women's Hospital, Boston, MA; ²Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4057049)

BACKGROUND: In February 2023, the Center for Medicare and Medicaid Innovation proposed the Medicare High-Value Drug List Model, which would impose $2/month out-of-pocket (OOP) cost limits for about 150 generic drugs treating chronic conditions such as hypertension and hyperlipidemia. The patient savings from such a policy are unknown.

METHODS: We conducted a cross-sectional study using the 2014-2021 Medical Expenditure Panel Survey. Among Medicare beneficiaries filling at least 1 prescription for a generic hypertension or hyperlipidemia drug (e.g., thiazide, beta blocker, statin), we identified patients who paid >$2 per 30-day supply. We estimated annual per-patient and total savings from a $2/month cap. We used chi-squared and two-sided t-tests to calculate unadjusted differences in age, sex, education, race/ethnicity and income between those with vs. without potential savings. Results were weighted to reflect the US population and presented with 95% confidence intervals. Spending was adjusted to 2021 dollars using the Consumer Price Index.

RESULTS: We included 46,326 individuals who represented 462 million Medicare beneficiaries from 2014-2021. Overall, 70.9% (95% CI 70.1%-71.7%) filled a generic hypertension or hyperlipidemia medication annually, and 36.4% (95% CI 35.5%-37.3%) would have saved from a $2/month OOP cap. Among those with savings, median annual savings were $13.70 (IQR $4.81-$36.20). Those who would have saved were more likely to be white (79.7%% vs 71.8%, p<0.01), male (48.5% vs 44.1%, p<0.01), older (mean age 73.1 vs 69.6, p<0.01), to have higher household income (435.8% vs 410.2% of the federal poverty limit, p<0.01) and to have more years of post-secondary education (0.4 years vs 0.16 years, p<0.01). The $2/month cap would have saved $1.08 billion (95% CI, $0.92-$1.24 billion) for 52.3 million beneficiaries in 2014 and $407 million (95% CI $351-$464 million) for 61.8 million beneficiaries in 2021.

CONCLUSIONS: Over one-third of Medicare beneficiaries would have lower OOP costs had a $2/month OOP cap for generic hypertension and hyperlipidemia drugs been in effect from 2014-2021. Most of these patients would have saved <$36/year. The policy might disproportionately benefit those who are white, higher income, and better educated, likely because some Medicare beneficiaries already benefit from low-income subsidies. Alternatively, lower SES populations may not fill medications with OOP costs over $2, so the policy could increase access to these medications. To strengthen this policy, the cap should target drugs for which OOP costs are frequently a barrier to access and which are preferentially used by vulnerable populations.

PREDICTORS OF IMPLEMENTATION OF GUIDELINE-DIRECTED CARE FOR PEOPLE WITH TYPE 2 DIABETES AND CARDIORENAL DISEASE

Michael E. Bowen^1,2; Shubham Agarwal¹; Daniel F. Heitjan²; Ildiko Lingvay^1,2; Christine Mai³; Kelsea Marble⁴; Jonathan Pak⁵; Zichang Xiang⁶; Mujeeb Basit¹. ¹The University of Texas Southwestern Medical Center Department of Internal Medicine, Dallas, TX; ²Peter O'Donnell Jr. School of Public Health, Dallas, TX; ³HSIR, The University of Texas Southwestern Medical Center, Dallas, TX; ⁴Clinical Informatics Center, The University of Texas Southwestern Medical Center, Dallas, TX; ⁵Boehringer Ingelheim, Ridgefield, CT, Ridgefield, CT; ⁶Southern Methodist University Dedman College of Humanities and Sciences, Dallas, TX. (Control ID #4065075)

BACKGROUND: Type 2 diabetes (T2D) is an independent risk factor for the development of cardiovascular disease (CVD) and chronic kidney disease (CKD). Current treatment guidelines recommend the preferential use of glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium glucose co-transporter-2 inhibitors (SGLT2i) in people with T2D and certain metabolic co-morbidities. Despite these guidelines, use of GLP-1 RA and SGLT2i remains sub-optimal in high-risk populations with CVD, HF, and CKD. We explored patient, provider, and system factors associated with inadequate prescription of guideline directed therapy.

METHODS: We conducted a cross sectional analysis using an electronic health record (EHR) registry identifying people with T2D and CVD, HF, and/or renal disease in a large, academic medical center. An eligible encounter was defined as an encounter occurring in a primary care, endocrinology, cardiology, or nephrology clinic between Jan 1, 2019 (date of first guideline recommending these drugs) and August 23, 2023, where a patient was eligible for treatment but had not yet been prescribed a GLP1 or SGLT2i. The eligibility status (GLP1, SGLT2i, SGLT2i or GLP1, or SGLT2i Primarily) and the treatment outcome (Eligible Drug Prescribed or Eligible Drug Not Prescribed) were assessed for each eligible encounter. Demographics, lab and imaging results, ICD-9/10 diagnoses, prescriptions, provider and encounter-specific details were extracted. We estimated a mixed logistic model for the probability that a subject would receive a prescription, given that (s)he had not received one yet. Potential predictors included baseline (e.g., demographic) and time-varying (e.g., clinic type, clinical status) variables. We used stepwise logistic regression to select a best-fitting regression model with age, race, and sex forced in the model. We then re-estimated the selected model including a random subject effect to account for correlation within patients.

RESULTS: Our analysis included 62,632 eligible encounters completed by 9,495 patients. Of the 9,495 eligible patients, only 14.6% received a prescription for a guideline-directed medication. Patients who were younger, male, new to clinic, of Asian or Black race, or with eGFR>60 were more likely to be prescribed (P<0.05 for all). Patients seen by trainees (compared with attending physicians) and in Cardiology or Endocrinology (compared to primary care) were also more likely to be prescribed (p<0.05 for all). The prediction model including these seven factors had an area under the receiver operating characteristic curve (AUC) of 0.718.

CONCLUSIONS: Guideline-directed prescribing of GLP1 and SGLT2i among patients with T2D and cardiorenal disease remains low. Identification of patient and provider factors associated with prescribing gaps may inform development and implementation of targeted interventions to close gaps in guideline-indicated prescribing.

PRESCRIPTION DRUG RATIONING IN PATIENTS WITH OBESITY

Alissa S. Chen¹; Caroline G. Borden²; Joseph S. Ross³; Kasia J. Lipska¹. ¹Internal Medicine, Yale School of Medicine, Branford, CT; ²General Internal Medicine, Yale School of Medicine, New Haven, CT; ³Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4057812)

BACKGROUND: Recently, multiple effective medications have been approved to treat obesity, but they are priced at over $1000 per month. Most private insurance and federal health programs do not cover anti-obesity medications. We examined rates of cost-related prescription rationing among patients with obesity to determine whether the expensive pricing of these new medications will preclude their widespread adoption. We also assessed how this varies across subgroups defined by race, ethnicity, and cardiovascular disease (CVD).

METHODS: We analyzed data from the National Health Interview Survey, a nationally representative survey of American households, from years 2020-2022. We included adults who were nonpregnant, had obesity (defined by body mass index >30), did not have diabetes, used at least 1 prescription medication, and answered all 3 rationing questions. Prescription rationing was defined as any self-reported skipping, taking less, or delaying filling a medication to save money. Rates of rationing were calculated overall and by race, ethnicity, and CVD history, determined by self-report, with subgroup comparisons made using chi-squared tests. All analyses used survey weights to account for complex survey design to determine nationally representative estimates.

RESULTS: There were 16,768 adults in our cohort representing 46,921,106 U.S. adults; 75.4% were White, 85.7% non-Hispanic, and 10% had CVD. The overall rate of prescription drug rationing was 8.3%. Rates of rationing varied significantly across race and ethnicity subgroups (Table 1). The rate of prescription drug rationing for patients with CVD was 10.2%, significantly higher than the rate of drug rationing in participants without CVD (p=0.005).

CONCLUSIONS: Eight percent of adults with obesity reported prescription drug rationing, with higher rates among Black and Hispanic patients. Patients with CVD, who may benefit the most from these medications, had the highest rates of rationing. High prices of these medications are likely to pose significant financial barriers for many patients and may worsen health disparities.

PRIMARY CARE PHYSICIANS ON CARING FOR PATIENTS WITH COMPLEX COMORBIDITIES AND HISTORY OF BREAST CANCER

Benjamin Bates^1,4; Jenna Howard²; Jennifer R. Hemler²; Lisa Mikesell³; Sarah J. Fadem²; Shawna Hudson^2,4; Benjamin Crabtree². ¹Department of Medicine, Rutgers Biomedical and Health Sciences, New Brunswick, NJ; ²Department of Family Medicine and Community Health, Rutgers Biomedical and Health Sciences, New Brunswick, NJ; ³School of Communication and Information, Rutgers The State University of New Jersey, New Brunswick, NJ; ⁴Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ. (Control ID #4063470)

BACKGROUND: For nearly 20 years, there have been calls for primary care physicians (PCPs) to take a greater role in the care of patients with a history of cancer. Using a clinical vignette and list of American Society of Clinical Oncology (ASCO) recommendations for long-term survivorship care, we sought to understand how PCPs approach the care of patients with a history of breast cancer and with co-occurring multiple chronic health conditions.

METHODS: As part of a larger NCI-funded study, we conducted qualitative, semi-structured interviews with a purposeful selection of general PCPs representing diverse settings. Participants for our study were identified by our advisory board and through snowball sampling. We concluded recruitment following content saturation. Interviews were virtual, recorded, and professionally transcribed. We started each interview with a clinical vignette of a person with history of breast cancer and multiple chronic conditions and proceeded to ask physicians which ASCO recommendations they incorporated into their care. We identified themes using an emergent-crystallization process, which includes reflecting on transcripts, summaries and detailed matrices until coherent themes emerge, and then compared themes among interviews to identify commonalities across the PCPs on care of patients with history of breast cancer.

RESULTS: We interviewed 8 PCPs with knowledge of survivorship care. All interviewees shared the perspective that a PCP’s role is to provide whole-person, patient-centered care and that many survivorship recommendations are already part of general primary care. The interviewees described care of persons with history of cancer across a spectrum from easy to difficult, though even PCPs who felt survivorship recommendations were more easily addressable acknowledged time constraints limit their ability to address the recommendations. Most interviewees mentioned that the lack of clarity in roles for primary care and oncology affected their practice, while acknowledging roles may differ across regions, patient contexts, and whether there was access to a survivorship clinic. The majority indicated they relied heavily on the patient’s perspective and physical exam to make decisions on survivorship and described poor communication between PCPs and oncology as furthering reliance on the patient. The few interviewees who had access to a cancer survivorship clinic used the clinic to supplement information from the patient and as a communication tool to bridge gaps between PCPs and oncology.

CONCLUSIONS: PCPs adopt a generalist, whole-person perspective and are comfortable addressing most breast cancer survivorship recommendations. Barriers to addressing survivorship in primary care, such as lack of communication between primary care and oncology, impact PCP’s perspective of the ease or difficulty with which they may integrate survivorship into practice. Local resources are required to better support the integration of survivorship care in most primary care settings.

PROJECTED U.S. HOSPITAL BED SHORTAGE AND ASSOCIATED EXCESS MORTALITY: 2024-2034

Richard K. Leuchter^1,2; Benjo A. Delarmente¹; Sitaram Vangala¹; Yusuke Tsugawa¹; Catherine Sarkisian^1,3. ¹Division of General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Division of Hospital Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ³VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, CA. (Control ID #4047916)

BACKGROUND: Over 6-months post-Covid-19 pandemic, U.S. hospitals are still experiencing unprecedented stress with national hospital occupancy remaining 10 percentage points higher than pre- pandemic. It is unknown if the aging U.S. population will place further strain on hospitals over the next decade.

METHODS: We projected the number of annual non-critical care U.S. hospitalizations between 2024-2034 for five age bands (0-17, 18-44, 45-64, 65-79, 80+) by multiplying U.S. Census Bureau population projections by the National Inpatient Sample 2019 hospitalization rate for that age band. We projected aging-adjusted average hospital occupancy for each year from 2024-2034 by multiplying the projected hospitalizations for that year by the ratio of how 2023 hospital occupancy (through November 18, 2023) corresponded to 2023 hospitalizations. We obtained 2019 in-hospital mortality rates and length of stay for adults ≥65 years from the 100% Medicare file, and estimated excess mortality associated with a hospital bed shortage using previously published assumptions that an 85% national hospital occupancy results in an increase in the odds of in-hospital mortality of 2% per day hospitalized.

RESULTS: National hospital occupancy ranged from 63-67% between 2002-2019, peaked at 79% in January 2022, and remained at an average of >75% throughout 2023 (Figure 1). Total hospitalizations were projected to increase by 11% from 38,085,000 in 2024 to 42,316,000 in 2034, which corresponds to a critical national hospital occupancy of 85% being reached by 2031 for adult beds and by 2034 for adult and pediatric beds combined (Figure 1). Among adults ≥65 years, an 85% hospital occupancy in 2031 would be associated with over 40,000 excess deaths annually.

CONCLUSIONS: The persistently elevated post-pandemic hospital occupancy, superimposed on an aging U.S. population, may lead to an unprecedented hospital bed shortage and over 40,000 excess deaths annually between 2031-2034 unless urgent policy is implemented to increase hospital capacity and reduce unnecessary hospitalizations.

PUBLIC SECTOR CONTRIBUTIONS TO THE JOHNSON AND JOHNSON VACCINE FOR COVID-19 AND THE "ADVAC" PLATFORM

Karim Sariahmed¹; Matthew Herder²; Janice Graham⁴; Christopher Morten³. ¹General Internal Medicine, Boston Medical Center, Boston, MA; ²Health Law Institute, Dalhousie University, Halifax, NS, Canada; ³Law School, Columbia University, New York, NY; ⁴Technoscience & Regulation Research Unit, Dalhousie University, Halifax, NS, Canada. (Control ID #4064856)

BACKGROUND: The Johnson & Johnson (J&J) vaccine for COVID-19 uses the ad26 vector and has been widely used in low- and middle-income countries. The Food and Drug Administration limited its use after thrombosis with thrombocytopenia syndrome was linked to the vaccine. J&J brands its proprietary ad26 vector as “AdVac,” though it discontinued research on infectious diseases in 2023. The contributions of the National Institutes of Health (NIH) to the development of the J&J vaccine and the ad26 vector are not well established.

METHODS: We conducted a qualitative study using evidence from publicly held patents, interviews with patent holders and authors of key scientific papers, and the scientific literature. The US Government Accountability Office maintains a database of patents issued by the US Patent & Trademark Office and owned by the Department of Health & Human Services. We screened the 4,446 patents in the database issued between 1980 and 2019 for inclusion of key terms related to viral vector vaccines. We selected relevant patents for full review of inventorship, timing of filing, and scientific literature cited.

NIH scientists named in multiple patents were contacted for interview along with authors on scientific papers cited by the patents and additional experts recommended by participating scientists. Scientific literature cited by patents and referenced by interviewees was used to create a timeline of key milestones in the development of ad26 and related vectors.

After obtaining informed consent, interviews were transcribed with Otter-AI software and transcripts were uploaded to Nvivo qualitative analysis software. One coder developed a codebook and identified themes with the assistance of two experts in qualitative analysis.

RESULTS: 81 patents were selected for full review. 13 scientists were invited to be interviewed and 8 agreed to participate. Participants had experience in academic, government, and industry research settings. 12 hours of interview data was analyzed. Triangulation of patent, interview, and scientific evidence supported the following three themes:

1. The NIH made major contributions to the development of the ad26 vector.

2. Intellectual-property (IP)-protected vectors may influence the trajectory of research and development.

3. Inventors want reform of the drug development system, but confidence in the potential of public science in research and development varies.

CONCLUSIONS: IP-protected vectors or “platforms” are an important point of tension between commercial and public health interests in vaccine development. Policy intervention is needed to ensure that public science is responsive to the needs of public health.

PURCHASING BEHAVIOR OF PATIENTS CERTIFIED FOR MEDICAL CANNABIS IN AN URBAN, ACADEMIC SETTING

Paul Baik²; Yuval Zolotov²; Bailey Fink²; Julia Goetz²; Julia Zimmerman²; Julia Arnsten³; Deepika Slawek¹. ¹Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY; ²Medicine, Albert Einstein College of Medicine, Bronx, NY; ³Medicine, Albert Einstein College of Medicine/Montefiore Medicine, Bronx, NY. (Control ID #4062368)

BACKGROUND: Clinicians certifying patients for medical cannabis (MC) in New York (NY) are required to either provide recommendations on cannabinoid content to patients during certification or defer to a dispensary pharmacist. The percentage of patients certified for MC that purchase MC products, as well as the concordance of patient purchases with physician cannabinoid content recommendation is unknown. Using data from Montefiore’s Medical Cannabis Program (MMCP) and NY’s Prescription Monitoring Program (PMP), we examined whether certified patients purchased MC and whether the cannabinoid content of purchased products is associated with clinician recommendation. We hypothesized that there would be discordance between recommendations and products purchased.

METHODS: From electronic health record data of new MMCP patients (4/2022-11/2022), we extracted demographic characteristics (age, gender, race, ethnicity, insurance), clinical characteristics (co-morbidities; prior unregulated cannabis use; indication for certification), and recommended cannabinoid content (high THC, 1:1 THC:CBD, high CBD). From PMP data, we extracted number of MC purchases and cannabinoid content of products purchased 1 year after certification. We categorized patients by the predominant cannabinoid content of purchased products and defined them as ‘concordant’ if the predominant cannabinoid content matched the clinician recommendation. We used descriptive statistics to summarize demographic and clinical characteristics. We used chi-square and Fisher’s exact tests to test associations between demographic characteristics, clinical characteristic, and concordance.

RESULTS: We identified 307 patients certified for MC by MMCP. Most identified as female (n=196 [64%]), 51% were Hispanic (n=157), 41% were Black (n=126), and 85% were publicly insured (n=261). The most common indication for certification was chronic pain (n=239 [78%]). Only 33% (n=100) of patients purchased any MC one year after certification. High THC products were recommended to 41% (n=125) of patients, 1:1 THC:CBD to 36% (n=129), and a recommendation was deferred to a pharmacist in 23% (n=69) of patients. Of those who purchased, 67% were concordant with clinician recommendation (n=67). Most purchased predominantly high THC products (n=73 [73%]); 21% (n=21) purchased predominantly 1:1 THC:CBD products. Demographic and clinical characteristics were not associated with concordance. Patients who were recommended high THC products were more likely to be concordant (vs. 1:1 THC:CBD or high CBD products) (48% vs. 25% vs. 0%; p<0.001).

CONCLUSIONS: Among a diverse group of patients, we observed a low rate of MC purchase and a preference for high THC products. Non-concordant products may pose risks, though patients may prefer them if they more effectively address their symptoms. More studies are needed to understand why so few patients purchase MC, as well as preferences regarding cannabinoid content.

RACIAL AND ETHNIC DIFFERENCES IN HEALTH CARE EXPERIENCES FOR VETERANS RECEIVING VA COMMUNITY CARE FROM 2016 TO 2021

Sudarshan Krishnamurthy¹; Yaming Li²; Florentina E. Sileanu²; Utibe R. Essien^3,5; Megan E. Vanneman^4,6; Maria K. Mor⁷; Michael J. Fine^8,11; Carolyn T. Thorpe^9,2; Thomas R. Radomski^10,2; Katie Suda^2,11; Walid F. Gellad^11,2; Eric T. Roberts^2,12. ¹Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; ²VA Center for Health Equity Research and Promotion, Pittsburgh, PA; ³University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁴Internal Medicine & Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, UT; ⁵VA Center for the Study of Healthcare Innovation Implementation and Policy, Los Angeles, CA; ⁶VA Informatics, Decision Enhancement and Analytic Sciences Center, Salt Lake City, UT; ⁷Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; ⁸Center for Health Equity Researh and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; ⁹Pharmaceutical Outcomes and Policy, The University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC; ¹⁰Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ¹¹Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ¹²General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4057311)

BACKGROUND: Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. The objective of this study was to examine differences in Veterans’ experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016-2021.

METHODS: Observational analyses of Veterans’ ratings of community care experiences by self-reported race and ethnicity were conducted. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors. The study population included respondents to the 2016-2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey. We examined Veterans’ experiences with community care in 9 domains: overall satisfaction with the community provider, overall rating of the community provider, eligibility determination for VA community care, first appointment access, scheduling a recent appointment, provider communication, care coordination, non-appointment access (e.g., after-hours access to providers, waiting time in the office), and billing.

RESULTS: The sample of 231,869 respondents included 24,306 Black and 16,490 Hispanic Veterans. In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in 5 of 9 domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from -0.04 to -0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Across all domains, mean ratings improved from 2016-2021. However, differences in ratings between racial and ethnic groups persisted.

CONCLUSIONS: This study identified small but persistent racial and ethnic differences in Veterans’ experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in 5 domains and, respectively, higher ratings in 3 and 2 domains. Interventions to improve Black and Hispanic Veterans’ patient experience could advance equity in VA community care.

RACIAL AND ETHNIC DIFFERENCES IN TIMELINESS OF DIABETES CARE

Dan Ly. Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4060377)

BACKGROUND: Rates of complications from diabetes differ by race and ethnicity. Glycemic control lowers the risk of several diabetes complications. Diabetes therefore must be identified and treated promptly to forestall complications of prolonged hyperglycemia, and one possible reason for racial and ethnic differences in diabetes complications is that diabetes is identified and treated later for patients from racial and ethnic minority groups. We use longitudinal data of Veterans from 2010 to 2019 to measure timeliness of diabetes testing, diagnosis, and treatment.

METHODS: We used nationwide Veterans Affairs (VA) electronic health record data on 3.3 million Veterans who had a first hemoglobin A1c (HbA1c) test between 2010 and 2019. We used multivariable regressions to first examine racial and ethnic differences in 1) rates among all Veterans of having very elevated HbA1c (HbA1c≥9%) when first tested (a proxy for delayed testing). Then, among those whose first HbA1c was in the diabetes range, we examined racial and ethnic differences in 2) rates of being diagnosed with diabetes, 3) time from HbA1c testing to diabetes diagnosis among those diagnosed, 4) rates of starting a diabetes medication, and 5) time from testing to starting a diabetes medication among those who started a medication. Fixed effects for VA sites were included to examine differences across Veterans cared for at the same VA site.

RESULTS: In adjusted analysis, there were significant differences by race and ethnicity in odds of having a very elevated HbA1c at initial testing. For example, the odds for American Indian or Alaska Native Veterans relative to White Veterans was 2.06 (95% CI 1.89-2.24), and for Black Veterans 1.36 (95% CI 1.32-1.40). Among those with first HbA1c in the diabetes range, Black Veterans also had lower odds of being diagnosed with diabetes (0.72; 95% CI 0.70-0.74), and for Black Veterans diagnosed with diabetes, it took 3.3 months longer to be diagnosed. We also found significant differences by race and ethnicity in odds of starting medication for diabetes; for example, the adjusted odds for American Indian or Alaska Native Veterans was 0.74 (95% CI 0.68-0.80) and for Black Veterans 0.70 (95% 0.68-0.71). Furthermore, for Black Veterans who did start a diabetes medication, it took 3.6 months longer to start medication.

CONCLUSIONS: Veterans from several racial and ethnic minority groups, including Black Veterans, were more likely to have very elevated HbA1c on initial testing, and among those with a HbA1c in the diabetes range, Veterans from racial and ethnic minority groups were less likely to be diagnosed with diabetes, had a longer time from testing to being diagnosed, were less likely to start a diabetes medication, and had a longer time from testing to starting a medication. Our results suggest that Veterans from several racial and ethnic minority groups have less timely diabetes care, which may influence differences in rates of diabetes complications.

RACIAL AND ETHNIC DISPARITIES IN PREVENTIVE AND CHRONIC DISEASE CARE IN MEDICARE ADVANTAGE VS. TRADITIONAL MEDICARE

Renuka Tipirneni^1,2; Andrei Stefanescu³; Alexandra G. Hames⁴; Dominic A. Ruggiero⁵; John Z. Ayanian^2,1; Eric Roberts⁶. ¹Internal Medicine, Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI; ²Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; ³General Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ⁴Health Policy and Management, University of Pittsburgh, Pittsburgh, PA; ⁵Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA; ⁶General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4063989)

BACKGROUND: Over half of Medicare beneficiaries are enrolled in Medicare Advantage (MA), with Black and Hispanic beneficiaries disproportionately in MA. Cardiovascular conditions drive health disparities. Little is known about whether disparities in Black and Hispanic vs. white beneficiaries’ use of preventive and chronic disease care differ in MA (with care management and cost-sharing that facilitate preventive care) vs. traditional Medicare (TM, with broader provider networks and fewer service restrictions that facilitate physician visits). We investigated differences in preventive and chronic disease care by MA vs. TM among beneficiaries with chronic conditions and whether MA mitigated racial/ethnic care disparities.

METHODS: Pooled cross-sectional analysis of Medicare Current Beneficiary Survey (2015-20), using propensity score weighted difference-in-disparities analysis to compare care among Black vs. white and Hispanic vs. white beneficiaries in MA and TM. N=68,788 person-years with cardiovascular disease (coronary artery disease, congestive heart failure, atherosclerosis, peripheral vascular disease, stroke/TIA, other cardiovascular disease) or risk factors (diabetes, hypertension, hyperlipidemia), with 7,897 Black, 2,682 Hispanic, and 58,209 white person-years. Primary outcomes were flu vaccine, pneumonia vaccine, blood pressure check, cholesterol test, colorectal cancer screening, preventive care index (sum of above; 0-5), mammogram, and annual wellness visit. All models adjusted for age, sex, education, marital status, smoking, ADLs, rurality, reason for Medicare enrollment, chronic diseases, and survey weights.

RESULTS: Black and Hispanic beneficiaries in both MA and TM, compared to white beneficiaries, had lower rates of annual wellness visit, flu vaccine, pneumonia vaccine, and colorectal cancer screening, but higher rates of breast cancer screening. Black beneficiaries in MA vs. TM had higher overall preventive care use (preventive care index 3.63 vs. 3.44), including higher rates of annual wellness visit (46.2% vs. 30.9%), flu vaccine (68.6% vs. 64.2%), colorectal cancer screening (64.7% vs. 60.6%), and breast cancer screening (53.8% vs. 46.6%). Hispanic beneficiaries in MA vs. TM also had higher overall preventive care use (index 3.51 vs. 3.38), including annual wellness visit (46.8% vs. 39.9%) and colorectal cancer screening (62.9% vs. 57.6%). Black-white disparities in care were smaller in MA than TM for the preventive care index (difference in disparities +0.12 index, 95% CI 0.02-0.22), and Black beneficiaries in MA had higher breast cancer screening rates (53.8%) compared with white beneficiaries in either MA (44.6%) or TM (43.7%).

CONCLUSIONS: In MA, Black and Hispanic beneficiaries’ greater use of preventive and chronic disease care helped to mitigate, though with few exceptions did not eliminate, health disparities. These findings highlight the importance of policies to address persistent health care inequities among older adults from minoritized racial/ethnic groups.

RACIAL AND ETHNIC DISPARITIES IN SATISFACTION WITH HEALTHCARE ACCESS AND AFFORDABILITY IN MEDICARE ADVANTAGE VS. TRADITIONAL MEDICARE

Eric Roberts¹; Dominic A. Ruggiero⁵; Andrei Stefanescu²; Syama Patel³; Alexandra G. Hames⁴; Renuka Tipirneni^2,6. ¹General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²General Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ³Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ⁴Health Policy and Management, University of Pittsburgh, Pittsburgh, PA; ⁵Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA; ⁶Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI. (Control ID #4064441)

BACKGROUND: Medicare Advantage (MA) now accounts for over 50% of Medicare enrollment and covers a disproportionate share of Black and Hispanic Medicare beneficiaries. Much of this growth has been fueled by MA plans’ coverage of supplemental benefits and lower cost-sharing—features that may alleviate cost burdens and improve access compared to traditional Medicare (TM), particularly for people with limited incomes and without supplemental insurance. However, MA plans employ utilization management and may have narrow specialist and hospital networks, which may restrict access to needed care. This study compared racial and ethnic disparities in satisfaction with healthcare access and affordability in MA vs. TM between Black, Hispanic, and White Medicare beneficiaries. We characterized disparities separately for beneficiaries with vs. without dual eligibility for Medicaid, which eliminates out-of-pocket costs and covers supplemental benefits for the lowest-income Medicare beneficiaries.

METHODS: Cross-sectional analyses of the 2016-2019 Medicare Current Beneficiary Survey. We compared ratings of healthcare access and affordability in MA vs. TM by respondents’ self-reported race and ethnicity. We used difference-in-disparity models with propensity score weighting to compare MA-TM differences in satisfaction between Black vs. White and Hispanic vs. White beneficiaries. Separate analyses were performed for dual-eligible vs. non-dual beneficiaries.

RESULTS: Our sample consisted of 40,413 respondent-years (N=4,620, 4,765, and 31,028 for Black, Hispanic, and White beneficiaries, respectively). Among non-dual-eligible beneficiaries identifying as non-Hispanic Black, 11.0% of those in MA and 13.5% in TM were very satisfied with out-of-pocket costs, significantly lower than White beneficiaries (19.2% in MA and 21.3% in TM). Hispanic beneficiaries were more likely to be very satisfied with out-of-pocket costs in MA vs. TM (17.5% vs. 9.6%), implying that MA was associated with a 10.25-point smaller Hispanic-White disparity than TM (95% CI: 5.39%, 15.11%; P<0.0001). White non-dual beneficiaries were more likely than Black and Hispanic beneficiaries to be very satisfied with overall care and access to specialists; disparities were similar in MA and TM. Across racial and ethnic groups, dual-eligible beneficiaries reported greater satisfaction with out-of-pocket costs. However, White dual-eligible beneficiaries reported greater satisfaction on all 3 measures than Black and Hispanic dual-eligible beneficiaries in MA and TM.

CONCLUSIONS: These findings add to evidence that MA narrows some—but not all—health care disparities. However, Black and Hispanic individuals reported lower satisfaction with access to specialists than White beneficiaries in both MA and TM, irrespective of Medicaid enrollment. The findings underscore the importance of policies to address structural barriers to healthcare access in minoritized, older adult populations.

REDUCED COST SHARING AND MEDICATION MANAGEMENT SERVICES FOR COPD AND DIFFERENCES IN EFFECTS BY RACE – A RANDOMIZED TRIAL

Sumit Agarwal^1,2; Elizabeth Metzler³; Michael Chernew²; Emily Thomas³; Valerie G. Press⁴; Emily Boudreau³; Brian Powers^3,5; J. Michael McWilliams^2,1. ¹Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, MA; ²Harvard Medical School Department of Health Care Policy, Boston, MA; ³Humana Inc, Louisville, KY; ⁴Medicine, University of Chicago, Chicago, IL; ⁵Department of Medicine, Tufts University School of Medicine, Boston, MA. (Control ID #4048864)

BACKGROUND: High out-of-pocket costs and improper use of maintenance inhalers contribute to poor outcomes among patients with chronic obstructive pulmonary disease (COPD). To address these barriers, a large Medicare Advantage insurer developed a program that provided substantial relief from cost sharing for maintenance inhalers and medication management services, including teaching on proper inhaler use.

METHODS: The insurer randomized beneficiaries with COPD to receive an invitation to enroll in the program. In addition to the intention-to-treat analysis for the effect of the invitation, we used a standard instrumental-variable approach, in which random assignment to receive the invitation was the instrument for enrollment in the program, to estimate the effect of receiving the cost sharing reduction and medication management services. This analysis of the program effect, or the complier average treatment effect, accounts for differences in take up of the program between the two study arms without introducing selection bias. We included interaction terms to estimate the additional effect of being in the treatment group on Black individuals beyond the treatment effect on White individuals. The primary outcome was maintenance inhaler adherence, measured using proportion of days covered. Secondary outcomes included moderate-to-severe exacerbations, short-acting inhaler fills, and total spending. All outcomes and analyses were prespecified (ClinicalTrial.gov, NCT05497999).

RESULTS: Program enrollment was 24.1 percentage points (pp) [95% CI, 23.1 to 25.1] higher in the invited group than in the control group. Adherence significantly improved in the invited group (31.9% vs. 28.4%; adjusted difference, 3.7 pp [95% CI, 3.3 to 4.4]); the estimated effect of the program (the complier average treatment effect) was 15.5 pp [95% CI, 12.8 to 18.2], representing a 55% increase in adherence. There was a significant reduction in out-of-pocket spending for prescription drugs (invitation effect: -$49.0 [95% CI, -68.4 to -29.7]; program effect: -$203.3 [95% CI, -283.5 to -123.0]) but no significant difference in moderate-to-severe exacerbations, short-acting inhaler fills, or total spending. Stratified by race, the adjusted difference in adherence between the invited and control groups was higher among Black individuals (invitation effect: 5.5 pp [95% CI, 3.3 to 7.7]; program effect: 19.9 pp [95% CI, 12.6 to 27.2]) than among White individuals (invitation effect: 3.6 pp [95% CI, 2.9 to 4.4]; program effect: 15.1 pp [95% CI, 12.1 to 18.1]), but the difference between these effects for Black and White individuals was not statistically significant (P = 0.11).

CONCLUSIONS: Large reductions in cost sharing with medication management services significantly increased inhaler adherence for Black and White beneficiaries in Medicare Advantage, leading to a meaningful but statistically nonsignificant narrowing of the racial disparity in inhaler use. The program did not reduce COPD exacerbations or affect total spending.

SOURCES OF INFORMATION AND TRUST AMONG PATIENTS ENROLLED IN A STATE MEDICAL CANNABIS PROGRAM

Alan T. Kelley^1,2; Michael A. Incze¹; Carter Reeves¹; Clint Hardy¹; Rajiv Radhakrishnan³; Kristi Carlston¹; Adam J. Gordon^4,2; Gerald Cochran^1,2. ¹Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT; ²Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT; ³Psychiatry, Yale School of Medicine, New Haven, CT; ⁴Department of Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4064413)

BACKGROUND: Medical cannabis (MC) is now available in most states to treat conditions such as chronic pain, PTSD, and symptoms associated with cancer/cancer treatment. Ensuring patients are informed regarding MC use—including evidence, safety, risks, and benefits—is a priority in these states, yet little is known about sources of information patients trust or rely upon when participating in MC programs.

METHODS: We surveyed patients enrolled in a state MC program and conducted an exploratory analysis of patient levels of trust and reliance among various MC information sources, including MC dispensary pharmacists, MC card-issuing providers, the state-run MC program (e.g., online/print materials, helpline), friends/peers who use MC, and the internet (“Google”). Differences in trust and reliance were then analyzed using Wilcoxon rank-sum tests. We further stratified our results by three patient-reported qualifying conditions for MC use (chronic pain, PTSD, and symptoms associated with cancer/cancer treatment) and compared levels of trust and reliance across groups using chi-square tests and logistic regression.

RESULTS: MC enrollees (N=191; median age 37.4; 57.6% female, 86.4% White, 11.5% Latinx, 19.4% rural) reported comparably high levels of “trust” or “strong trust” toward dispensary pharmacists (90.1%) and card-issuing providers (88.5%) but a significantly lower level toward the state MC program (62.3%, P’s <0.01). Enrollee trust toward a friend/peer was comparable to the state MC program (64.9%), and trust toward a friend/peer and the state MC program were both significantly higher than trust toward the internet (29.8%, P’s<0.01). For reliance on information, more enrollees reported obtaining a majority of MC information from dispensary pharmacists (56.5%, P’s<0.01) than from other sources; enrollees relied on dispensary pharmacists (56.5%), card-issuing providers (45.5%), friends/peers (38.2%), and the internet (28.8%) for most MC information significantly more than the state MC program (17.8%, P’s<0.01). Neither trust nor reliance on information differed across groups reporting MC use for chronic pain (n=155), PTSD (n=65), or cancer-related symptoms (n=11) and their counterparts who do not use MC for those respective conditions. In regression analysis, those with an MC card to treat cancer symptoms were more likely to trust their medical provider (OR=1.8, P=0.03); there were no differences across groups for reliance on MC information.

CONCLUSIONS: Patients enrolled in a state MC program trusted dispensary pharmacists and MC providers more than their state MC program, which was comparable to a friend/peer. However, enrollees relied on MC information primarily from dispensary pharmacists and relied on friends and the internet significantly more than the state MC program. States may benefit from focusing patient education efforts through dispensary pharmacists and medical providers and exploring why some unofficial information sources are preferred over official ones.

THE COVID-19 PANDEMIC, DELAYS IN CARE, AND THE DEVELOPMENT OF CHRONIC CONDITIONS AMONG U.S. OLDER ADULTS

Lahari Vuppaladhadiam¹; Kristen Wroblewski²; Philip Schumm²; Elbert Huang¹. ¹Medical School, University of Chicago Pritzker School of Medicine, Chicago, IL; ²University of Chicago Division of Public Health Sciences, Chicago, IL. (Control ID #4060349)

BACKGROUND: The COVID-19 pandemic was a major global public health and economic crisis that disrupted the life and livelihood of every person, some more than others. Over 40% of U.S. adults disclosed delaying both urgent and routine medical care during the pandemic due to COVID-19 concerns. Delays in care may have long-term effects we are yet to observe. We aimed to evaluate cohort prevalence of chronic conditions before and after the COVID-19 pandemic and the association of care delays on new chronic condition incidence.

METHODS: Data was utilized from 2,257 community-dwelling older adults who completed the nationally-representative National Social Life, Health, and Aging Project (NSHAP) 2015-16, COVID-19 (2020-21), and 2021-23 surveys. Reported delay in medical care from the COVID-19 survey was the independent variable. Physician-diagnosed report of chronic conditions was the outcome. McNemar’s, Wilcoxon rank-sum, and χ2 tests were performed to compare categorical variables and t-tests for continuous variables. Multivariate logistic and linear regressions were used to assess associations of new conditions in 2021-23 with medical care delays. Covariates included age, gender, ethnicity, education, and baseline physical health.

RESULTS: Those who delayed care were younger (p < 0.001), more female (p = 0.002), more concerned about the pandemic (p < 0.001), and had poorer self-reported physical health (p = 0.007). Respondents had an average of 1.14 chronic conditions in 2015-16, which rose to 1.78 in 2021-23 (p < 0.001). Prevalence of each condition rose across rounds; for example, in age-stratified analyses for respondents aged 70-79, hypertension increased from 46% to 69% (p < 0.001). Delays were not associated with an increase in new chronic condition diagnoses. The exception was for stroke, with the group who reported delays being more likely to have had a stroke (p = 0.05 and p = 0.03, respectively).

CONCLUSIONS: For this cohort of older adults who lived through the COVID-19 pandemic, the prevalence of all chronic conditions rose, indicating worsening population health. However, delays in medical care during the pandemic were overall not associated with chronic condition development. Delays in care may have been compensated for by telehealth, medication delivery, and other services specific to the pandemic. Next steps include comparing incidence of new chronic conditions in earlier rounds before the pandemic to the incidence post-pandemic.

THE DIGITAL DIVIDE: COUNTY-LEVEL DISPARITIES IN ACCESS TO BROADBAND AND MEDICAL PROVIDERS IN THE UNITED STATES

Bhav Jain¹; Khushi Kohli²; Kavya M. Shah^6,2; Shriya K. Garg³; Tej Patel⁴; Aakash Shah⁷; Ali Khan^8,9; Sandeep Palakodeti⁵. ¹Department of Health Policy, Stanford University School of Medicine, Stanford, CA; ²Harvard University, Cambridge, MA; ³University of Georgia, Athens, GA; ⁴Healthcare Management and Policy, University of Pennsylvania, Philadelphia, PA; ⁵Mishe Health, New York, NY; ⁶University of Cambridge, Cambridge, United Kingdom; ⁷Hackensack Meridian Health, Edison, NJ; ⁸Oak Street Health LLC, Chicago, IL; ⁹University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #4063780)

BACKGROUND: Telemedicine has been touted as effective in expanding access to care, with rates of virtual visits rising tenfold since the pandemic. However, the ability of telemedicine to bridge in-person provider gaps may be limited in communities without broadband internet. Here, we use county-level data to correspond access to broadband with the density of medical providers in the United States.

METHODS: Using the University of Michigan’s 2017 National Neighborhood Data Archive, we collected data on the population density of non-mental health physicians (general practitioners or specialists), mental health physicians (psychiatrists), and dentists (dentists, orthodontists, or periodontists) for each of 3,133 counties in the United States. Additionally, county-level sociodemographic data on broadband access, urbanization level, household poverty rate, employment status, insurance status, sex, age, and race were obtained from the 2020 Mapping Broadband Health in America Platform and 2022 American Community Survey. Two-sample t-tests (unadjusted) and multivariate linear regressions (adjusting for all listed sociodemographic covariates) were conducted to quantify the association between broadband internet access and the density of providers.

RESULTS: We found that US counties with low broadband (below the median) have fewer non-mental health physicians (65.5 vs. 105.1 per 100,000 residents), mental health physicians (3.3 vs. 5.2 per 100,000 residents), and dentists (30.0 vs. 47.4 per 100,000 residents) than counties with high broadband (above the median) (P < 0.001). Multivariate linear regressions demonstrated that a 1% decrease in county-level broadband access is associated with a decrease of 0.6 non-mental health physicians, 0.02 mental health physicians, and 0.2 dentists per 100,000 people (P < 0.001).

CONCLUSIONS: Our findings expose dual-disparities in counties facing limited access to both broadband internet and in-person medical providers, which is especially pronounced in low-income and rural areas. Exploring public-private collaborations with internet service providers and leveraging policy solutions that extend broadband, such as the Affordable Connectivity Program, are likely necessary to expand telemedicine access across primary and specialty care.

THE EFFECTS OF TELEMEDICINE EXPANSION ON TOTAL MEDICAL SPENDING IN THE UNITED STATES

John N. Mafi^1,2; Sitaram Vangala³; Chi-Hong Tseng⁴; Manying Cui⁵; Catherine Sarkisian⁴; Katherine L. Kahn¹; Lauryn Walker⁶; Melody Craff⁷; Dale Skinner⁸; Michael Hadfield⁹; Michelle S. Rockwelll¹⁰; A. Mark Fendrick¹¹; Cheryl Damberg¹². ¹Medicine, University of California Los Angeles, Los Angeles, CA; ²RAND Corporation, Santa Monica, CA; ³Medicine, University of California, Los Angeles, Los Angeles, CA; ⁴Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵General Internal Medicine, University of California Los Angeles Health System, Los Angeles, CA; ⁶Virginia Center for Health Innovation, Midlothian, VA; ⁷MedInsight, Milliman Inc, Seattle, WA, US, Seattle, WA; ⁸MedInsight, Milliman Inc Seattle, Seattle, WA; ⁹Strategic Analytics, MCG Health, Seattle, WA; ¹⁰Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA; ¹¹Internal Medicine, University of Michigan, Ann Arbor, MI; ¹²Health Care, RAND Corporation, Santa Monica, CA. (Control ID #4063848)

BACKGROUND: As Medicare’s pandemic-era flexibilities approach the 12/31/2024 expiration deadline, policymakers need to weigh continuing the flexibilities vs the threat of potential spending growth due to telemedicine-driven increased utilization. We examined whether telemedicine expansion replaced or added to total medical spending by increasing spending rates beyond pre-pandemic levels, and whether its effects varied by socioeconomic status or clinical categories.

METHODS: Employing pre/post and difference-in-differences analyses of spending changes, we analyzed healthcare claims from Milliman MedInsight’s de-identified Emerging Experience research database, including patients enrolled in Medicare fee-for-service, Medicare Advantage, Medicare-Medicaid, Medicaid or commercial plans in all 50 U.S. states. Our cohort included adults with ≥12 months of prior coverage in each month from 1/1/2018-5/31/2023 and ≥1 ambulatory visit(s) of any type after 3/1/2020. We compared telemedicine users, defined as patients exposed to ≥1 telemedicine visit(s) after 3/1/2020, vs the comparison group, defined as those with ≥1 in-person visits but 0 telemedicine visits after 3/1/2020. Total medical spending was defined as the sum of facility inpatient, facility outpatient, professional, prescription drug, and ancillary spending as a per-member-per-month (PMPM) rate. We estimated age-sex-comorbidity adjusted Poisson regressions of total monthly spending, and stratified by payer, area-level Social Vulnerability Index (SVI) quintiles, and primary diagnosis category.

RESULTS: We identified 19 million insured U.S. adults; mean age: 50 years; 56% female; 57% telemedicine users; 2019-pre-pandemic PMPM spending for the cohort=$760. Pre- vs post-3/1/2020, telemedicine users experienced a 17% [95% CI 17-17%] rise in total medical spending relative to their pre-pandemic rates. Conversely, the comparison group experienced a 4% [4-4%] decline. Assuming telemedicine users’ trends would have paralleled the comparison group without telemedicine expansion, difference-in-differences analyses found that telemedicine was associated with a 22% [22-22%] relative increase in total medical spending. This effect was mainly driven by telemedicine users’ spending rates increasing beyond their pre-pandemic levels. Telemedicine-associated spending growth was most concentrated in Medicaid, the most vulnerable SVI quintile, and behavioral diagnoses (e.g., depression). For example, in May-June 2023, telemedicine was respectively associated with 28% [28-28%] vs 6% [6-6%] higher spending in Medicaid vs commercial plans, 21% [21-21] vs 15% [15-15%] higher spending in the most vs least vulnerable SVI quintiles, and 36% [36-36%] vs 12% [12-12%] higher spending for behavioral vs musculoskeletal conditions.

CONCLUSIONS: Telemedicine appeared to add to U.S. healthcare spending after the onset of COVID-19. Importantly, telemedicine-associated spending growth was most pronounced for marginalized groups and for those with behavioral conditions.

THE FAMILY DIABETES PREVENTION PROGRAM PILOT STUDY: FEASIBILITY, ACCEPTABILITY (AND A PRELIMINARY EXAMINATION OF IMPACT) OF A MULTI-GENERATIONAL INTERVENTION

Maya S. Venkataramani^1,4; Michelle Eakin³; Kathy Michalski¹; Sheela Magge⁴; Mohammed Abusamaan¹; May Thu Thu Maw¹; Tina L. Cheng²; Nisa Maruthur¹. ¹Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ²Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; ³Pulmonary and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD; ⁴Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #4063794)

BACKGROUND: The rising prevalence of type 2 diabetes in adults and children calls for innovative, multi-generational prevention efforts. Leveraging the adult Diabetes Prevention Program (DPP) platform, we developed the Family DPP (FDPP). The FDPP augments the 12-month DPP curriculum for adults with child-focused sessions delivered to adult-child dyads. These sessions are designed to improve child health behaviors (and thus maintain or improve weight status). We examine outcomes from a pilot feasibility study.

METHODS: The FDPP Pilot Study enrolled DPP-eligible adults, in the Baltimore metro area, and 1 child they cared for (5-12 years) into 1 of 2 virtual intervention groups in October 2022. Primary outcomes were process measures including delivery feasibility (e.g., attendance) and acceptability. Secondary outcomes were changes from baseline in adult and child health behaviors (e.g., self-reported vegetable, fruit, and sugary drink intake and physical activity (PA) minutes, in the past week), self-reported adult weight, and measured child weight status. Secondary outcomes were examined for dyads that attended at least 1 child-focused session (these sessions began at 6 months). We calculated descriptive statistics.

RESULTS: Out of 12 dyads enrolled, 8 (75%) attended at least 1 child-focused session (indicating retention in the program through 6 months). Among adults in the 8 dyads, mean age was 47.8 years (range 36-70); 75% were female and 75% were Black. Mean child age was 10.2 years (range 5-12); 63% were female. At baseline, 12.5% of children had overweight and 37.5% had obesity.

The majority of dyads (87.5%, or 7) completed at least 6 of 8 didactic child-focused sessions. All adults who answered 12-month satisfaction surveys (N=7) agreed (on Likert-scale based items) that the sessions helped to address child behaviors and that they would recommend the FDPP to others.

Among adults, mean weight change was -4.3% (95% confidence interval [CI]: -6.9,-1.6); 37.5% met the DPP's 5% weight loss goal. Among children with 12-month data (N=7), no child crossed into a higher weight status category. Mean BMI z-score change was -3.2% (95% CI: -34.0,27.7) in children with overweight or obesity at baseline.

50% of adults had higher average weekly PA minutes over the program compared to their first week. 43% of children increased the number of days/week they had 60 PA minutes. Adults exhibited a trend towards decreased sugary drink intake (mean change -0.2 times/day, 95% CI:-0.5, 0.1); no significant changes were noted for other diet categories.

CONCLUSIONS: The FDPP Pilot Study demonstrates the feasibility and acceptability of engaging adult-child dyads in child-focused sessions during the DPP. 75% of dyads were retained through 6 months, which is similar to DPP participant retention nationally. The majority of retained dyads completed at least 75% of, and reported satisfaction with, child sessions. As this study was not designed to definitively assess impacts of child sessions, a larger trial is planned.

THE HOSPITAL READMISSIONS REDUCTION PROGRAM’S SPILLOVER EFFECTS ON THE UTILIZATION OF ELECTIVE CORONARY PROCEDURES

Benjo A. Delarmente^1,2; Darrell J. Gaskin³. ¹Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; ²School of Economics, University of the Philippines Diliman, Quezon City, Metro Manila, Philippines; ³Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4065086)

BACKGROUND: Medicare’s Hospital Readmissions Reduction program (HRRP) is a national pay-for-performance program that imposes financial penalties on hospitals whose excess readmission rates for six conditions are higher than the national averages beginning in 2012. Most studies demonstrate a significant decline in hospital readmissions due to acute myocardial infarctions (AMI) but few studies have examined possible spillover effects from the HRRP. We explore whether the HRRP had spillover effects on the utilization of coronary procedures in elective settings as a response to penalties incurred from excess AMI readmissions.

METHODS: We use aggregated discharge data from the Healthcare Cost and Utilization Project’s (HCUP) State Inpatient Databases (SID) linked with HRRP hospital penalty data and Medicare Advantage penetration rate from CMS, hospital characteristics data from the American Hospital Association Annual Survey and the Medicare Impact file, and county-level poverty rate from the American Community Survey. The final sample for this analysis consists of 959 hospitals from six states (AZ, CO, FL, NJ, NY, NC, and WA) for 2009, 2011, 2013, and 2015. The outcome variables of interest are the numbers of elective PCIs, all PCIs, and diagnostic angiograms while the main independent variable of interest is the HRRP penalty due to excess AMI readmissions. We ran several zero-inflated negative binomial regressions of procedure counts on HRRP penalties, controlling for diagnostic catheterization, interventional catheterization, and adult cardiac surgery capabilities, total admissions, number of full-time equivalent (FTE) physicians and dentists, number of FTE nurses, teaching hospital status, Medicare case mix index, county-level percentage of population in poverty, Medicare Advantage penetration, and Herfindahl-Hirschman Index (HHI) at the Hospital Referral Region (HRR) level.

RESULTS: A $10,000 increase in the AMI penalty is associated with 1.832 more elective PCI procedures and 2.388 more total (i.e., elective and emergency) PCIs overall. Total HRRP penalties were associated only with the number of elective PCIs with an increase of $10,000 in the total HRRP associated with an increase of only 0.365 elective PCIs. A $10,000 increase in AMI and total penalties are associated with 2.497 more, and 0.603 more diagnostic angiograms, respectively. Similar results were observed in our sensitivity analyses.

CONCLUSIONS: The results suggest that the HRRP penalties, particularly AMI penalties, increased the number of elective cardiac catheterization procedures performed in hospitals. HRRP penalties may have influenced providers’ treatment decisions for nonacute coronary artery disease (CAD). Providers may have responded to HRRP penalties by exercising discretion to increase the utilization of elective coronary procedures. Whether medical, albeit not fully supported by evidence, or financial incentives predominate remains an open question and future research should examine both motivations further.

THE IMPACT OF HEALTH INSURANCE ON HEALTHCARE UTILIZATION AND HEALTH: EVIDENCE FROM MEDICAID EXPANSION IN INDIANA

Andrew L. Owen¹; Sadia Farzana²; Justin Blackburn³; Ronald T. Ackermann¹; Bernard Black^4,2. ¹Institute for Public Health & Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Northwestern University Kellogg School of Management, Evanston, IL; ³Indiana University Purdue University Indianapolis, Indianapolis, IN; ⁴Northwestern University School of Law, Chicago, IL. (Control ID #4063719)

BACKGROUND: The effect of health insurance on morbidity and mortality is often studied but with mixed results. In 2015 Indiana expanded Medicaid to all adults with incomes up to 138% of the federal poverty limit. We combine this external shock with longitudinal, visit level data from the Indiana Health Insurance Exchange (IHIE), to study the effects of gaining health insurance on healthcare utilization, across outpatient visits, emergency department (ED) visits, and hospitalizations.

METHODS: We link visit-level electronic health record data from IHIE with state Medicaid enrollment data. We use a difference-in-differences design in which we compare Medicaid enrollees who became eligible in 2015 (expansion year), mostly childless adults, aged 35-64, to previously eligible adults (mostly parents with children at home), over 2013-2022. Our control group includes 30,378 patients of which 72.6% are female, 78.6% are white, 16.6% are Black, and 5.6% are Hispanic with an average age of 46.4 at Medicaid expansion. The treatment group contains 42,167 patients of which 55.2% are female, 77.8% are white, 17.4% are Black, and 6.3% are Hispanic with an average age of 48.9 at Medicaid expansion. We aggregate patient observations to quarterly data for analysis. We use inverse-probability weights to balance the treatment and control groups on demographic characteristics.

RESULTS: We find a sharp, immediate, and sustained increase in outpatient visits for newly eligible enrollees in 2015. We also find a sharp increase in emergency department visits and hospitalizations which lasts for about two years after expansion. Estimated treatment effect point estimates are provided in the included table. These results are significant at α = 0.001. We also find evidence of increased diagnosis of diabetes for the treatment group.

CONCLUSIONS: We provide, to our knowledge, the first visit-level, long-time period evidence on the response of healthcare utilization to gaining Medicaid insurance. The immediate increase then tapering of ED and hospitalizations in the treated group suggests a phenomenon of pent-up demand among previously uninsured populations. This finding has implications for policy and care delivery for vulnerable populations re-entering healthcare systems after a period of fragmented care.

THE IMPACT OF MEDICAID EXPANSION ON ENROLLEE CREDIT OUTCOMES

Nora V. Becker¹; Helen Levy²; Richard Hirth³; Sarah J. Clark⁴; Lisa Cohn⁴; Renuka Tipirneni⁵; John Z. Ayanian¹. ¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²University of Michigan Institute for Social Research, Ann Arbor, MI; ³University of Michigan School of Public Health, Ann Arbor, MI; ⁴University of Michigan Medical School, Ann Arbor, MI; ⁵Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI. (Control ID #4045827)

BACKGROUND: Prior work has shown that enrollment in Medicaid expansion helps improve credit outcomes for non-elderly adults, but to date, these outcomes have not been studied using longer-term data for individual Medicaid enrollees with a comparison group.

METHODS: We identified all non-elderly adults who enrolled in the Healthy Michigan Plan (HMP), Michigan’s Medicaid expansion program, between 2014-2017. HMP enrollees were linked to their longitudinal Experian consumer credit reports from 2013-2021 and compared to a randomly selected comparison sample of low-income individuals living in non-expansion states from Experian’s national database. HMP enrollees were assigned to an annual cohort of enrollment by their earliest enrollment date (2014, 2015, 2016, 2017). For each annual cohort of enrollment, we used a synthetic control analysis to estimate the impact of HMP enrollment on four credit outcomes: medical debt in collections, non-medical debt in collections, having a subprime credit score (<600), and bankruptcy in the prior two years. We also conducted several different sensitivity analyses and subgroup analyses to examine the validity and stability of our results across different patient cohorts.

RESULTS: All HMP enrollment cohorts experienced large and significant reductions in mean medical debt in collections compared to their synthetic control groups, with larger impacts seen in earlier enrollment cohorts (range: $271 to $403 lower average debt per-person, all p<0.001). These reductions in medical debt in collections were consistent and increasing over time. Enrollees in 2014 and 2015 also experienced significant reductions in mean non-medical debt in collections and rates of subprime credit score, but this effect decreased with each subsequent year of enrollment and reversed for those who enrolled in 2016 and 2017. HMP enrollment was also associated with small but statistically significant increases in absolute rates of bankruptcy (Range: 0.55 – 0.67 percentage point increases, all p<0.001).

CONCLUSIONS: Our results strongly suggest that HMP enrollment significantly and consistently reduces medical debt in collections for up to seven years post-enrollment. For some patients, HMP enrollment also conferred additional financial benefits in reductions in non-medical debt in collections and improvements in credit score, although these result estimates were not consistent across all patient cohorts. We also find counterintuitive evidence of small increases in rates of personal bankruptcy after HMP enrollment. Our results overall suggest that Medicaid enrollment provides excellent financial protection from the out-of-pocket costs of medical care, which may improve enrollees’ ability to access care and improve their subsequent health and well-being.

THE MAJORITY OF PRIMARY CARE PATIENTS TAKE ANTIDEPRESSANTS FOR EXTENDED PERIODS OF TIME

Elizabeth R. Pfoh¹; Rebecca Schulte²; Michael B. Rothberg³. ¹Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ²Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; ³Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4064569)

BACKGROUND: Antidepressants are effective in treating depression. Patients can remain on antidepressants up to two years to prevent relapse, but the effectiveness and risks of this approach are unclear. Knowing treatment duration in the real world informs the need for long-term studies. We used electronic health record data (EHR) to identify antidepressant duration and the correlates of long-term use.

METHODS: We included patients with an initial depression diagnosis and a primary care visit between 2016 and 2018 who were prescribed an antidepressant within 30 days of their initial depression diagnosis. We collected EHR data through 2020 to ensure 2 years of follow-up. We required individuals to have a second visit within 25 months of their initial diagnosis to ensure they were active primary care patients. We calculated the length of antidepressant use based on the number, frequency, dose, and number of refills. We capped the number of prescription days at 365 or the days specified in the Sig. If the gap in prescriptions was >30 days, we presumed disengagement. We used a Kaplan–Meier curve to plot the length of use. We used a regression model to identify the association between demographics, number of primary care visits, or a psychiatrist visit and continuation beyond 2 years.

RESULTS: Our cohort included 8,418 patients, of whom 66% were female, 84% were White, and the median age was 49 years (IQR: 34-63). Fifty-four percent saw an Internal Medicine clinician at their diagnosis date, and had a median of 2 years of follow-up (IQR: 1-3). Over the study period, patients averaged 4 visits across 2 years (range 1-5). A quarter of patients (26%) were on an antidepressant ≤6 months, 28% for 6-12 months, 24% for 1-2 years, and 22% for ≥2 years (figure). Use for ≥2 years was associated with older age (AOR 1.02 per 1 year of age, p<0.01) and primary care visits (AOR: 1.15 per visit, p<0.01). Government insurance was associated with shorter use (AOR: 0.76 versus private, p<0.01). Having a psychiatry visit was not associated with treatment duration.

CONCLUSIONS: Almost a quarter of patients took an antidepressant over 2 years. Understanding the long-term efficacy and safety is important to ensure patients are receiving safe, high-quality care.

TIME TO OVERDOSE DEATH FOLLOWING DISCONTINUATION OF OPIOID THERAPY

Anne C. Black^1,2; Benjamin A. Howell³; Maryam Kazemitabar³; Hsiu-Ju Lin⁴; Lauretta E. Grau³; Robert Heimer⁹; Gail D'Onofrio⁵; Kathryn Hawk⁶; David A. Fiellin⁷; William Becker⁸. ¹Internal Medicine, Yale School of Medicine, New Haven, CT; ²Department of Veterans Affairs, West Haven, CT; ³Medicine, Yale University School of Medicine, New Haven, CT; ⁴School of Social Work, University of Connecticut, Hartford, CT; ⁵Emergency Medicine, Yale School of Medicine, New Haven, CT; ⁶Emergency Medicine, Yale University, New Haven, CT; ⁷Internal Medicine, Yale School of Medicine, New Haven, CT; ⁸Internal Medicine, VA Connecticut Healthcare System, West Haven, CT; ⁹EMD, Yale University School of Public Health, New Haven, CT. (Control ID #4064687)

BACKGROUND: Amidst efforts to reduce opioid-related harms, there is growing concern that rapid tapering or abrupt discontinuation of opioids have unintended consequences, including serious withdrawal symptoms, psychological distress, use of illicit substances, opioid-related overdose, and death. In this study, we investigated factors associated with time to opioid-related overdose death among decedents whose opioid therapy had been discontinued. We hypothesized that rapid taper and discontinuation from higher opioid doses would be associated with death within the month of discontinuation.

METHODS: The study involved secondary analysis of a merged dataset, combining data from Connecticut State agencies, including the Connecticut Hospital Association and Office of the Chief Medical Examiner. The sample included 463 adults who had discontinued opioid therapy and experie